South Mountain Hc

Inspectors wroteBased on observation, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the development and implementation of menus to consistently provide adequate portions of milk and bread to residents in accordance with the facility's diet manual, policy and national nutritional standards for a four-week cycle menu. This deficient practice was evidenced by the following:On 8/18/25 at 8:59 AM, during entrance conference it was determined that the facility was licensed for a capacity of 195 beds and had a current census of 189 beds. On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD) in the presence of a second surveyor. [...]

Inspectors wroteBased on observations, interviews, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during two kitchen tours and was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor and observed the following:To the left of the handwashing sink, and to the right of the walk-in freezer, there was a damaged wall with a penetration, which the FSD stated had been that way since she started in May 2025 and the Director of Maintenance (DOM) was aware. [...]

Inspectors wroteBased on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to implement an effective pest control program in the kitchen. This deficient practice was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor. The surveyors observed a live bug walking up a white tiled wall above a stainless-steel table which had food preparation equipment on it, uncovered. The FSD observed the bug as well and stated, we have a pest control problem here; it was like this when I got here; maintenance is aware; we have a company [name redacted] that comes every Tuesday. The surveyors then observed two live bugs walking on the floor, in the dry storeroom. There were also two glue traps of the floor of the storeroom filled with bugs. [...]

Inspectors wroteBased on observation, interview and review of facility documents, it was determined the facility failed to maintain a comfortable and homelike environment for the residents (Resident #131). This deficient practice was identified on 1of 5 nursing units reviewed for environment and was evidenced by the following:On 8/18/2025 at 11:29 AM, the surveyor observed Resident #131, in the day room. The surveyor observed the resident's room and noted the resident's dresser, with the 3rd drawer down broken. The surveyor observed nails sticking out of the inside of the drawer. On 8/19/2025 at 10:29 AM, the surveyor observed Resident # 131, in a reclining chair, next to their bed. The resident's eyes were closed. The surveyor again noted the dresser with the broken drawer. On 8/20/2025 at 8:50 AM, the surveyor observed Resident # 131, in a reclining chair, in front of the dresser. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that an air mattress (designed to prevent and treat pressure wounds) was accurately set in accordance with the resident's weight for one (1) of one (1) resident reviewed for pressure ulcers, Resident #172. This deficient practice was evidenced as follows:On 8/19/2025 at 10:39 AM, the surveyor interviewed Resident #172, who was in bed. The surveyor observed an air mattress pump at the foot of the resident's bed. The setting on the pump was set at approximately 360. The resident stated, All I know is the pump is for the air mattress because I have a wound. On 8/20/2025 at 8:45 AM, the surveyor observed the resident in bed with the air mattress pump set at approximately 360. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of six (6) residents (Resident #202) observed during the medication observation pass. The deficient practice was evidenced by the following: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 observations, interviews, 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 morning medication administration observation on 8/19/25, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41%. The deficient practice was identified for two (2) of six (6) residents, (Resident #55 and #74), that were administered medications by two (2) of four (4) nurses that were observed. The deficient practices were evidenced by the following:1). On 8/19/25 at 8:32 AM, during the medication administration observation, the surveyor observed Licensed Practical Nurse (LPN#1) entered the room of Resident #55. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly secure medications in one (1) of four (4) medication carts observed during Medication Administration Pass. This deficient practice was evidenced by the following: On 8/19/25 at 09:16 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN#1) enter the room of Resident #74. The surveyor observed RN#1 identify Resident #74 and then observed RN#1 taking the resident's vitals. RN#1 then informed Resident #74 that she would be administering the resident's medications. [...]

Inspectors wroteBased on observation, interview, and a review of pertinent medical records, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1of 4 nurses observed during medication pass on 1 of 4 nursing units. This deficient practice was evidenced by the following. On 08/19/25 at 8:34 AM, during medication administration observation the surveyor observed a Registered Nurse (RN#1) taking Resident #202's Blood Pressure (BP) with a blood pressure monitor. After taking Resident #202's BP the nurse was observed taking the BP monitor (without sanitizing) and placing it next to her medication cart. RN#1 was then observed preparing Resident #202's medications (no observation of performing hand hygiene) and was then observed entering the resident's room. [...]

Inspectors wroteBased on observation, interview and review of pertinent documents it was determined that the facility failed to ensure: a) a consistent system for labeling and dating was implemented to ensure all potentially hazardous foods were labeled with a use by date, b) the kitchen environment, all equipment and dishware was maintained in a clean and sanitary manner and transported appropriately, and c) staff performed appropriate hand hygiene, to limit the potential for contamination, and the risk of potential foodborne illness. The deficient practice was evidenced by the following: On 05/08/24 at 9:26 AM through 10:40 AM, the surveyor conducted a tour of the kitchen with the Registered Dietitian (RD) and the Food Service Director (FSD) and observed the following: 1. The step garbage can next to hand washing sink did not open when the foot pedal was stepped on and this was confirmed by the RD. 2. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for Ten (10) of Ten (10) newly hired staff reviewed. This deficient practice was evidenced by the following: On 05/14/24, the surveyor reviewed Ten (10) randomly new employee files which revealed the following: Staff #1-a Certified Nursing Assistant (CNA), with a hire date of 09/22/22, did not have a previous employee reference on file. Two (2) undated typed personal reference letters were on file. Staff #2-a CNA, with a hire date of 04/12/24, did not have a previous employee reference on file. An emailed personal reference letter dated 05/09/24 and an undated typed personal reference was on file. [...]

