Raritan Post Acute and Healthcare Center

Inspectors wroteComplaint #: 3054992 Based on interview and record review on 7/23/26 and 7/24/26, it was determined that the facility failed to follow acceptable standards of clinical practice when a nurse obtained Resident #3's blood sugar without a physician order. This deficient practice was identified for one of two residents reviewed (Resident #3) for medication administration and was evidenced by the following:Resident #3 was not at the facility at the time of the survey. A closed record review was completed. A review of the admission Record face sheet (an admission summary) revealed Resident #3 was admitted to the facility with diagnoses which included but were not limited to: spinal stenosis (the narrowing of one or more spaces within your spinal canal), scoliosis (a side-to-side curve of the spine), and hypertension. [...]

Inspectors wroteCOMPLAINT #2976477 Based on interviews, review of medical records and other pertinent facility documentation on 7/23/26 and 7/24/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to document details related to the transfer of Resident #1 including: a) contacting the treating provider and the family, and b) entering an order obtained to start intravenous fluids. This deficient practice was identified for 1 of 2 residents reviewed for discharges (Resident #1) and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed medical record review was conducted. [...]

Inspectors wroteBased on record review, interview, review of facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. The facility further failed to ensure staff wore the proper personal protective equipment (PPE) when providing care to one (Resident (R)3) out of one reviewed for proper PPE being donned (put on) out of a total sample of 35 residents. This had the potential for an increase in infections for all the residents of the facility.

Inspectors wroteBased on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure five of five residents (Resident (R) 116, R21, R114, R121, and R26) out of 35 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer four of five residents (Resident (R) 21, R26, R114, and R121) reviewed for flu/pneumonia vaccinations out of 35 sample residents and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for this resident to contract pneumonia.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one resident (R 116) out of one reviewed for accommodations of needs, out of a survey sample of 35, was provided and assessed for an appropriate wheelchair. This had the potential for R116 not to be able to propel herself and have to wait for staff assistance.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure an open window was covered with a screen for one of 33 Initial Pool residents (Resident (R) 73) whose rooms were observed. This failure had potential to increase pest activity and risk of infection for R73.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure adequate monitoring for the use of psychotropic medications for two of five residents (Resident (R) 8 and R10) reviewed for unnecessary medications out of a total sample of 35 residents. For R8, behaviors were not identified for monitoring of medication effectiveness and failed to ensure ongoing assessment for adverse side effects of medication for R10. These failures had the potential to contribute to unnecessary psychotropic medication use and risk for adverse side effects of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident (R)7) reviewed for a hospital transfer out of a total sample of 35 was provided with a written transfer notice. This failure has the potential to affect all residents by not having knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR), Level II Determination recommendations were developed and implemented for one of four residents (Resident (R) 73) reviewed for PASARR out of a total sample of 35 residents. This failure had the potential to lead to continued or worsening behavioral symptoms without intervention.

Inspectors wroteBased on observation, record review, review of facility policy, and interview, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for two of 35 sampled residents (Resident (R)116 and R56) reviewed for care plans. The failure had the potential for the residents to have unmet care needs.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure one of five residents reviewed for unnecessary medications (Resident (R) 12) received antibiotic eye medication as ordered and failed to notify the physician of missed doses of the medication out of a total sample of 35 residents. This failure had the potential to delay healing or contribute to worsening infection and pain.

Inspectors wroteBased on interview, record review, facility document review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure pressure ulcer prevention measures were in place for two residents out of four reviewed (Resident (R) 116 and R3) for pressure ulcers out of a total sample of 35 residents. This had the potential for the residents to develop pressure ulcers and/or worsen current pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure interventions were in place for one of one resident (Resident (R) 56) out of two residents reviewed for range of motion (ROM) out of a total sample of 35 residents. This had the potential for the residents contracture to worsen.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to provide respiratory care per standards of practice for one of two sampled residents (Resident (R)142) reviewed for respiratory care out of a total sample of 35 residents. Specifically, the facility failed to ensure respiratory equipment (Ambu-bag) was accessible. The failure had the potential for the resident to have respiratory issues and unmet care needs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the physician responded to the consultant pharmacist medication reviews for one resident (Resident (R7) out of five reviewed for unnecessary medications in a total sample of 35 residents. This failure placed the resident at risk of receiving unnecessary medications.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure the medical record was complete and accurate for three residents (Residents (R)7, R64, and R70) out of total sample of 35 residents reviewed. This failure had the potential for the resident's health status not be accurate, complete, and possibly create unmet care needs.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure a potential allegation of physical abuse by staff was reported timely to the Director of Nursing (DON) and to the State Survey Agency (SSA) when a resident sustained an injury during a transfer from the wheelchair to the bed for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused. Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to protect a resident during an investigation of a potential allegation of physical abuse by staff when a resident sustained an injury during a transfer from the wheelchair to the bed by two nursing aides for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused. Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. [...]

