Alaris Health At The Chateau

F-F328.

During an interview on 01/09/25 at 5:01 PM, Registered Nurse (RN)3 stated when new pressure ulcers were discovered the physician and family were both notified right away. RN3 stated the notification should be documented in Progress Notes.

During an interview on 01/09/25 at 6:54 PM, the Administrator stated notification of the pressure ulcer was covered at discharge in the Discharge Instructions regarding the application of Skin Prep treatment. The Administrator stated she did not know if the family was notified prior to that.

NJAC 8:39-13.1(a)(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27104

Residents Affected - Few Based on record review, interview, and facility policy review, the facility failed to ensure pharmacy recommendations were responded to by the physician for one resident (Resident (R)160) out of five residents reviewed for unnecessary medications out of a total sample of 43 residents. This had the potential for the resident to have unmet health needs by not providing medication management.

Findings include:

Review of the facility policy titled, Consultant Pharmacy Reports last revised 04/2024 revealed, It is the policy of the facility that a Licensed Nurse along with the Consultant Pharmacist will review the resident drug regimen upon admission, throughout the stay depending on the resident condition and in any event of risk of adverse consequences . Any irregularities will be reported and documented to the attending physician and DON [Director of Nursing] . Procedure . 4. Any medication irregularities identified will be documented on a separate, written report and notification to the attending physician, and director of nursing, listing the resident name, relevant drug irregularity that was identified with the resolution noted by the physician . 6. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician will communicate with a licensed professional.

Review of Resident R160's Profile located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses of dementia and Alzheimer's disease.

Review of Resident R160's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/23/24 revealed a Brief Interview for Mental Status (BIMS) score of one out of 15 indicating the resident was severely cognitively impaired.

Review of Resident R160's Physician's Orders located in the EMR under the Orders tab revealed Resident R160 was ordered Donepezil (Aricept) five milligrams (mg), give one table by mouth at bedtime for dementia with a start date of 08/14/24 and an order for Memantine (Namenda) five mg, by mouth two times a day for dementia with a start date of 08/15/24.

Review of the Certified Consultant Pharmacist Monthly Progress Notes provided by the facility dated 08/29/24, revealed the pharmacist recommended to consider increasing the resident's Aricept after four weeks. Under the section titled Please consider implementing these recommendations and document below any changes made in response to the recommendations written, or should the recommendations be rejected, please document a rationale. There were initials in the space with no response documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Review of the Certified Consultant Pharmacist Monthly Progress Notes provided by the facility dated 09/26/24 and 10/25/24 revealed the pharmacist requested to consider increasing the dosage of Resident R160's Level of Harm - Minimal harm or Aricept and Namenda. Under the section titled Please consider implementing these recommendations and potential for actual harm document below any changes made in response to the recommendations written, or should the recommendations be rejected, please document a rationale. There were initials in the space with no Residents Affected - Few response documented.

Review of Resident R160's Medication Administration Record (MAR) from 08/01/24 through 01/09/25 revealed the resident was still receiving the same ordered dosage of Namenda and Aricept that was originally ordered on 08/14/24 and 08/15/24.

During an interview on 01/09/25 at 5:00 PM with the Director of Nursing - North (DON-N) confirmed the consulting pharmacist had made physician recommendations for Resident R160's Namenda and Aricept to be increased three separate times and there was no documentation from the physician agreeing with the recommendations and/or any rationale as to why the recommendations were not agreed upon.

During an interview on 01/09/25 at 6:00 PM with the Consulting Pharmacist (CP) revealed the reason she requested to increase the resident's Aricept on 08/29/24 after four weeks was due to the resident being on a low dose at the beginning and you want to titrate up to get the maximum effectiveness of the medication. The CP confirmed she also made follow-up recommendations to the physician to increase the Namenda and Aricept two more times and the recommendations were not responded to by the physician. She revealed the two medications are intended to slow the progression of the Dementia/Alzheimer's.

NJAC 8:39-29.3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27104

Residents Affected - Few Based on observation, interview, review of the Maintenance Logbook, and facility policy review, the facility failed to ensure eight resident rooms (Rooms 225W, 213W, 209, 211D, 227P, 262, 230 and 229) on the second floor of the north building was maintained to promote a homelike environment. The facility further failed to ensure formica coverings on a half wall in the Activity room was repaired to potentially prevent injury. This affected eight rooms of 38 resident rooms occupied on the second floor of the north building and

the Activity room. This had the potential for the residents not to have a home like room in good repair and had the potential to cause an injury.

Findings include:

Review of the facility policy titled, Maintenance Repairs last revised 05/24 revealed, Policy: To maintain a safe, clean, and functional environment for residents, staff, and visitors through timely repairs, routine maintenance, and room inspections. Procedures: 1. The Maintenance Department is responsible for conducting routine checks, repairs, and inspections throughout the facility . 3. Staff report issues (e.g., broken equipment, hazards) to the Maintenance Department. 4. Submit repair requests via the maintenance logbook on the designated floor of the issue . 6. The Maintenance Department checks the logbook for needed repairs and logs completion status/date in the logbook. 7. Maintenance performs routine checks/inspections of common areas, hallways, and safety systems (e.g., lighting, HVAC, and plumbing) on daily rounds . 12. Maintenance ensures fixtures, furniture, and systems are inspected for damage and repaired as needed.

