Jewish Home for Rehabilitation and Nursing, the

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a) maintain kitchen equipment in a clean and sanitary manner and b) maintain a clean, sanitary environment in 3 of 3 kitchenettes used by residents. The evidence was as follows: On 5/28/25 at 9:56 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following during the kosher kitchen tour: 1. The steam table on the dairy side had four individual wells that held water for the steam. All four of the wells had food, corrosion, and white flakey build-up floating in the water. The surveyor interviewed the Cook, in the presence of the FSD, who stated she only cleaned the water well weekly. The FSD acknowledged and stated, it was not cleaned according to facility policy. 2. The surveyor toured the 3 of 3 kitchenettes on the units. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan (ICCP) for a resident with a physician's order for tube feeding (delivers nutrition directly into the digestive system through a tube) whose tube feedings were discontinued. This deficient practice was identified for 1 of 2 residents reviewed for tube feeding (Resident #8), and was evidenced by the following: On 5/28/25 at 11:10 AM, during the initial tour of the facility, the surveyor observed Resident #8 seated in their wheelchair watching television. The surveyor did not observe a feeding pump or tube feeding being administered. On 5/29/25 at 11:15 AM, the surveyor reviewed the medical record for Resident #8. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to report to the State Survey Agency (SSA) an allegation of physical abuse and an injury of unknown source in a timely manner for two of three residents (Resident (R) 10 and R2) reviewed for Abuse of 24 sample residents. This failure had the potential to affect resident safety at the facility.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure that one of two residents (Resident (R) 4) reviewed out of a sample of 24 received their medications as ordered by the physician. This failure has the potential for R4 not to get the full benefit of her medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that thorough incontinence care was provided for two (Resident (R) 6 and R7) residents out of a sample of 24 residents. This failure has the potential to cause urinary tract infections (UTI) if inappropriate care was provided.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were six medication errors observed out of 29 opportunities, resulting in a 20.69% error rate. This had the potential to place three residents (Residents (R) 4, R8, and R9) at risk of not receiving the full benefit of their medication therapy.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure that staff changed gloves when going from a dirty area to a clean area during incontinence care for two of two resident (Resident (R) 6 and R7) and for one of one resident (R4) during suprapubic catheter care, to prevent possible cross contamination in a sample of 24. In addition, the facility failed to ensure that staff wore personal protective equipment (PPE) during incontinence care for one resident (R6) that was on enhanced barrier precaution (EBP). This failure has the potential to spread multi-drug-resistant organisms (MDROs) throughout the facility and/or has the potential to increase urinary tract infections (UTI).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) disposition (destruction) of controlled dangerous substance (narcotic; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 4/20/23, the surveyor observed two (2) nurses administer medications to two (2) residents. There were 25 opportunities, and five (5) errors were observed which calculated to a medication administration error rate of 20%. This deficient practice was identified for one (2) of two (2) residents, (Resident #38 and #80), that were administered medications by two (2) of two (2) nurses. The deficient practice was evidenced by the following: 1. On 4/20/23 at 8:15 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing to administer 11 medications to Resident #38 which included one pink round tablet of Cyanocobalamin (Vitamin B12) 500 micrograms (MCG). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to resolve a resident's grievance recorded in the Resident Council Minutes in a timely manner for one (1) of six (6) residents (Resident #82) who attended the Resident Council meeting. The deficient practice was evidenced by the following: The surveyor reviewed the Resident Council Minutes dated 3/30/23 at 2:36 PM that was facilitated by the Director of Life Enrichment. The minutes revealed under the category of Nursing that Resident #82 had expressed buzzed during the 11-7 shift because he/she was having trouble breathing. No one responded to his/her call bell until 40 minutes and then the aid had an attitude with him/her. I could have been there dead. The call should take precedence. There was only one nurse on. Need for more staff. [...]

Inspectors wroteComplaint #NJ00160939 Based on observation, interview, and record review, it was determined that the facility failed to observe two residents take medication or assess them for self administration of medication. This was found with 2 of 25 residents reviewed, Resident # 16 and Resident # 17 . Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to administer oxygen in accordance with physician's orders. This was found with Resident # 32, who was 1 of 2 residents reviewed for Respiratory Care. The deficient practice was evidenced by the following: On 4/17/23 at 12:16 PM, the surveyor observed the resident sitting in a recliner in their room. The resident was receiving oxygen through a nasal cannula (a tube with 2 prongs at the end that deliver oxygen through the nose) that was connected to an oxygen concentrator that was set between 3 and 4 liters per minute (lpm). The oxygen concentrator was on the opposite side of the bed from where the resident was sitting. The resident said they received 3 lpm. On 4/24/23 at 11:35 AM, the surveyor observed the resident sitting in a recliner in their room. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) appropriately administer pain medication in accordance with a physician's order, b.) accurately document the administration of pain medication, and c.) document communication with the Physician for 1 of 24 residents reviewed (Resident #96) professional standards of practice. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a call light was placed within reach for a resident with a history of falls. This deficient practice was identified for 1 of 2 resident reviewed for accidents (Resident #53), and was evidenced by the following: On 6/29/21 at 10:59 AM, the surveyor observed Resident #53 in bed asleep. The call light was observed not within reach of the resident located on the opposite side of the room clipped to the call light wall outlet. On 7/1/21 at 10:11 AM, the surveyor observed Resident #53's room. The resident was not in his/her room, but the call light was observed clipped to the call light outlet. The surveyor reviewed the medical record for Resident #53. [...]