Inspectors wroteBased on interviews and record review, the facility failed to prevent an injury during an improper transfer for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of residents experiencing injuries during transfers. Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure nursing staff received ordered medications from the pharmacy for residents for one out of 22 sample residents (Resident (R) 16). This failure had the potential for residents not to receive their ordered medications and could result in negative outcomes. Review of the facility's policy titled Accepting Delivery of Medications, revised November 2022, revealed Policy Statement 1. All staff follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications are brought to the attention of the pharmacist and director of nursing services. Policy Interpretation and Implementation 1. A nurse accepts each medication delivery. 2. Before signing to accept the delivery, the nurse reconciles the medications in the package with the delivery ticket/order receipt. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure nursing staff stored medications not administered to residents in the locked medication cart not at bedside for one out of 22 sampled residents (Resident (R) 16) observed during the medication administration. This failure had the potential for wandering residents to self-administer other residents' medications. Review of R16's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed he/she was admitted in 08/24 with a diagnosis of epilepsy. [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure staff perform hand hygiene after serving and assisting residents with setting up their meals for one out of 22 sample residents (Resident (R) 22) observed during the lunch meal. This failure had the potential to cause cross contamination and spread germs to vulnerable residents. During an observation on the fourth floor in the common area on 08/19/25 at 12:19 PM, Recreation Aide (RA) 2 placed R21's meal tray on the table, removed the plate cover, lids on the cups, and then used the fork to cut up the food without performing hand hygiene afterward. Next, RA2 walked to the food cart and picked up another food tray and placed it in front of R22. [...]

Inspectors wroteComplaint #: 186850 Based on interviews and medical record review (MR) and other pertinent facility documentation on 6/4/25, it was determined that facility failed to thoroughly investigate an allegation of abuse for 1 of 4 residents (Resident #4). This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #4 was admitted with diagnoses including but not limited to: Visual Loss, Presence of Artificial Eye, Unspecified Hearing Loss, and Anxiety Disorder. A review of the Minimum Data Set (MDS), an assessment tool dated 3/30/25, revealed that Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #4 was cognitively intact, and was Supervision/Touch assistance with ADLs (Activities of Daily Living), independent with transfers and continent of bowel and bladder. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to identify and prevent worsening of a contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) for one of four residents (Resident #13) reviewed for position and mobility. This deficient practice was evidenced by: On 03/25/24 at 10:28 AM, during the initial tour of the 3rd floor, the surveyor observed Resident #13 in bed. The resident's right hand was closed from the middle finger to the pinky finger and the index finger was pointing out. When asked by the surveyor, Resident #13 stated that they were not able to turn or open his/her right (R) hand/fist or extend his/her R arm. [...]

Inspectors wroteBased on observations, interviews, and pertinent facility documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 3/25/24 at 09:00 AM, the survey team entered the facility and was made aware by the Licensed Nursing Home Administrator (LNHA) that the facility was licensed for 180 beds and the facility census was 123 (the number of residents who currently resided at the facility). On 03/25/24 at 10:10 AM, the surveyor toured the kitchen with the facility's Food Service Director (FSD) and the Regional FSD. During the initial tour, the surveyor was escorted to a storage room which contained the emergency water and food supply. [...]

