Rose Mountain Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Brunswick, New Jersey.
- Location
- Route 1 & 18, New Brunswick, New Jersey 08901
- CMS Provider Number
- 315384
- Inspections on file
- 13
- Latest survey
- December 12, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rose Mountain Care Center during CMS and state inspections, most recent first.
The facility failed to conduct ongoing activity assessments and provide activities per care plans for residents. A resident was observed without their daily newspaper, and the Activities Director was unaware of who was responsible for providing it. Additionally, several residents lacked updated activity assessments and participation documentation. The facility could not provide evidence of residents' participation in activities, and the administration had no further information.
The facility failed to have a qualified Activities Director, as the current AD had only been in the role for two weeks and lacked necessary training and experience. The facility had not had a consistent AD since July, and the new AD, previously a unit clerk, was unfamiliar with key responsibilities. This deficiency had the potential to affect all residents.
The facility failed to ensure timely physician visits and documentation for residents, with several instances of late entries and missing progress notes. A resident had not seen a doctor regularly, and another's records showed inconsistent physician and nurse practitioner visits. Staff interviews revealed uncertainty about documentation timelines, and a physician documented a visit after a resident's discharge. The facility's policy was outdated and did not address admission visit requirements.
The facility failed to inform residents about the arbitration agreement included in the Admission Agreement, which was mandatory and not explained to them. During a survey, it was found that residents were unaware of the arbitration agreement's implications, and the facility did not track who signed or refused it. The Admission Director confirmed that the agreement must be signed, and residents did not have the option to refuse it.
The facility failed to implement an effective infection prevention and control program, with deficiencies in identifying residents on Enhanced Barrier Precautions (EBP), inadequate staff education, and improper hand hygiene practices. Observations revealed a lack of clear signage for EBP, improper use of gloves, unsanitary ice storage, and staff failing to perform hand hygiene between tasks. These actions were contrary to the facility's infection control policies and CDC guidelines.
The facility was found deficient in ensuring two of its exit doors were accessible for emergency use. A sliding bolt lock on the Kitchen exit door and a keyed lockset on the Main dining room exit door could restrict emergency egress. These issues were confirmed during a surveyor's observations and interview.
The facility failed to ensure continuous or automatic lighting for egress areas, as required by NFPA 101. Observations revealed that the Kitchen corridor, East Hall, and West Hall lacked lighting when switches were off, potentially affecting all 83 residents. This issue was confirmed by staff and reported during the Life Safety Code survey exit conference.
The facility failed to ensure proper protection of hazardous areas as per NFPA 101:2012 standards. Observations revealed that East and West wing shower rooms, used for storing combustibles, lacked self-closing devices on their doors. This deficiency, confirmed through an interview, had the potential to affect all 83 residents by compromising fire safety measures.
The facility failed to ensure that all five kitchen hood suppression systems had spray nozzle caps in place, leaving the nozzles vulnerable to grease clogs. This deficiency, observed during an inspection, had the potential to affect all 83 residents. The issue was confirmed by a representative and discussed at the Life Safety Code exit conference.
The facility failed to ensure fire alarm manual pull stations were accessible, as required by NFPA 72:2010. Observations revealed that a pull station in the dining room was blocked by a table, and another in the physical therapy room was obstructed by wheelchairs and a bed. This deficiency could potentially affect all 83 residents.
The facility failed to maintain its fire sprinkler system as required by NFPA standards. Observations revealed oxidation on several kitchen and laundry fire sprinkler heads, with some covered in lint. Additionally, there were no records of backflow preventer test inspections. These issues were confirmed by a facility representative.
The facility failed to ensure corridor doors resisted smoke passage as required by NFPA 101: 2012 Edition. Observations revealed gaps in the double doors between the West wing and Main dining room, and the door to room #9. These deficiencies could potentially affect all 83 residents.
The facility did not conduct fire drills with varying activation types as required, affecting all 83 residents. Over the past year, 12 fire drills lacked documentation on the type of device used to activate the fire alarm system, such as pull, smoke, or page. This deficiency was confirmed during a survey and communicated to the facility's representative.
The facility failed to maintain and test patient-care related electrical equipment (PCREE) as required by NFPA 99: 2012 Edition. Observations revealed that PCREE lacked inspection stickers, and interviews confirmed the absence of a maintenance policy. This deficiency potentially affected all 83 residents.
The facility failed to provide meals in a dignified manner, with staff using tray lids as garbage receptacles and neglecting hand hygiene while assisting residents. Additionally, a staff member was observed feeding a resident while standing, contrary to safety protocols.
The facility failed to provide adequate supervision and implement appropriate interventions for a cognitively impaired resident at high risk for falls, resulting in multiple falls with injuries. Additionally, the facility lacked a consistent smoking process, leading to potential safety risks for residents who smoked. Staff were not adequately informed about smoking procedures, and there was no secure storage for smoking supplies.
The facility failed to conduct a comprehensive assessment addressing the needs of residents who smoke and the cultural needs of Asian American residents. Staff interviews revealed inconsistencies in the smoking process, and a resident's family member expressed concern about the lack of a Korean newspaper. The facility's assessment tool did not adequately address these needs, indicating a gap in providing culturally competent care.
The facility failed to ensure corner guards in the main dining room were free from sharp edges and lacked protective endcaps, potentially affecting all residents on the east wing. This was confirmed by the Maintenance Director during an observation.
A facility failed to maintain an unobstructed exit door in the West Wing, as required by NFPA 101:2012. During an observation, a chair was found blocking the small dining room's designated exit door, potentially affecting 14 residents. This issue was confirmed through an interview and reported during the Life Safety Code survey exit conference.
The facility failed to provide exit and directional signs in the kitchen area, as observed during a survey. This deficiency, noted at 8:59 AM, involved the absence of an exit or directional sign for the kitchen exit access, potentially affecting approximately 18 residents. The observation was confirmed during an interview, and the facility's representative was informed of the issue during the Life Safety Code Survey exit conference.
The facility failed to construct corridor walls to resist smoke passage as required by NFPA 101, evidenced by a hole above the laundry corridor door in the East Wing ceiling. This was confirmed by a staff member and reported during the Life Safety Code exit conference.
The facility failed to separate empty and full portable oxygen cylinder tanks as required by NFPA standards. During an inspection, five full tanks were found in a rack marked for empty tanks, potentially affecting 31 residents in the east wing. This was confirmed by a staff member and noted during the Life Safety Code exit conference.
