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Deficiency Records for Regalcare at Glen Ridge
A list of the most recent deficiencies for Regalcare at Glen Ridge. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Regalcare at Glen Ridge. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-10 | 2023-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-26 | 2023-12-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-26 | 2023-12-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-26 | 2023-12-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-26 | 2023-11-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-26 | 2023-11-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-26 | 2023-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-26 | 2023-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-26 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-26 | 2023-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-26 | 2023-11-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-26 | 2023-11-22 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-26 | 2023-11-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-26 | 2023-11-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-26 | 2023-11-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-26 | 2023-11-22 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-26 | 2023-11-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-26 | 2023-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-26 | 2023-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-26 | 2023-11-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-10 | 2023-06-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-16 | 2023-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2023-02-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-16 | 2023-02-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-16 | 2023-02-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-16 | 2023-01-13 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-12-16 | 2023-01-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-16 | 2023-01-13 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-16 | 2023-01-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-16 | 2023-01-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-16 | 2023-01-13 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-16 | 2023-01-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2023-01-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-16 | 2023-01-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-16 | 2023-01-13 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-12-16 | 2023-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-01-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-16 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-24 | 2021-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-24 | 2021-08-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-24 | 2021-07-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-24 | 2021-07-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-24 | 2021-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-24 | 2021-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-24 | 2021-07-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-24 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-24 | 2021-07-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-24 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-07-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-24 | 2021-07-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-24 | 2021-07-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-24 | 2021-07-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-24 | 2021-07-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-24 | 2021-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-24 | 2021-07-12 | N |
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