A 64-year-old male (A.S.) was admitted to The Jewish Home from the Centra State Medical Center with an admitting diagnosis of falling off a horse and sustaining a left tibial plateau fracture which required a surgical procedure (Open Reduction and Internal Fixation) and acute fracture of the 6th and 7th ribs. The surgery was performed by Dr. Garret Sobol. The patient has a history of BPH and hyperlipidemia.

Clinical Care Interventions:

Monitor Labs – CBC w/diff and CMP
Wound Management – Monitor and Care for Surgical Incision Site Daily
Maintain Safety – Fall Precautions, Left Lower Leg Immobilizer
Monitor Pain Management and Bowel Regimen
Monitor HTN Medication Management

The patient was followed closely by Dr. Gopal, Primary Care Physician, and Dr. Gregg Berkowitz Orthopedic, along with Dr. Stacey Miller-Smith, Physiatrist.

Upon admission, the patient presented with pain, Non-Weight Bearing to the Left Lower Extremity requiring moderate assistance with ADLs, transfers, and ambulating with a rolling walker. The patient worked with therapy to obtain his goal of returning home. On discharge, he was at supervisor level for transfers, ADLs, and ambulation with a rolling walker.

After a stay in short-term rehab at The Jewish Home, the patient returned home with VNA Home Care Services and the support of his family. He was managed in-house without any unplanned discharges. He is followed by his Primary Care Physician Dr. Hany Gendy in the community. Patients will also continue to follow up with the Orthopedic team on discharge.


85 years old female patient admitted to The Jewish Home Healthcare and Rehabilitation Center from Jersey Shore University Medical Center Hospital with admitting diagnosis of pulmonary edema and s/p TAVR. Cardiac Surgeon Dr. Brook Dejene performed a Transcatheter aortic valve replacement (TAVR). The patient also has an extensive Cardiac history of NSTEMI, HTN, and Anemia along with a CVA.

Nursing Interventions:

Electrolyte monitoring: Daily weight management and dietitian oversite Medication Management: Diuretic, Beta Blocker, Statin, Anticoagulation, Supplements
Diagnostic Testing and Labs: Weekly laboratory monitoring including CBC and CMP, Inhouse EKG
Pain Management – Therapy modalities and interventions along with medications
Respiratory Management – Energy conservation and respiratory assessment

Reviewed weekly at IDT led by Cardiologist Garden State Heart Care, Dr. Aaron VanHise, and Nina Kotlyar APN; Cristina Tursi ADON, Specialty Program Coordinator and In-house Respiratory Therapist Deborah Meyer.


Upon admission, the patient required minimal assistance with transfers and moderate assistance for bed mobility and ambulation. She worked diligently with therapy to obtain her goal of going back to her home. On discharge, the patient was ambulating 100′ with rolling-walker standby assistance and was able to perform all self-care tasks with supervision.

Patient returned home to Sunrise Assisted Living Facility after completing 14-days of rehab at The Jewish Home. Prior to discharge, all follow-up appointments were made including Dr. Matthew Schoenfeld Cardiologist in the community.


96-year-old female admitted to The Jewish Home after a 6-day hospitalization at CentraState Medical Center. Diagnosis NSTEMI followed by Monmouth Cardiology Associates, Dr. Lance Berger. Other Diagnosis include S/P Fall, CKD, Hypertension, Chronic Back Pain, UTI and Heart Murmur.

Clinical Team Interventions:

Dietary / Weight Management – Heart Healthy (low fat/low cholesterol/
2-2.5gm Na, Frequent weights
Medication Management- Amlodipine, Atenolol, Aspirin
Infection Management – Antibiotic Therapy
Monitor Labs, Vitals and Diagnostics- CBC and CMP as ordered
Pain Management – Tramadol, Gabapentin

She was followed in the center by Garden State Cardiology Vennansha Williams, NP; weight management remained stable.

At time of admission, patient required assistance with ADL’s, transfers and ambulation. Upon discharge, supervision with ADL’s, walked with a walker 300 feet, able to climb 10-12 stairs with standby assistance.


Patient returned home with her daughter after a 25-day LOS in Short Term Rehab. She will continue to follow with PCP Dr. Kapoor in the community. Discharge to home with a live-in caregiver from Senior Helpers, VNA Services and support of her family. Fox Rehab Services as well at home upon conclusion of VNA Services.


90-year-old male admitted to The Jewish Home after a 17-days hospitalization at Jersey Shore University Medical Center. S/P Transcatheter Aortic Valve Replacement (TAVR) by Monmouth Cardiology Associates, Dr. Daniel Kiss. Diagnosis also include Heart Failure, HTN, CAD and CKD. The Shore Nephrology Group were also involved in patients care.

Clinical Team Interventions:

Monitor Fluid Balance- weights monitored daily and Lasix dose titration
Medication Management- Lasix, Bumetanide, Aspirin, Eliquis, Amlodipine Besylate, Metoprolol Tartrate, Retacrit and Potassium Chloride
Monitor Labs, Vitals and Diagnostics- CBC w/diff, CMP, BMP, Iron Studies

Patient was followed weekly in the center by Garden State Cardiology Vennansha Williams NP.

Upon admission patient was deconditioned. Required assistance with transfers, ambulation, and ADLs unable to do stairs. Patient discharged home with supervision for all ADL’s, ambulating 150 feet with a rollator at Stand-by assistance. Additionally, able to go up and down 4 steps with CGA to Minimal assistance.

The care at The Jewish Home is #nextlevelcare and #Multifocusspecialtyprogram!

Patient returned home with his wife and daughter after a 17-day LOS in Short Term Rehab at The Jewish Home. He will continue to follow with PCP, Dr. Shetty in the community and home health services will be provided by B/P Senior Care & VNA Home care for additional support.

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