Inspectors wroteBased on obervations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 8 of 8 residents (Resident #4, #11, #23, #33, #77, #130, #135 and #147) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 5/9/24 at 12:25 PM, the surveyor observed Resident #77 sitting in her chair who stated, I have been here for almost 2 years, and I saw the doctor only 2 or 3 times. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to serve hot and cold food items at appropriate and appetizing temperature for 3 of 5 resident units (1 South, 2 North and 2 South), for 1 of 1 resident reviewed for food (Resident #165) and for 3 of 5 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 05/08/24, at 11:12 AM, the surveyor interviewed Resident #165 who stated the main concern was that the hot food was cold, along with the coffee for all three meals. On 05/09/24 at 9:46 AM, during a follow up interview with Resident #165, the resident stated the temperatures were off and the hot food was not hot, and the cold food was not cold. [...]

Inspectors wroteBased on observation, interviews and review of pertinent documentation, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for donning (put on) the required Personal Protective Equipment (PPE) prior to providing care to residents on isolation and Enhanced Barriers Precautions. (Resident #23 and #279) and b.) perform appropriate hand hygiene according to the Center for Disease Control (CDC) and the facility's policy. The deficient practice was evidenced by the following: 1. On 5/8/23 at 10:30 AM, during initial tour on unit 1 North, the surveyor observed a white signage posted at Resident #23's door. The door was closed and there was a PPE bin with yellow disposable gowns, outside the room. The surveyor observed the Contact Precautions signage which included but were not limited to; Everyone must: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide personal hygiene and provide timely assistance for 2 of 2 residents dependent on staff for incontinence care, Resident #21 and #147 and b.) provide nail care to Resident #280 who required assistance with ADL's care. This deficient practice was evidenced by the following: 1.) On 5/9/24 at 10:20 AM, the surveyor observed Resident #147 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry, the resident stated he/she had not been provided with incontinence care since last night. Resident #147 further stated that, I have asked the Certified Nursing Assistance (CNA) to change me in the morning, but they haven't. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently assess a resident's dialysis access site when returning from the dialysis clinic. The deficient practice was identified for 1 of 2 residents, Resident #4, reviewed for dialysis care and services and is evidenced by the following. On 5/9/24 at 10:15 AM, the surveyor observed the resident seated in a wheelchair in their room eating breakfast. The resident was alert but refused an interview. The resident told the surveyor that they had dialysis the previous day. The surveyor reviewed the medical record for Resident #4. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteComplaint #: NJ00170376 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 6 residents (Resident #227) reviewed for medication management. The deficient practice was evidenced by the following: 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 interview and review of other facility documentation, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee, that identified quality concerns, failed to utilize the Facility Performance Improvement Plan to follow the facility process to measure and utilize data acquired for frequency of physician visits. This deficient practice was evidenced by the following: On 05/16/24 at 9:40 AM, the surveyor reviewed the facility provided QAPI Plan Primary physicians' documentations compliance Effective Date: February 26, 2024 which revealed Design and Scope: Statements and Guiding Principles: PMD's (primary medical doctor)/NP's (Nurse Practitioner) Federal documentations compliance. Other Services Provided: Nursing and medical record staff will monitor physician visits compliance and informing the upper management. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for four of six Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following: On 05/16/24 at 9:53 AM, the surveyor reviewed the facility provided QAPI book, that included the quarterly sign in sheets for the QAPI meetings, which revealed: - Employee In-Service Education; Date: Jan (January) 2023; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 7/26/23; Subject: QAPI 2nd Quarter April-June 2023 the IP did not sign in as being in attendance. - Employee In-Service Education; Date: 10/17/23; Subject: QAPI the IP did not sign in as being in attendance. - Daily Department Head Meeting; Date: 1/31/24; Subject: [...]

Inspectors wroteBased on observation, interview, and review of medical records, it was determined that the facility failed to act upon the Wound Doctor (WD) treatment recommendations according to professional standards of clinical practice for 2 of 2 residents reviewed for pressure ulcers, Resident #15 and #85. The deficient practice was evidenced by the following: 1. On 4/8/22 at 11:00 AM, the surveyor interviewed Resident #15 who stated, I have bedsore in my buttock area. The resident was receiving wound treatment daily. The surveyor reviewed Resident #15's hybrid (paper and electronic) medical records that revealed the following: According to the admission Record, Resident #15 had diagnoses that included but were not limited to Cerebral infarction (Stroke) with Right hemiplegia (severe loss of strength) and Morbid obesity. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined the facility failed to ensure two residents were receiving supplemental oxygen as prescribed by the physician. This was found for 2 of 3 residents reviewed for oxygen, Resident #53 and Resident #98, and was evidenced by the following: 1. On 04/07/22 at 10:32 AM, during the initial tour of the facility Resident #53 was out of the bed in a wheelchair. The resident had nasal cannula oxygen (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) on at the time of the observation that was connected to an oxygen concentrator (a medical device that provides extra oxygen). The resident's oxygen concentrator was set on four liters of oxygen. The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 2/7/22. [...]

Inspectors wroteBased on observation, interview, and review of facility's documentation, it was determined that the facility failed to maintain a safe, functional and sanitary environment involving 2 of 34 resident room hand sinks (Rooms #150 and #152) The deficient practice was evidenced by the following: On 4/7/22 at 11:40 AM, the surveyor observed, during the initial tour, in room [ROOM NUMBER] the hand sink had a yellowish-brownish color pooling of water and a sign taped to the mirror above the sink with the a message to not use the sink. On 4/11/22 at 10:30 AM, the surveyor observed, in room [ROOM NUMBER], the same sign taped to the mirror above the sink and the sink had yellowish-brownish water pooling in the sink. [...]