A facility failed to provide a homelike environment by administering medications to a resident in the dining room during breakfast. An RN gave medications to a resident with severe cognitive impairment while they were seated in the dining area, contrary to the care plan. The medications were not ordered to be given with meals, and the facility's policy did not address this practice. The DON acknowledged the error when informed by a surveyor.
The facility failed to provide adequate nail care to two residents who were unable to perform activities of daily living independently. Both residents had long, jagged nails with a brown substance underneath, despite requiring maximal assistance with personal hygiene. Staff interviews revealed inconsistencies in the nail care process, and documentation was not readily available, indicating a lapse in the facility's adherence to its policy on grooming and hygiene.
A facility failed to properly store and date respiratory equipment for a resident requiring oxygen therapy. The nasal cannula was observed undated and improperly stored, contrary to facility policy. Interviews confirmed the equipment should be changed weekly, dated, and stored in a labeled bag for infection control. The resident had a history of COPD and required continuous oxygen, but the care plan lacked interventions for equipment labeling and storage.
The facility failed to ensure a self-closing door to a hazardous area could automatically close upon fire alarm activation. A surveyor observed the laundry dryer room door held open with a rope tied to a storage rack, potentially affecting limited residents. This was confirmed in an interview, and facility representatives were notified during the Life Safety Code survey exit conference.
Failure to Conduct Activity Assessments and Provide Activities
Penalty
Summary
The facility failed to carry out activities according to a resident's care plan and did not conduct ongoing activity assessments for residents. Specifically, Resident #25 was observed multiple times without the daily newspaper in their preferred language, which was part of their care plan. The Activities Director (AD) was unaware of who was responsible for providing the newspaper and admitted to a lack of documentation regarding Resident #25's participation in activities. The AD also mentioned that activity assessments should be conducted quarterly, but there was no evidence of this being done. Additionally, the facility did not have updated activity assessments or participation documentation for several residents, including Residents #3, #21, #25, #83, and #84. For instance, Resident #3's last documented activity assessment was from 2022, and there were no participation logs available. Resident #21 had no activity assessments or documentation, and Resident #83's assessment was incomplete and not entered into the electronic medical record (EMR). Resident #84 also lacked activity assessments and participation documentation. The facility was unable to provide any documentation confirming residents' participation in activities. The surveyor requested the facility's policy on activities but only received a job description for the Recreation Director, which outlined responsibilities such as coordinating and documenting assessments and designing a comprehensive activity program. The facility administration had no additional information to offer when these concerns were discussed.
Plan Of Correction
1: The facility implemented a recreation attendance record for the 7 residents identified. All care plans for the 7 residents identified were updated appropriately. 2: All residents had the potential to be affected by the deficient practice so the facility implemented a recreation attendance record for all other residents as well. 3: The care plans for all current residents were reviewed and updated as needed. The Activities director and staff were educated on proper care planning of activity preferences as well as the recreation attendance record policy/process. 4: The Administrator/designee will audit 5 care plans weekly x4 to ensure they reflect activity preferences that were identified in the assessment. The administrator/designee will also audit 10 resident attendance records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025 Element One Corrective Actions: A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #1. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #6. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #6 and activity staff were re-educated about the changes. A Certified Activities Director reviewed, revised as appropriate, and signed the activity participation review (APR) for Resident #7. The care plan was also reviewed and updated as needed to reflect the current interests, abilities, and preferences of Resident #7 and activity staff were re-educated about the changes. The facility implemented a recreation attendance record to be completed each day to reflect attendance at group activities. In-room visits are documented on the same form noting date and Resident. Element Two Identification of At-Risk Residents: All residents had the potential to be affected by the practice. Element Three Systemic Change: An audit of the most recent APR for current Residents was completed by Certified Activity Directors and changes made as appropriate to reflect the current interests, abilities, and preferences of each Resident. The care plan of each Resident was reviewed and updated as appropriate based on the APR and activity staff educated about any changes. Activities staff were re-educated about the recreation attendance record to be completed daily that reflects attendance at group programs and in-room visits. A Certified Activity Director (CAD) was hired and started on March 3, 2025. The new CAD is being mentored by sister facility CADs as needed. Element Four - QAPI: The Activity Director/designee will audit resident group attendance and in-room visit records weekly x4 then monthly x2 ensuring proper compliance. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025
Unqualified Activities Director and Inconsistent Program Management
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The Activities Director (AD) had only been in the position for two weeks and previously worked as a unit clerk for several years. The AD was unfamiliar with key aspects of the role, such as the process for delivering a daily newspaper to a resident and the documentation of resident activity participation. Additionally, the AD had not attended any Quality Assurance or resident care plan meetings, indicating a lack of experience and training for the position. The facility had not had a consistent Activity Director since July, and the current AD was not qualified according to the job description, which required a Bachelor's degree in a relevant field and 2-3 years of experience. The Staffing Coordinator/Lead Certified Nursing Aide (SC/LCNA) was identified as the new AD, but she had not yet completed the necessary training or attended relevant meetings. This lack of a qualified and consistent Activities Director had the potential to affect all residents in the facility, as evidenced by the issues observed during the survey.
Plan Of Correction
1: The facility was successful in hiring a full-time certified U.S. FOIA (b) (6) with a start date of NU Exec Order 26.4b1. 2: All residents had the potential to be affected by the deficient practice. 3: The non-certified U.S. FOIA (b) (6) who is now a U.S. FOIA (b) (6) and the other activity staff were made aware of the hiring and were also educated that the certified AD will be responsible for completing the assessments. 4: The Administrator / designee will audit the new director's performance in general and specifically with completing the assessments accurately and timely. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025. Element One: Corrective Actions The facility hired a full-time U.S. FOIA (b) (6) who started employment on NJ Ex Order 26.4(b)(1). The facility had sister facility Certified Activity Directors review, revise as needed, and sign the most recent APR for each resident and then review and update the care plan as appropriate to ensure the assessment and care plan met the current interests, abilities, and preferences of each resident. Element Two: Identification of at-risk Residents All residents had the potential to be affected by this practice. Element Three: Systemic Change All residents and facility staff were informed of the hiring of a Certified Activity Director and all activity staff were re-educated about their role and that of the CAD for completing the assessment and updating care plans. Element Four: QAPI A sister facility CAD/designee will monitor the new certified activity director's performance through audits of 10% of APR assessments weekly for two weeks, then monthly for two months to ensure they are properly completed and signed, and the care plan has been updated. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025.
