Rose Mountain Care Center

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide qualified interpreter services for a resident identified as having a language barrier. The deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for language and communication. The deficient practice was evidenced by the following:On 5/13/2026 at 9:32 AM during initial tour, the surveyor observed Resident #5 laying in his/her bed speaking a foreign language later identified as Spanish. The surveyor introduced self to the resident who responded in Spanish. A review of Resident #5's quarterly Minimum Data Set (MDS; an assessment tool) dated 04/30/2026 revealed under section B that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating Resident #5 had moderately impaired cognition. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide appropriate and sufficient services based upon current standards of practice to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 2 residents (Resident # 7) investigated for Urinary Catheter. The deficient practice was evidenced by the following:On 05/14/2026 at 9:35 AM, Resident #7 was observed seated in a wheelchair in the Dining Room reading a magazine. At that time Resident #7 stated that he/she had a urinary catheter (tube inserted into the bladder to drain urine) but no longer has one. On 05/18/2026 at 12:37 PM during an interview, the Unit Manager (UM) stated that Resident #7 does have a urinary catheter. A review of the quarterly Minimum Data Set (MDS; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 1 of 3 forms provided. The evidence was as follows:On 5/19/2026 at approximately 10:00 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed one of the three provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The following forms were reviewed:Order form number:260545518-voided260545519- Part 5 was not completed to include number received and date received.260545520- awaiting pharmacy delivery. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficient practice was identified for 1 of 6 residents (Resident # 89) reviewed under the Infection Control task. The deficient practice was evidenced by the following: On 05/13/2026 at 10:20 AM while in the hallway outside of Resident # 89's room. Outside of the room was a sign that revealed, Stop: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) carry out activities per a resident's care plan for 1 of 5 residents reviewed (Resident #25), and b.) conduct on-going activity assessments to determine resident's interests, hobbies, and cultural preferences to acquire a meaningful life for 5 of 5 residents (Resident #3, #21, #25, #83, #84) reviewed for activities. This deficient practice was evidenced by the following: 1. On 12/3/2024 at 9:58 AM, the surveyor observed Resident #25 lying in bed. Resident #25's family member was present and stated that the resident was supposed to be getting a daily newspaper in their preferred language. On 12/5/2024 at 8:27 AM, the surveyor observed Resident #25 lying in bed and no newspaper was available. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility activities program was directed by a qualified therapeutic recreation specialist or activity professional. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: On 12/03/2024 at 9:58 AM, Surveyor #1 observed a family member in resident #25's room. The family member stated they were upset because Resident #25 was supposed to be getting a daily newspaper in their language, but no newspapers were being delivered. On 12/04/24 at 9:19 AM, Surveyor #2 observed a staff assisting residents at mealtime in the main dining room. The staff identified herself as the Staffing Coordinator/ Lead Certified Nursing Aide (SC/LCNA). [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, b.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days, and c.) documented an admission History and Physical (H&P) within 72 hours of a resident's admission to the facility. This deficient practice was observed for 4 of 18 residents and 1 closed record (Resident #13, #33, #81, #83 and #85) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 12/05/24 at 09:42 AM, the surveyor observed Resident #33 sitting in the wheelchair, in their room. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure that residents were explicitly informed of and understanding was assessed prior to having the residents enter into a arbitration agreement which was identified as a mandatory part of the admission Agreement for 9 of 9 Residents who attended a resident council meeting (Resident #6, #11, #20, #21, #24, #27, #40, #71, #78) and was evidenced by the following: On 12/03/24 at 10:07 AM, during the facility entrance conference held with the Liscensed Nursing Home Administrator (LNHA) and the [NAME] President of Clinical Services Registered Nurse (VPRN). The surveyor asked if the facility utilized arbitration agreements. The LNHA stated absolutely, we offer arbitration and it is in their admission agreement. The LNHA then stated, but it is a separate area, and it is overseen by legal. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documentation, it was determined that the facility failed to a.) ensure a process was in place to identify residents who were on Enhanced Barrier Precautions (EBP) (an infection control intervention used to reduce the transmission of resistant organisms in accordance with the Centers for Disease Control and Prevention), by posting clear signage outside of resident rooms indicating the type of Protective Personal Equipment (PPE) to be worn and defining the high risk resident care activities associated with EBP for 8 of 8 EBP rooms, b.) provide residents with hand hygiene (hh) and ensure staff performed hh in between serving and setting up residents with meals, c.) remove contaminated gloves prior to walking around in a non-clinical area, the dining room and making contact with multiple residents, d.) ensure the ice containers on 2 [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a) meals were consistently provided in a dignified and homelike manner, and b) provide resident meal assistance in a dignified manner. The deficient practice was observed in the main dining room, for 2 of 2 residents (Resident #33 & #48) and on 2 of 2 units (East and West). The deficient practice was evidenced by the following: a) On 12/03/24 at 12:10 PM, Surveyor #1 observed the meal service in the main dining room. A staff member brought a tray over to Resident #33, who had just returned from the smoking area. The staff did not offer Resident #33 hand hygiene upon re-entering from the smoking area. The staff then proceeded to set up the resident's meal, without removing the food items from tray, then she dropped a peanut butter and jelly sandwich on the floor. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to a) ensure a cognitively impaired resident was provided with adequate supervision to prevent falls with injury and reassess, reevaluate, and implement appropriate fall interventions to the Care Plan (CP) for a resident who was at high risk for falls, and sustained multiple falls. This deficient practice occurred for 1 of 2 residents reviewed for falls (Resident #39), and b) ensure the facility, developed and implemented a consistent smoking process to prevent potential injury or fire. The deficient practice was identified for 5 of 5 residents (#11, #33, #54, #63 and #388) reviewed for smoking and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment of the needs of the population of residents who smoked and included policy, services, and staff competencies for those residents, and b.) for the Asian American populations which identified ethnic, cultural, religious preferences and staff competencies. The deficient practice affected residents who resided on both the East and [NAME] wing of the facility and was evidenced by the following: Refer to F679 and F689 On 12/03/2024 at 8:50 AM, two surveyors were present in the conference room and requested the surveyor information from the Licensed Nursing Home Administrator (LNHA) regarding residents who smoked, the smoking policy, and smoking times. [...]

