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 The facility's policy was outdated and did not address admission visit requirements.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 schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