Inspectors wroteBased on observations, interviews, record review and other facility documentation, it was determined that the facility failed to complete weekly skin evaluations for 3 of 3 residents (Resident #5, #49 and #86) reviewed for pressure ulcers. This deficient practice was evidenced by the following: 1. On 03/25/24 at 11:10 AM, during initial tour of the 4th floor, the surveyor observed Resident #5 in bed. The surveyor attempted to interview the resident but he/she was unable to answer the surveyor's questions. A review of Resident #5's Electronic Medical Record (EMR) revealed the following: According to the admission Record, Resident #5 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) staff followed a Physician Orders (PO) for the administration of an insulin medication for 1 of 1 resident (Resident #96) reviewed for the management of insulin, b.) medications were observed as accurately and timely administered to one (1) of five (5) residents, (Resident #54) reviewed for medication administration, and c.) to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS) located on the 2nd floor nursing unit. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to provide nail care to a resident who required extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice was identified for 1 of 7 residents (Resident #13) reviewed for ADL care. The deficient practice was evidenced by the following: On 03/25/24 at 10:28 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed, with his/her right hand from middle finger to pinky finger closed into a fist and the index finger pointing out with an elongated thickened non-smooth nail. The surveyor was not able to observe the resident's right hand nails from the middle finger to pinky finger. Resident #13's left hand had long nails on the thumb, index finger and the pinky finger. The third and fourth fingernails had jagged appearance. [...]

Inspectors wroteBased on observation, interviews, record review and review of other relevant facility documentation, it was determined that the facility failed to obtain and carry out an order to discontinue a Peripheral Intravenous line (IV [In a vein]) and to maintain the site according to professional standards of practice. The deficient practice was identified for one of one residents (Resident #326) reviewed for IV therapy. The deficient practice was evidenced by the following: On 3/26/24 at 11:43 AM, the surveyor observed the resident's left forearm (region of the upper limb between the elbow and the wrist) with an IV line in place. The IV line was covered by a transparent dressing. The tape holding the dressing to the skin was peeling off. The surveyor noted the IV line was not dated or initialed. There were no medications or fluids infusing through the IV line during this observation. [...]

Inspectors wroteNJ #159787 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of foods served to the residents. This deficient practice was identified for 5 of 5 residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 04/05/24 for 1 of 3 nursing units (2nd Floor unit) tested for food temperatures and was evidenced by the following: On 03/27/24 at 10:51 AM, the surveyor met with five residents for a resident council meeting. Three out of five residents resided on the 3rd floor. Two out of five residents resided on the 4th floor. Five of five residents agreed that the food trays were not warm. [...]

Inspectors wroteBased on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure foods were provided in accordance with physician's orders and resident preferences identified in their plan of care. This deficient practice was identified for 2 of 4 residents reviewed for nutrition (Resident #114 and #120). This deficient practice was evidenced by the following: 1. On 3/27/24 at 10:57 AM, the surveyor observed Resident #114 seated in a wheelchair at a table in the dining area drinking water. On 3/28/24 at 12:18 PM, the surveyor observed the resident's lunch tray. The meal ticket indicated the tray items should have included four ounces (oz.) of red bean chili, a creamy peanut butter and jelly sandwich, a ½ cup of Fortified mashed potatoes, a ½ cup of green peas, one piece of cornbread, six oz. [...]