During observations on 01/08/25 at 3:10 PM with the Regional Maintenance Director (RM) and the facility Maintenance Director (MD) revealed the following concerns in residents' rooms on the second floor of the north building:

-In room [ROOM NUMBER]W the closet doors would not shut, there was a missing handle/knob on one of

the doors on the closet, there was paint peeling off the closet doors, there was paint peeling off the walls that surround the sink in the middle of the room. There was one ceiling tile sagging above the bed by the door;

-In room [ROOM NUMBER]W there was paint peeling all around the sink in the middle of the room with cracks between the sink and the wall;

-In room [ROOM NUMBER] there was paint peeling off the walls around the sink in the middle of the room;

-In room [ROOM NUMBER]D there was paint peeling off the walls around sink in the middle of the room. The heating unit (radiator) had paint peeling and it was rusted;

-In room [ROOM NUMBER]P there was paint peeling off walls by the window and the top of heating vent (radiator) was rusted;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 -In room [ROOM NUMBER] the closet doors had paint peeling, there was paint peeling off the walls surrounding the sink in the middle of the room; Level of Harm - Minimal harm or potential for actual harm -In room [ROOM NUMBER] above the resident headboard of the bed by the window had a large section of peeling paint approximately 12 inches by 12 inches. A ceiling tile above the entrance to the door was Residents Affected - Few sagging;

-In room [ROOM NUMBER] the walls surrounding the sink in the middle of the room was peeling.

-In the Activity room there was a half side wall surrounding the activity room with formica (laminated composite) covering the top ledge. A piece was broken off the top of the ledge leaving a sharp pointed piece of formica sticking up. The wall was approximately three feet in height, making it the same height for a resident in a wheelchair and if they would use the wall to help propel themselves it had the potential to stick

the resident in the hand or arm and cause an injury.

Review of the Daily Maintenance Logbook provided by the facility dated 2024 and 2025 revealed there were no requests completed by staff to complete any painting, repair any closet doors, repair any sagging ceiling tiles, or to fix the wall surrounding the Activity room. Further review of the logbook was an entry dated 01/09/25 revealed there were no maintenance issues reported by staff or found on maintenance rounds.

During an interview with the RM and MD at the time of the above observations, they confirmed the rooms needed to be painted and the closet doors needed to be repaired.

NJAC 8:39-31.4(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0924 Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27104 potential for actual harm Based on observation, interview, review of Maintenance Logbooks, and facility policy review, the facility Residents Affected - Few failed to ensure handrails located in the corridors throughout the second floor of the north building on all four hallways had handrails in good repair and/or were not missing. This had the potential for the residents to potentially injure themselves when using the handrails during ambulation. This affected all four hallways of

the second floor in the north building out of three floors in the building.

Findings include:

Review of the facility policy titled, Maintenance Repairs last revised 05/24 revealed, Policy: To maintain a safe, clean, and functional environment for residents, staff, and visitors through timely repairs, routine maintenance, and room inspections. Procedures: 1. The Maintenance Department is responsible for conducting routine checks, repairs, and inspections throughout the facility . 3. Staff report issues (e.g., broken equipment, hazards) to the Maintenance Department. 4. Submit repair requests via the maintenance logbook on the designated floor of the issue . 6. The Maintenance Department checks the logbook for needed repairs and logs completion status/date in the logbook. 7. Maintenance performs routine checks/inspections of common areas, hallways, and safety systems (e.g., lighting, HVAC, and plumbing) on daily rounds . 12. Maintenance ensures fixtures, furniture, and systems are inspected for damage and repaired as needed.

During observations on 01/08/25 at 3:10 PM with the Regional Maintenance Director (RM) and the facility Maintenance Director (MD) revealed the following concerns with handrails in the corridors on the second floor of the north building:

-Handrail between rooms [ROOM NUMBERS] had duct tape with foam around the ends of the handrails;

-Handrail on the left side of the hall starting right before room [ROOM NUMBER] had duct tape on the ends securing the handrail to the wall;

-Handrail on the left side of the hallway between the soiled utility room and MDS office door had duct tape on both ends of the handrail;

-Missing handrail in front of the women's shower on the north hall;

-Missing handrail in between the elevators;

-Handrail to the right of the elevator had duct tape on both ends;

-Handrail in front of the TV room was loose and pulled away from the wall.

Review of the Daily Maintenance Logbook provided by the facility dated 2024 and 2025 revealed there were no requests to fix handrails on the corridors of the second floor. Review of the entry in the logbook dated 01/09/25 revealed there were no maintenance issues reported by staff or found on maintenance rounds related to handrails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 315494 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315494 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alaris Health at the Chateau 96 Parkway Rochelle Park, NJ 07662

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0924 During an interview at the time of the above observations the MD said they were waiting on caps to come into place on the ends of the handrails so they could be replaced. A request was made for a copy of the Level of Harm - Minimal harm or invoice showing handrails and caps were ordered so the handrails could be fixed. The RM said they would potential for actual harm not be able to produce any invoices for copies of any orders to show replacement parts for the handrails had been ordered. Residents Affected - Few

During an interview on 01/09/25 at 9:25 AM Interview with the Unit Manager 2nd floor - North (UM2N) revealed she was not sure how long the handrails were in need of repair and confirmed there was no record

in the logbooks of the needed repairs for the handrails.

During an interview on 01/09/25 at 9:30 AM Licensed Practical Nurse (LPN)2 she was unsure how long the duct tape and foam had been on several of the handrails. She said she knew they were working on the handrails last night.

During an interview with the Assistant Administrator on 01/09/25 at 1:30 PM revealed she had heard there was a plan to remodel the second floor but did not know when that would be started.

NJAC 8:39-31.2(e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 315494