Childrens Specialized Hospital Mountainside

In the surveyor’s words

From the most serious findings on record at Childrens Specialized Hospital Mountainside, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods (PHF) in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/24/24 at 10:30 AM, in the presence of the Assistant Dietary Manager (ADM), the surveyor observed the following: In the walk-in refrigerator, the surveyor observed the following: -a 1/4 size steam table pan which contained green beans in a liquid with a sticker on the top of the container that indicated a use by date of 9/20/24, -an opened, half used package of sliced salami with no use by date on it, - an opened, half used package of un-sliced beef bacon with no use by date on it, In the reach in cheese refrigerator, the surveyor… […]

• No harm, potential for more than minimal, patternF842Jul 19, 2024

  Complaint # NJ175565 Based on observations, interviews, medical record review, and other pertinent facility documents on 07/18/2024 and 07/19/2024, it was determined that the facility who has been in an active outbreak of the Multi-Drug Resistant Organism (MDRO) of Carbapenem-Resistant Acinetobacter baumannii (CRAB - bacteria resistant to nearly all antibiotics and difficult to control and irradicate from the environment) failed to provide documentation in the residents' medical records of consents, declinations, and family education for CRAB testing. […]

• No harm, potential for more than minimal, patternF641Jun 27, 2023

  Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 12 of 21 residents, (Residents #2, #3, #11, #14, #21, #27, #28, #33, #36, #41, #44, and #48) reviewed, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. […]

• No harm, potential for more than minimal, patternF756Jun 27, 2023

  Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify medication irregularity during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for three (3) of five (5) residents reviewed for unnecessary medications, Residents#14, #24, and #28. This deficient practice was evidenced by the following: According to [NAME]-Drugs (or Lexicomp an evidenced-based drug referential content; that provides evidence and recommendations to help clinicians as they treat and advise patients with complex conditions) included that review of the Erythromycin with pharmacologic category of antibiotic; Gastroparesis (off-label use; gastoparesis is a condition that affects the normal spontaneous movement… […]

• No harm, potential for more than minimal, patternF886Oct 5, 2021

  Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure 4 of 5 unvaccinated facility staff were tested for COVID-19 twice a week in accordance with the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements; and nationally accepted guidelines for infection prevention and control, and the facility's testing schedules related to the high COVID-19 county positivity rate. The evidence was as follows: According to the U.S. […]