Inspectors wroteBased on facility staff interviews and review of other facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with the facility job description, Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to complete weekly weights and consistently monitor a resident with a history of weight loss. This deficient practice was identified for 1 of 6 residents (Resident #15) reviewed for nutrition and was evidenced by the following: On 09/19/22 at 12:37 PM, the surveyor observed Resident #15 sitting up in bed with a lunch tray positioned on the overbed table. The resident was pleasantly confused and was observed feeding self without difficulty. The surveyor observed that the resident ate approximately 25% of the lunch meal. When interviewed, the resident stated the meal was alright and that he/she did not want anything else to eat. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) document the size and type of resident's tracheostomy tube on the resident's Care Plan (CP) and b.) obtain a physician order for oxygen and include oxygen use and care on a CP. This deficient practice was identified for 2 of 3 residents (Residents #89 and #120) reviewed for respiratory care and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor and manage a resident's pain consistent with professional standards of practice or develop a comprehensive person-centered care plan for 1 of 4 residents who exhibited signs and symptoms of pain, Resident # 55. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) coordinate medication administration times and accuchecks (blood sugar monitoring) with scheduled renal dialysis days, b.) identify and monitor the dialysis access site, c.) consistently maintain ongoing complete communication notes between the facility and the dialysis center, and d.) implement a person-centered care plan for a resident on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by not clarifying medication orders in timely manner for 1 of 4 residents (Resident #127) reviewed for tube feeding. This deficient practice was evidenced by the following: On 09/19/22 at 12:18 PM, the surveyor observed Resident #127 in bed with the head of bed elevated. The resident had no facial grimacing and showed no signs or symptoms of distress or discomfort. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 09/16/22 at 10:00 AM, the surveyor, in the presence of the Food Service Director (FSD) and Ambassador of Dietary Services (ADS), observed the following during the kitchen tour: 1. A food service worker (FSW) was observed walking in the kitchen with a blue baseball cap with hair sticking out the back. When interviewed, the FSD stated the FSW's hair should be covered. 2. A stack of uncovered coffee filters was stored directly on the shelf and a second stack of uncovered coffee filters was stored in a bin containing coffee packets. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) utilize an infection assessment tool for 4 of 4 residents (Resident #124, #127, #487, and #488) prescribed antibiotic medications in the facility, and b.) monitor and review actual antibiotic use according to the facility's Antibiotic Stewardship Program. This deficient practice was evidenced by the following: Review of the Antibiotic Stewardship Meeting Minutes, dated 07/26/22, provided by the Infection Preventionist (IP), revealed a section titled Discussion with the following listed below it: Antibiotic Stewardship Program Goals, Antibiotic Use Reports, Antibiotic Resistance Reports, Newly Diagnosed Infection Report, C Difficile Report (Outcome Measure Review), and Antibiotic Prescription Review. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set, an assessment tool used to facility the management of care, to identify that the resident was on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN), who was assigned to Resident # 107. The LPN stated that the resident went out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 1 of 4 residents (Resident #58) reviewed for pain. This deficient practice was evidenced by the following: On 09/16/22 at 10:03 AM, the surveyor observed Resident #58 in bed with the head of the bed elevated. When interviewed at that time, Resident #58 stated that he/she was always in pain. According to the admission Record, Resident #58 was admitted with diagnoses that included, but were not limited to, aftercare following explantation (revision) of knee joint prosthesis, infection, and inflammatory reaction due to internal left knee, and pain in the left knee. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently document in the Medication Administration Record (MAR). This deficient practice was identified for 1 of 5 residents (Resident #58) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that staff delivered meal trays to the correct residents. This deficient practice was identified for 2 of 2 residents observed during lunch meal services (Resident #34 and #36) and was evidenced by the following: On 09/19/22 at 12:27 PM, the surveyor observed Resident #36 lying in bed with his/her lunch meal tray on the overbed table. Resident #36 stated they had finished their partially eaten lunch and needed assistance to bring the Styrofoam cup filled with water closer. On 09/19/22 at 12:29 PM, the surveyor observed Resident #36's roommate, Resident #34, walking around in the room. Resident #34 used a walker and walked towards the meal tray on the overbed table. The surveyor tried to get the attention of Resident #34, but the resident did not acknowledge the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag (urine collection bag) was stored in a way to prevent the spread of infection. This deficient practice was identified for 1 of 3 residents reviewed for the use of indwelling urinary catheters (Resident #56) and was evidenced by the following: According to the admission Record, Resident #56 had diagnoses that included, but were not limited to: encounter for attention to other openings of urinary tract. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/29/2022 , revealed the resident had a Brief Interview for Mental Status (BIMS) of 15/15 which indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to a) identify that medications were not scheduled to accommodate a resident's dialysis schedule during the monthly CP medication review and b.) act on or respond to recommendations made by the Consultant Pharmacist (CP) in a timely manner . This deficient practice was identified for 2 of 6 residents reviewed for medication regimen review (MRR) (Residents #107 and #583) and was evidenced by the following: 1.) On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN #2) who was outside in the hallway and indicated that she was providing care for Resident #107 today who was out to dialysis. The surveyor was unable to interview the resident currently. [...]