Deficiency in Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was observed in several residents, including one who had not seen a doctor regularly and only met their physician for the first time in four years. The medical records revealed late entries and inconsistencies in documentation, with some residents not having a documented History and Physical (H&P) within the required timeframe of 72 hours after admission. Another resident's records showed that the attending physician and nurse practitioner did not consistently alternate monthly visits, with missing progress notes for several months. Additionally, a resident admitted in October 2024 did not have any physician progress notes beyond the initial H&P, indicating a lack of regular physician oversight. Interviews with facility staff revealed uncertainty about the timelines for completing H&P documentation and the frequency of physician visits, further highlighting the facility's failure to adhere to regulatory requirements. The survey also uncovered instances where a physician documented a visit after a resident had been discharged, which was deemed inappropriate by the Medical Director. The facility's policy on physician visits was outdated and did not address the requirement for a physician visit upon admission. The survey team presented these findings to the facility's management, who did not provide additional information or refute the findings.
Plan Of Correction
Rose Mountain Care Center Facility ID: 315384 Survey Completion date: 12-12-2024 **F712 SS-F Physician visits - frequency/Timeliness/ALT NPP** **ELEMENT ONE: CORRECTIVE ACTION:** It is the practice of the Center to ensure that all residents are seen by a physician every 30 days for the first 90 days and at least every 60 days thereafter. An audit was completed by the Regional DON of the last 30 days of physician visits to ensure that all physician visits were completed by their primary designated physician within the required time frame. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** The standard was not met for residents #13, #33, #81, #83 and #85. Any resident which is assigned to a physician has the potential to be affected. **ELEMENT THREE: SYSTEMIC CHANGES:** All RN/LPNOs, Physicians and APNs were educated on the facilities policy regarding Physician visits. A certified letter was also sent to all Primary Physicians/APNs to ensure they received a copy of the policy. **QUALITY ASSURANCE:** To maintain and monitor ongoing compliance, Administrator/DON and or designee will audit monthly x 3 months, 10 random residents per unit and quarterly thereafter to ensure all primary physicians monthly visits are completed timely. Needed corrections will be addressed as they are discovered. Results will be reported to the QAPI team for review. Date of Compliance: 12/25/24
Failure to Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents were explicitly informed of and understood the arbitration agreement before signing it as part of the Admission Agreement. During a survey, it was revealed that the arbitration agreement was a mandatory part of the admission process, yet residents were not adequately informed about its implications. The Licensed Nursing Home Administrator (LNHA) and the President of Clinical Services acknowledged the use of arbitration agreements but indicated that they were managed by legal and not actively tracked. A review of the admission documents showed that the arbitration agreement was included as a mandatory section, with no option for residents to refuse it. During a resident council meeting, nine residents confirmed that they were unaware of what an arbitration agreement was and that it had not been explained to them, despite having signed it during the admission process. The Admission Director admitted that the arbitration agreement must be signed and that there was no list of residents who had signed or refused it. The surveyor's review of the electronic medical records further confirmed that the arbitration agreements were signed without proper explanation or understanding by the residents.
Plan Of Correction
12/25/24 Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 F847 SS-F Entering into Binding Arbitration Agreements Element One: Corrective Action The Admissions director signed and dated Exhibit 1. The facility immediately modified the agreement making it very clear to prospective residents that the agreement is completely voluntary and not a condition of admission or continued care at the facility. Element Two: Identification Of At Risk Residents All residents had the potential to be affected by the deficient practice. Element Three: Systemic Changes The U.S. FOIA (b) (6) was educated on explaining the agreement in a form and manner that the prospective resident or representative fully understands. Element Four: Quality Assurance The Administrator / designee will observe and monitor the Admissions director while explaining the admission agreement and arbitration agreement to residents / families and ensure that the Admissions Director explains what arbitration is and answers all questions they may have appropriately weekly x4 then monthly x2. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not have a clear process to identify residents on Enhanced Barrier Precautions (EBP), as there was no signage outside resident rooms indicating the type of Personal Protective Equipment (PPE) required. This was observed in 8 out of 8 EBP rooms, where only an orange dot sticker was used, which staff and visitors did not understand. Additionally, PPE bins were not readily available outside these rooms, and staff education on EBP was inadequate, as evidenced by a CNA who was unaware of the meaning of the orange dot. The survey also revealed that the facility failed to ensure proper hand hygiene practices among staff and residents. During a lunch meal observation, staff did not offer hand hygiene to residents entering the dining room from the smoking area, nor was hand hygiene performed by staff between serving meals and assisting residents. An LPN was observed handling multiple meal trays and assisting residents without performing hand hygiene, despite passing several alcohol-based hand rub dispensers. The facility's hand hygiene policy was not adhered to, as staff did not wash their hands before and after assisting residents with meals. Additional deficiencies included improper use of gloves by an Occupational Therapist, who wore gloves while walking through non-clinical areas and interacting with multiple residents without removing them. The facility also failed to maintain sanitary conditions for ice storage, as observed with undated ice containers and non-self-draining ice scoops. Furthermore, a CNA was observed using a cell phone and then assisting a resident with feeding without performing hand hygiene. These actions were contrary to the facility's infection control policies and CDC guidelines, highlighting a lack of adherence to established protocols for preventing the spread of infection.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 **F880 SS-F Infection Control and Prevention** **ELEMENT ONE: CORRECTIVE ACTION** All staff were in-serviced on the process and identification of residents on Enhanced Barrier Precautions (EBP) on 12/3/2024. The family/residents on EBP were educated on the precautions and why they are utilized. All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. The therapist who was observed in the hallway with gloves was inserviced immediately. The self-draining holders were installed in both units on 12/12/24. C.N.A. #2 was immediately re-in serviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-in serviced on sitting level with resident while assisting with meals. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** All residents on EBP have the potential to be affected. All residents that require hand hygiene prior to meals and require assistance with meals can be affected. All residents who receive ice have the potential to be affected. All residents can be affected by staff personal cell phone use. **ELEMENT THREE: SYSTEMIC CHANGES:** All staff were inserviced on the process and identification of residents on Enhanced Barrier Precautions (EBP) on 12/3/2024. The family/residents were educated on the precautions and why they are utilized. Moving forward EBP will be discussed for residents/family to remind them of the precautions and their purpose at the residents care plan meeting. All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. The U.S. FOIA (b) who was observed in the hallway with gloves was inserviced immediately. The self-draining holders were installed in both units on 12/12/24. C.N.A. #2 was immediately re-in serviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-in serviced on sitting level with resident while assisting with meals. A visual audit of meal pass was completed daily x 5 days starting 12/5/2024 at various mealtimes to assess any staff members that may not be practicing proper hand washing with residents and when passing out trays, as well as when assisting residents to eat, staff is sitting. The Director of Nursing/Licensed Nursing Home Administrator completed daily facility rounds at different times to audit staff personal cell phone use. **ELEMENT FOUR: QUALITY ASSURANCE:** The infection preventionist will audit the residents on EBP monthly x 3 months and then quarterly. Food Service Director/Dietician/Designee will visually audit (and document) dining services at various times/meals to assess staff compliance with resident and staff hand hygiene, and staff are sitting when assisting resident with meals, daily x 5, weekly x 4 and monthly x 3. Needed corrections will be addressed as they are discovered. Findings to be reported to the QAPI team for review and action as necessary. **DATE OF COMPLIANCE: 12/25/24**
Deficient Egress Door Accessibility
Penalty
Summary
The facility failed to ensure that two of its fifteen exit doors in the means of egress were readily accessible and free of obstructions or impediments to full instant use in case of fire or other emergencies. During an observation at approximately 8:54 AM, it was noted that the Kitchen designated exit door to the exit discharge was equipped with a sliding bolt lock on the egress side, which was engaged and could restrict emergency use of the door. This deficiency was observed in the presence of a surveyor. Additionally, at 11:35 AM, another observation revealed that the exit door located in the facility's Main dining room to the Courtyard had a keyed lockset on the egress side. The surveyor tested the door by locking and attempting to open it, but was unable to do so, confirming that the device could restrict emergency use of the exit. These deficiencies were confirmed during an interview with the surveyor at the time of the observations. The facility's representative was notified of these issues at the Life Safety Code survey exit conference.
Plan Of Correction
The lock from the dining room door to the courtyard was immediately removed and a passage way door lock was installed. The sliding bolt lock on the kitchen exit door was immediately removed. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on ensuring designated exit / Egress doors are readily accessible and free of all obstructions or impediments. Element Four: The Maintenance Director / designee will audit the courtyard and kitchen exit doors to ensure the exit access remains readily accessible and free of all obstructions or impediments monthly x3. Results to be reported to the QAPI team for review.
Failure to Provide Continuous Egress Illumination
Penalty
Summary
The facility failed to provide proper illumination for the means of egress, as required by NFPA 101: 2012 Edition, Sections 19.2.8 and 7.8. This deficiency was identified during observations and interviews conducted on December 3, 2024. Specifically, the Kitchen corridor, which is over 27 feet long leading to the exit door, lacked lighting when the switch was in the OFF position. Similarly, the East Hall and West Hall were observed to have no lighting when their respective switches were in the OFF position. These observations were confirmed by the staff present during the survey. The deficiency had the potential to affect all 83 residents in the facility. The facility's representatives were informed of this issue during the Life Safety Code survey exit conference on December 5, 2024.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K281 - (F) Illumination of means of Egress Element One: The lights in the kitchen corridor were immediately repaired to have continued lighting while the switch is in the OFF position. The lights in the East wing hall were immediately repaired to have continued lighting while the switch is in the OFF position. The lights in the West wing hall were immediately repaired to have continued lighting while the switch is in the OFF position. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements for continuous lighting even while the light switch is in the OFF position. Element Four: The Maintenance director / designee will audit the West wing, East wing, and the Kitchen corridors to ensure there is continuous lighting even while the light switch is in the OFF position monthly x3. Results will be reported to the QAPI team for review.
Deficiency in Hazardous Area Protection
Penalty
Summary
The facility was found to have a deficiency related to the protection of hazardous areas as per NFPA 101:2012 standards. During observations conducted between 8:15 AM and 3:45 PM, it was noted that the East and West wing shower rooms, which exceeded 55 square feet, were being used to store combustible materials. These rooms did not have self-closing devices on their doors, which is a requirement for hazardous areas to ensure they are properly enclosed and protected. The deficiency was confirmed through an interview with a representative present during the survey. The lack of self-closing devices on the doors of these shower rooms, which were used for storing combustibles, was identified as a failure to comply with the necessary fire safety standards. This issue had the potential to affect all 83 residents of the facility, as it compromised the fire safety measures required for hazardous areas.
Plan Of Correction
K321 - F Hazardous Areas - Enclosure Element One: A self closing device was immediately installed at the East and West wing shower rooms to protect the hazardous areas. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding self closing doors for hazardous areas. Element Four: The Maintenance director / designee will audit the self closing doors monthly x3 ensuring its properly functioning. Results will be reported to the QAPI team for review.
Kitchen Hood Suppression System Deficiency
Penalty
Summary
The facility failed to ensure that all five kitchen hood suppression systems had spray nozzle caps in place to protect the nozzles from grease clogs, as required by NFPA 101:2012 edition, Section 19.3.2.5.3*(10) and NFPA 17 and 96. This deficiency was observed during an inspection on December 4, 2024, at 9:08 AM, where it was noted that the nozzle blow-off caps were missing, leaving the nozzles vulnerable to grease buildup. This oversight had the potential to affect all 83 residents in the facility. The findings were confirmed and acknowledged by a representative during an interview, and the issue was discussed at the Life Safety Code exit conference on December 5, 2024.
