Heritage Healthcare of Lyndhurst

In the surveyor’s words

From the most serious findings on record at Heritage Healthcare of Lyndhurst, in the surveyor’s own words.

• Immediate jeopardy, patternF760Jun 2, 2022

  Based on observation, interview, review of the Medication Administration Record (MAR), review of facility policy titled Insulin Administration, and review of the Medication Technician job description, the facility failed to administer insulin according to physician orders resulting in significant medication errors affecting four residents (Residents #89, #74, #68, and #19). This resulted in Immediate Jeopardy with actual harm or likelihood of actual harm including [CONDITION(S)] (high blood sugar), which could lead to hospitalization and death. This affected four of 32 residents residing on the second floor. The facility identified 38 residents as receiving insulin. The facility census was 93. On 05/26/22 at 4:40 P.M. […]

• Immediate jeopardy, isolatedF689Sep 1, 2022

  Based on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate supervision of one cognitively impaired resident (Resident #53), who was at high risk for elopement and required supervision with activities of daily living, resulting in the resident leaving the facility without staff knowledge on 08/16/22. This resulted in Immediate Jeopardy when Resident #53 was last observed on 08/16/22 at 7:00 P.M. sitting on the bed in his room by Registered Nurse (RN) #515 and State tested Nursing Assistant (STNA) #414 and was not identified as missing until Resident #53's wife called the facility at 8:05 P.M. […]

• Actual harm, patternF686Jul 13, 2022

  Based on observation, record review, interview, and facility policy review, the facility failed to timely initiate and provide adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #18, who was admitted to the facility on [DATE]. Resident #18 was dependent on two staff assistance for bed mobility and required [CONDITION(S)] care. Resident #18 developed a posterior neck pressure wound on 12/15/21. Continued treatments were not administered as ordered and by 06/13/22, Resident #18's pressure wound had reoccurred, received inadequate treatments, and required mechanical debridement. […]

• Actual harm, isolatedF684Apr 7, 2025

  Based on observation, interview, medical record review, review of hospice notes, and facility policy review, the facility failed to ensure care and services were provided to facilitate resident preference, comfort and hydration. Actual Harm occurred on 03/24/25 at 10:04 A.M. when Resident #58, a resident who was receiving end-of-life hospice care who staff believed was actively dying, was left alone behind a closed door, thirsty, in severe pain, and unable to call for assistance. Resident #58 was dependent on all aspects of care and unable to call for help, was denied hydration measures, and had minimal pain control for 2 days. This affected one resident (#58) of three residents reviewed for quality of care and treatment. […]

• Actual harm, isolatedF689Oct 16, 2024

  Based on record review, review of a facility fall investigation, review of staff disciplinary forms, review of a facility procedure and interview, the facility failed to provide adequate assistance to Resident #35 during incontinence care to prevent a fall with injury. This affected one resident (#35) of three residents reviewed for incontinence care. The facility census was 68. Actual harm occurred on 08/05/24 when Resident #35, who was severely cognitively impaired, required two staff assistance for bed mobility and was incontinent, sustained a fall out of bed when staff were providing incontinence care. At the time of the incident, the staff failed to maintain the resident's safety in bed. […]