Plan Of Correction
Completion Date: 12-25-2024 Element One: Our vendor was immediately called in for service. Upon arrival, they confirmed that there are in fact all 5 nozzle caps in place to protect from grease clogs. It is placed under the metal inside the nozzles (unlike the Ansul systems that have the orange visible caps.) Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding spray nozzle caps being in place to protect the nozzles from grease clogs. All 5 spray nozzle caps have been confirmed to be in place. Element Four: The Maintenance director / designee will audit the kitchen suppression system spray nozzle caps monthly x3 ensuring its in place and properly functioning. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Fire Alarm Manual Pull Stations Obstructed
Penalty
Summary
The facility failed to ensure that fire alarm manual pull stations were always accessible, as required by NFPA 72:2010 Edition, section 17.14.5. During an observation on December 4, 2024, it was noted that the manual fire alarm pull station in the small dining room by the exit door was obstructed by a dining table. Additionally, the manual fire alarm pull station in the physical therapy room by the exit door was blocked by four wheelchairs and a physical therapy bed. These obstructions were confirmed by a staff member at the time of the survey. This deficiency had the potential to affect all 83 residents in the facility.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K342 - (F) Fire Alarm System - Initiation Element One: The dining table blocking the fire alarm pull station at the exit door in the small dining room was immediately removed. The four wheelchairs and the Physical therapy bed blocking the fire alarm pull station in the Physical therapy room by the exit door were immediately removed. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding the fire alarm manual pull stations are always accessible without obstruction. All staff were trained and educated on the above topic as well as to report findings asap. Element Four: The Maintenance director / designee will audit the above mentioned fire alarm pull stations monthly x3 ensuring they remain accessible without obstruction. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Deficient Fire Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its fire sprinkler system in accordance with NFPA 101:2012 Edition and NFPA 25:2011 Edition standards. During observations, five out of eight kitchen fire sprinkler heads and three out of six laundry fire sprinkler heads were found to be green with a coating of oxidation, with the latter also covered in lint. Additionally, a documentation review revealed that there were no records of the fire sprinkler system backflow preventer test inspections. These deficiencies were confirmed and acknowledged by the facility representative during an interview and were discussed at the Life Safety Code exit conference.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K353 - (F) Sprinkler System - Maintenance and Testing Element One: The sprinkler heads in the kitchen and in the laundry area that were found to be green with a coating of oxidation and covered with lint were all replaced. The facility immediately reached out to our vendor to conduct the fire sprinkler system back flow preventer test. Element Two: This deficient practice had the potential to affect all residents. Element Three: The sprinkler heads in the kitchen and in the laundry area that were found to be green with a coating of oxidation were all replaced. The [R] was educated on the requirements related to maintaining the sprinkler heads as well as the annual back flow test requirements. Element Four: The maintenance director will audit all the fire sprinkler heads in the laundry and kitchen areas ensuring proper function and maintenance monthly x3. The maintenance director will also conduct a walkthrough of the facility sprinkler heads for visual corrosion. The maintenance director will also monitor and take necessary measures on all the sprinkler reports. Results will be reported to the QAPI team for review.
Deficient Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were able to resist the passage of smoke as required by NFPA 101: 2012 Edition. During a survey conducted on December 4, 2024, it was observed that the double doors between the West wing and the Main dining room had a gap between the meeting edges. Additionally, the door to room #9 had a gap on top. These deficiencies were identified during a tour conducted from 8:15 AM to 3:45 PM. The surveyor confirmed these observations through interviews conducted at the time of the inspection. The facility's representative was notified of these deficiencies during the Life Safety Code Survey exit conference on December 5, 2024. The failure to maintain corridor doors that resist the passage of smoke had the potential to affect all 83 residents in the facility.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K363 - (F) Corridor - Doors Element One: The gap on the double doors between the west wing and the dining room was immediately sealed leaving no room for smoke to pass through. The gap on door room #9 was immediately sealed. Element Two: This deficient practice had the potential to affect all 83 residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to corridor doors resisting the passage of smoke. Element Four: The maintenance director / designee will audit the above findings monthly x3 ensuring the doors are able to resist the passage of smoke. Results will be reported to the QAPI team for review.
Failure to Conduct Fire Drills with Varying Activation Types
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Section 19.7.1.4 through 19.7.1.7. This deficiency was identified during a documentation review and interview on December 4, 2024, where it was found that for 12 out of 12 fire drills conducted over the past year, there was no indication of the type of device used to activate the fire alarm system, such as pull, smoke, or page. This lack of documentation and variation in activation types had the potential to affect all 83 residents in the facility. The findings were verified by the surveyor at the time of the record review, and the facility's representative confirmed the absence of descriptive details in the fire drill reports. The issue was communicated to the facility's representative during the Life Safety Code survey exit conference on December 5, 2024.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K712 - (F) Fire Drills Element One: The facility immediately modified the fire drill reports to include the type of device used to activate the fire alarm system (pull, page, and smoke). Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to conducting fire drills with varying activation types. Element Four: The maintenance director / designee will audit the newly modified fire drill reports ensuring they are being followed through with an indication of an activation type monthly x3. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Deficiency in Electrical Equipment Maintenance and Testing
Penalty
Summary
The facility failed to comply with the requirements for testing and maintenance of patient-care related electrical equipment (PCREE) as outlined in NFPA 99: 2012 Edition. During observations conducted over three days, it was noted that none of the fixed and portable PCREE had inspection stickers, indicating a lack of documented inspections. This deficiency was confirmed through interviews with facility representatives, who acknowledged the absence of a policy for the maintenance and testing of PCREE. Additionally, a review of the facility's documentation revealed that there was no existing policy regarding the maintenance and testing of PCREE. This lack of policy and documentation was confirmed by facility representatives during the survey. The deficiency had the potential to affect all 83 residents in the facility, as it was noted during the Life Safety Code survey exit conference.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K921 - (F) Electrical Equipment - Testing and Maintenance Element One: The Maintenance director immediately conducted maintenance on the electrical equipment, as well as logging the inspection and the repairs if necessary. The facility immediately implemented a policy related to patient care related electrical equipment ensuring inspections annually and as needed. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to K921 PCREE, including conducting maintenance of electrical equipment and maintaining a record and log of all required tests and repairs if necessary.
Failure to Provide Dignified Meal Service and Assistance
Penalty
Summary
The facility failed to provide meals in a dignified and homelike manner, as observed in the main dining room and resident units. On multiple occasions, staff placed meal trays in front of residents without removing food items from the trays and used the tray lids as garbage receptacles, leaving trash in front of the residents. This practice was confirmed by the Registered Dietitian and the Food Service Director, who acknowledged that it was not dignified and that carts should be used for dirty items. Additionally, the facility failed to provide meal assistance in a dignified manner. A CNA was observed using a cell phone while assisting a resident with their meal, neglecting hand hygiene, which is crucial for infection control. Another staff member was observed feeding a resident while standing, contrary to the facility's policy that requires staff to be seated for safety reasons. These actions were acknowledged by the staff and the Director of Nursing as inappropriate and not in line with the facility's standards for resident care.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 F550 SS E **ELEMENT ONE: CORRECTIVE ACTION** All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. C.N.A. #2 was immediately re-inserviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-inserviced on sitting level with resident while assisting with meals. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** All residents that require hand hygiene prior to meals and require assistance with meals can be affected. All residents can be affected by staff personal cell phone use. **ELEMENT THREE: SYSTEMIC CHANGES:** All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. All staff were re-inserviced on zero tolerance on personal use of cell phones. All staff that assist residents with eating were re-inserviced on sitting level with resident while assisting with meals. A visual audit of meal pass was completed daily x 5 days starting 12/5/2024 at various mealtimes to assess any staff members that may not be practicing proper hand washing with residents and when passing out trays, as well as when assisting residents to eat, staff is sitting. The Director of Nursing/Licensed Nursing Home Administrator completed daily facility rounds at different times to audit staff personal cell phone use. **ELEMENT FOUR: QUALITY ASSURANCE:** Food Service Director/Dietician/Designee will visually audit (and document) dining services at various times/meals to assess staff compliance with resident and staff hand hygiene, and staff are sitting when assisting resident with meals, daily x 5 days, weekly x 4 and monthly x 4. Needed corrections will be addressed as they are discovered. Findings to be reported to QAPI team for review and action as necessary. DATE OF COMPLIANCE: 12/25/24
Inadequate Supervision and Smoking Policy Deficiencies
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions for a cognitively impaired resident at high risk for falls, resulting in multiple falls with injuries. Resident #39, who had a severe cognitive impairment and a history of falls, was observed without proper supervision and necessary safety measures, such as leg rests on their wheelchair. Despite being identified as a high fall risk, the resident experienced numerous falls over several months, with injuries including skin tears, bruises, and head trauma. The facility's fall risk management policy was not effectively implemented, as interventions were not consistently reassessed or revised following each fall. The facility also failed to develop and implement a consistent smoking process to prevent potential injury or fire for residents who smoked. Five residents were identified as being affected by this deficiency. The facility lacked a clear smoking policy, and staff were not adequately informed about the smoking process, including the supervision of residents while smoking and the secure storage of cigarettes and lighters. Observations revealed that residents had access to cigarettes and lighters, and there was no consistent use of protective devices, such as smoking aprons, for residents who required them. Interviews with staff and residents highlighted a lack of awareness and understanding of the smoking procedures, with some staff unable to provide information on where smoking supplies were kept or which residents required additional safety measures. The facility's failure to conduct thorough investigations and root cause analyses for falls, as well as the absence of a comprehensive smoking policy, contributed to the deficiencies identified by the surveyors.
Plan Of Correction
Survey Completion Date: 12/12/24 F689 SS - E (Free of Accident Hazards/Supervision/Devices) Element One: The facility's practice is to ensure that the resident's environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. An audit was completed immediately on all residents within the last month to ensure an intervention was in place and on the care plan. Education provided to staff to ensure a thorough investigation is conducted when a fall occurs. It is the practice of the facility to implement a smoking process to ensure the safety of residents to prevent injury or fire. Education provided immediately for the residents and staff on the smoking policy and process. Element Two: This standard was not met for Resident #39, #11, #33, #54, #63, and #388. All residents who have had an accident and/or smoke have the potential to be affected by this deficient practice. Element Three: The Administrator/Designee, DON/Designee, and Unit Managers/Designee met to review the incident and accident report procedure. All incident and accident reports will be reviewed with the Interdisciplinary team within 72 hours post fall/accident to ensure immediate interventions that were implemented are addressed and updated on the care plan, as well as any additional interventions needed. In addition, 6 residents with a PMH of multiple falls and poor cognition have been identified as a focus group to help decrease falls and injury with specialized diversional activities and groups. The Administrator met with residents and staff regarding the smoking process and implementation of a smoking binder. The residents were explained the importance of smoking safety and following the rules. They were educated about not holding their cigarettes and lighters as well as the designated smoking times. The residents were also educated on the facility's safety procedures regarding smoking. Element Four: An audit of two charts will be conducted weekly by the DON/Designee for three months to ensure residents with fall(s) have appropriate interventions in place and interventions are on the care plan. Results are to be reported to the QAPI team for review. The Administrator/Designee will complete observation of the smoking process monthly x 3 to ensure compliance. Date of compliance: 12/25/2024
Deficiency in Facility-Wide Assessment for Smoking and Cultural Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that adequately addressed the needs of residents who smoke and the cultural needs of the Asian American population. The deficiency was identified through observations, interviews, and document reviews. The Licensed Nursing Home Administrator (LNHA) provided smoking hours and a list of residents who smoke, but the facility's smoking policy was insufficiently documented as it was only represented by a 'Smoking Rules and Agreement' document. Staff interviews revealed a lack of clarity and consistency in the smoking process, with discrepancies in who was responsible for holding residents' cigarettes and lighters. Additionally, there was confusion about the existence and location of a list of residents requiring smoking aprons, indicating a lack of staff knowledge and a formalized smoking policy. The facility also failed to address the cultural needs of its Asian American residents. A family member of a resident expressed concern about the lack of a daily Korean newspaper, which was supposed to be provided. Although the facility had menus and activity calendars in Chinese, there was no clear process or responsibility for ensuring the delivery of culturally appropriate materials, such as the Korean newspaper. The Activities Director was aware of the resident's needs but was unsure who was responsible for providing the newspaper. The facility assessment tool did not adequately address these cultural needs, highlighting a gap in the facility's ability to provide culturally competent care.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 **F838 SS-E Facility Assessment** **Element One:** All staff were immediately educated on the smoking policy and process. A newspaper was immediately ordered for the resident. The facility assessment was updated ensuring all resources necessary for the care of the residents are documented. **Element Two:** All residents who smoke and the residents from the Asian population had the potential to be affected by the deficient practice. **Element Three:** All staff were educated regarding the facility's smoking policy and process. The activity staff and admissions staff were educated to inform the administrator if there are any delays in the newspaper being delivered. The facility Administrator was educated by the Regional Administrator on the facility assessment requirements and ensuring all resources necessary for the care of the residents are documented. The residents were explained the importance of smoking safety and following the rules. They were educated about not holding their cigarettes and lighters as well as the designated smoking times. The residents were also educated on the facility's smoking policy and process. **Element Four:** The Administrator/designee will continue to monitor the smoking program to ensure safety. The Administrator will review the facility assessment monthly for 3 months, then quarterly, as well as updating it on an as-needed basis. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Deficient Corner Guard Safety in Dining Room
Penalty
Summary
The facility failed to ensure that corner guards were free from sharp edges and lacked protective endcaps, which could potentially affect all residents on the east wing. During an observation conducted at 2:27 PM with the Maintenance Director (MD), it was noted that two metal corner guards by the handrails in the main dining room had sharp edges and no protective endcaps installed to prevent injury. The MD confirmed these findings during the observation. The facility's Administrator was informed of this deficient practice during the Life Safety Code survey exit conference.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 F921 SS-E Safe/Functional/Sanitary/Comfortable Environment Element One: On 12-4-24, the Maintenance Director installed protective endcaps to the corner guards by the handrails in the main dining room. Element Two: All residents had the potential to be affected by this deficient practice. Element Three: The U.S. FOIA (b) (6) was educated to ensure corner guards are free from sharp edges to prevent an injury. Element Four: The Maintenance Director/Designee will audit the handrails ensuring protective endcaps are installed and properly functioning, weekly x4 then monthly x2 months. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Obstructed Exit Door in West Wing
Penalty
Summary
The facility failed to maintain an unobstructed means of egress as required by NFPA 101:2012 Edition, Section 7.1.10.1. During an observation conducted on December 3, 2024, it was noted that one of the 15 exit doors, specifically the small dining room designated exit door, was blocked by a chair. This obstruction was identified at approximately 11:15 AM and confirmed through an interview conducted at the time of the observation. The deficiency had the potential to affect all 14 residents residing in the West Wing of the facility. The facility's representative was informed of this issue during the Life Safety Code survey exit conference on December 5, 2024.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K211 (E) Means of Egress Element One: The chair blocking the designated exit door was immediately removed and the door was left free of obstructions. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding means of egress is continuously maintained free of all obstructions to full use in case of emergency. Element Four: The Maintenance Director / designee will audit the Designated exit doors to continue to be free of obstructions weekly x4 then monthly x2. Findings to be reported to the QAPI team for review. Completion Date: 12-25-2024
Exit Signage Deficiency in Kitchen Area
Penalty
Summary
The facility failed to ensure that exit and directional exit signs were provided and marked by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This deficiency was observed during a survey on December 4, 2024, at 8:59 AM, when it was noted that the kitchen exit access was not equipped with an exit or directional sign. This oversight had the potential to affect approximately 18 residents. The observation was confirmed during an interview at the time of the survey, and the facility's representative was notified of the deficient practice during the Life Safety Code Survey exit conference on December 5, 2024.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K293 - E Exit Signage Element One: An exit sign was immediately installed at the kitchen back exit access. Element Two: This deficient practice had the potential to affect approximately 18 residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding proper exit signage. Element Four: The maintenance director / designee will audit the exit sign at that location monthly x3 ensuring its properly functioning. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Deficiency in Corridor Wall Construction
Penalty
Summary
The facility failed to ensure that the corridor walls were constructed to resist the passage of smoke as required by NFPA 101: 2012 Edition, Section 19.3.6.2 and 19.3.2.7. This deficiency was identified during an observation on December 4, 2024, at 9:41 AM, when a hole was found in the wall above the laundry corridor door in the ceiling of the East Wing. This observation was confirmed by a staff member present at the time. The issue was communicated to the facility's representative during the Life Safety Code exit conference on December 5, 2024, at 2:45 PM.
Plan Of Correction
Completion Date: 12-25-2024 Facility ID: 3145384 Survey completion date: 12-12-2024 K362 - E Corridors - Construction of Walls Element One: The hole in the wall above the laundry corridor door in the ceiling was immediately sealed. Element Two: This deficient practice had the potential to affect all East Wing residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements related to ensuring the corridor walls are constructed to resist the passage of smoke. Element Four: The Maintenance director / designee will audit the above findings monthly x3 to ensure the hole remains sealed and passage of smoke is resisted. Results will be reported to the QAPI team for review.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure proper separation of empty and full portable oxygen cylinder tanks, as required by NFPA 101: 2012 Edition, Section 19.3.2.4,8.7 and NFPA 99. During an observation conducted on December 4, 2024, it was noted that five out of twenty full portable oxygen cylinder tanks were incorrectly stored in a rack designated for empty tanks only. This observation was confirmed by a staff member at the time of the inspection. The deficiency was identified in the oxygen storage closet, which had the potential to affect all 31 residents in the east wing of the facility. The issue was brought to the attention of the facility's representative during the Life Safety Code exit conference on December 5, 2024. The failure to properly segregate empty and full oxygen tanks could lead to confusion and potential safety hazards, although specific consequences were not detailed in the report.
Plan Of Correction
Element Four: The maintenance director / designee will audit the patients equipment ensuring the policy is being followed through monthly x3. (policy including annual inspections and as needed, new admissions, new equipment) Results will be reported to the QAPI team for review. Completion Date: 12-25-2024 Rose Mountain Care Center Facility ID: 3145384 Survey completion date 12-12-2024 K923 - (E) Gas Equipment - Cylinder and Container Storage Element One: The 5 full portable oxygen cylinder tanks were immediately removed from the Empty tanks rack in the oxygen storage closet. Element Two: This deficient practice had the potential to affect all 31 residents on east wing. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding empty portable oxygen cylinder tanks are separated from full portable oxygen cylinder tanks. Element Four: The maintenance director / designee will audit the oxygen tanks ensuring they are kept separate monthly x3. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Medication Administration in Dining Room
Penalty
Summary
The facility failed to provide a homelike environment by administering medications to a resident in the dining room during breakfast. A Registered Nurse (RN) administered medications to a resident who was seated alone at a table in the main dining area, preparing to eat breakfast. This action was observed by a surveyor, who noted that there were multiple other residents present in the dining area at the time. The RN acknowledged that the resident was not care planned to have medications administered in the dining room and admitted fault for the oversight. The resident involved had been admitted to the facility with diagnoses including psychotic disturbance, mood disturbance, and anxiety, and had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 06 out of 15. The medications administered, which included calcium, magnesium, and vitamin D supplements, were not ordered to be given with meals. The facility's medication administration policy did not address the administration of medications in the dining room, and the Director of Nursing acknowledged that the practice was incorrect when informed by the surveyor.
Plan Of Correction
Rose Mountain Care Center Facility ID: 315384 Survey Completion date: 12-12-2024 F584 SS-D Safe/Clean/Comfortable/Homelike Environment ELEMENT ONE: It is the practice of the Center to ensure that all residents reside in a safe, clean, homelike environment. The nurse (RN #1) that administered the medication in the dining room to resident #83 was immediately educated on ensuring medication is not administered in the dining room to maintain resident privacy. ELEMENT TWO: The standard was not met for resident #83. All residents who receive medication have the potential to be affected by this deficient practice. ELEMENT THREE: All RN/LPNs were educated on the facilities policy for medication administration, including not administering medication in the dining room. The nursing education was completed by 12/25/24. QUALITY ASSURANCE: To maintain and monitor ongoing compliance, 3 nurses will be med passed monthly by the pharmacy consultant/DON/ADON. In addition, DON or their designee will conduct observation of the dining room weekly x 4 weeks, then monthly x 3 months, then quarterly. Needed corrections will be addressed as they are discovered. Findings to be reported monthly x 12 to Quality Assurance Performance Improvement team for review and action as necessary. Completion date: 12-25-2024
Failure to Provide Adequate Nail Care to Residents
Penalty
Summary
The facility failed to provide adequate nail care to residents who were unable to perform activities of daily living independently. This deficiency was observed in two residents, both of whom had long, jagged nails with a brown substance underneath. One resident, who was severely cognitively impaired and had physical limitations due to a cerebrovascular accident, was observed multiple times with untrimmed nails and reported that staff did not cut their nails. The resident required maximal assistance with personal hygiene, as documented in their care plan. Another resident, who was cognitively intact but had general weakness and lack of coordination, also had long, unkempt nails. This resident expressed dissatisfaction with the state of their nails and mentioned that they had to request staff assistance for nail care. The care plan for this resident indicated a need for maximal assistance with personal hygiene, yet the resident's nails remained untrimmed during the surveyor's observations. Interviews with facility staff, including CNAs and an LPN, revealed inconsistencies in the process for providing nail care. Staff indicated that nail care was part of morning care and required nurse approval before trimming. However, documentation of nail care was not readily available, and staff acknowledged the importance of nail care for hygiene and safety. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services, including grooming, but this was not consistently implemented for the residents in question.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 F677 SS D **Element One - Corrective Action:** Residents #19 and #33 had NEXTRY 20-40 completed on 12/12/24. **Element Two - Identification of at Risk Residents:** All residents that are dependent on their activities of daily living (ADL) are at risk. A facility-wide audit was completed on all dependent residents to ascertain grooming including nails on 12/12/24. **Element Three - Systemic Changes:** All clinical staff were re-educated on ensuring residents are groomed, including nail care on 12/12/24. **Quality Assurance:** To maintain and monitor ongoing compliance, Unit Managers/designees will audit 3 dependent residents per day per unit daily x 5 days, weekly x 4 weeks, and monthly x 4 months to ensure residents' hygiene including nail care is completed. Needed corrections will be addressed as they are discovered. Findings to be reported to the Quality Assurance Performance Improvement team for review and action as necessary. **Date of Completion:** 12/25/24
Deficiency in Respiratory Equipment Storage and Labeling
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored and dated according to professional standards for a resident requiring respiratory care. During an initial tour, a surveyor observed that a resident was using oxygen at 4 liters per minute via a nasal cannula, which was not dated. On a subsequent observation, the nasal cannula was found placed on top of the oxygen concentrator without being stored in a plastic bag, contrary to facility policy. Interviews with the Licensed Practical Nurse and Unit Manager confirmed that the nasal cannula should be changed weekly, dated, and stored in a labeled plastic bag when not in use for infection control purposes. The resident involved had a medical history including chronic obstructive pulmonary disease, anemia, depression, and anxiety, and was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan indicated a continuous oxygen requirement of 4 liters per minute via nasal cannula, but did not include interventions for labeling and proper storage of the nasal cannula. The facility's policy on oxygen administration was undated and did not address labeling or proper storage of equipment. The surveyor's findings were presented to the facility's management, who did not provide additional information or refute the findings.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 F695 SS D **Element One - Corrective Action:** Resident #36 [R] dated and placed in a labeled plastic bag. **Element Two - Identification of At-Risk Residents:** All residents that utilize oxygen are at risk. An audit was completed on all residents utilizing oxygen to ascertain proper labeling and storage when not in use on 12/12/24. **Element Three - Systemic Changes:** All clinical staff were re-educated on labeling oxygen tubing with date and placing tubing in labeled, dated, plastic bags when not in use. **Quality Assurance:** To maintain and monitor ongoing compliance, Unit Managers/designees will audit all residents utilizing oxygen weekly x4 and monthly x3 to ensure all oxygen tubing is dated and when not in use is placed in labeled, dated plastic bag. Needed corrections will be addressed as they are discovered. Findings to be reported to Quality Assurance Performance Improvement team for review and action as necessary. Date of Completion: 12/25/24
Failure of Self-Closing Door in Hazardous Area
Penalty
Summary
The facility failed to ensure that a self-closing door to a hazardous area was capable of automatically closing upon the activation of the facility's fire alarm system. This deficiency was observed during a survey on December 4, 2024, when the surveyor noted that the door to the laundry dryer room was held open with a rope tied around the door handle to a storage rack behind the door. This practice had the potential to affect limited residents in the area. The observation was confirmed in an interview at the time, and the facility's representatives were notified of the deficient practice during the Life Safety Code survey exit conference on December 5, 2024.
Plan Of Correction
Completion Date: 12-25-2024 Rose Mountain Care Center Facility ID: 3145384 Survey completion date 12-12-2024 K223 - (D) Doors with self closing Devices Element One: The rope tied around the door handle that held the laundry / dryer room open was immediately cut and removed. Element Two: This deficient practice had the potential to affect limited residents in the area. Element Three: The U.S. FOIA (b) (6) as well as the laundry staff were educated on the requirements regarding self automatic closing doors. Element Four: The Maintenance director will audit the laundry / dryer room door weekly x4 then monthly x2 to ensure proper automatic and self closing. Results will be reported to the QAPI team for review.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