Inspectors wroteBased on observation and interview on 12/4/2024 in the presence of the Maintenance Director (MD), it was determined that the facility failed to ensure corner guards were free from sharp edges and failed to provide protective endcaps to corner guards. This deficient practice had the potential to affect all residents on the east wing and was evidenced by the following: An observation at 2:27 PM with the MD, revealed two metal corner guards by the handrails in the main dining room had a sharp edge and no protective endcaps installed to prevent an injury. In an interview at the time, the MD confirmed the findings. The facility's Administrator was notified of the deficient practice at Life Safety Code survey exit conference on 12/5/2024 at 2:45 PM. NJAC 8:39-31.4(a)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment by administering medications to a resident who was in the dining room for the breakfast meal. This deficient practice was identified for 1 resident (Resident #83) during the meal observation and was evidenced by the following: On 12/06/2024 at 8:25 AM, the surveyor observed a Registered Nurse (RN) #1 approach Resident #83 sitting alone at a table in the main dining area preparing to eat breakfast which was on the table. RN #1 administered Resident #83 medications and exited the area. The surveyor observed there were multiple other residents throughout the main dining area as well. On 12/06/2024 at 8:30 AM, the surveyor inquired about administering medications in the dining area in front of other residents during breakfast. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to residents who were unable to carry out activities of daily living (ADLs). This deficient practice occurred for 2 of 2 residents (Resident #19 and #33) reviewed for nail care and was evidenced by the following: 1. On 12/3/24 at 10:19 AM, during an initial tour, the surveyor observed Resident #19 sitting in their bed. The surveyor observed the resident's fingernails to be long, jagged with a brown colored substance underneath the nails. On 12/4/24 at 9:14 AM, the surveyor observed the Resident #19 lying in their bed. Resident #19 had long, jagged nails with brown colored substance underneath the fingernails. When asked by the surveyor, the resident stated staff did not cut their nails. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was stored and dated in accordance with professional standards when not in use for 1 of 1 resident (Resident #36) reviewed for respiratory care. This deficient practice 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: [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to store foods, maintain sanitation in a safe, and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/18/23 at 10:15 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1. In the freezer the surveyor found one opened box of breaded eggplant without an open and use by date. The interior bag holding the eggplant strips were opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. She also stated, the interior bag once opened should be label and dated. 2. In the freezer the surveyor found one opened box of pancakes. The exterior of the box was labeled with 8/31 (no year was indicated). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to treat all residents in a dignified manner. This deficient practice occurred for two (2) of four (4) residents reviewed for dignity (Resident #14 and #67) and was evidenced by the following: On 9/20/23 at 10:25 AM, the surveyor met with Residents #8, #14, #27, and #67 for the Resident Council meeting (RCm) in a closed-door meeting. During the RCm, the surveyor followed the probes (the process of asking questions and examining facts in a situation) in the survey process, in question #18 for if resident rights were being respected in a dignified manner, Residents #14 and #67 both claimed they were not. On that same date and time, both residents informed the surveyor that staff at times do not knock before entering their room. [...]

Inspectors wroteComplaint# NJ00166296 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in a) one (1) of three (3) residents, (Resident #142) reviewed for environment concerns, b) the dining, and c) the laundry area observed and reviewed for a clean, comfortable, and homelike environment of residents. This deficient practice was evidenced by the following: 1. The surveyor reviewed Resident #142's medical records. The admission Record (or face sheet; [...]

Inspectors wrote2. On 9/20/23 at 02:45 PM, the surveyor reviewed the reportable event record/report AAS-45 (FRE; Facility Reported Event) dated 7/10/23 that was provided by the facility which included the following: Today's Date: 7/10/2023 Date of Event: 7/06/2023 Time of Event: unk [unknown] Was This a Significant Event? Yes Was Significant Event Called in? Yes Date: 7/10/2023 Time: 5:15 PM Type of Incident: Staff-to-Resident Abuse Narrative: 1) Describe the event . Resident #56 allegedly told Responsible Party (RP) that while changing his/her diaper the individual described as [redacted] slapped resident's forearm. He/she said that since the alleged incident, he/she has not seeing [seen] the person again . 3) What interventions were implemented after the incident/event? . Skin assessment reveals with no redness or bruising noted and Resident #56 was assessed and does not report any pain or discomfort. [...]

Inspectors wroteComplaints: #NJ00164042, # NJ00166566, NJ#165848 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident abuse in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for four (4) of six (6) investigations of reportable incidents reviewed (Residents #10, #13, #56 and #82). This deficient practice was evidenced by the following: 1. On 8/19/23 at 11:00 AM, the surveyor asked the Licensed Nursing home administrator (LNHA) for a copy of Resident #10, #13 and #82 Incident/Accident and Reportable (I/A&R) reports for the last five (5) months, and the LNHA stated that he will get back to the surveyor. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files within a year according to their date of hire. A review of the facility form, Continuing Education Record for 2022 to 2023 revealed the log did not include the mandated QAPI education training for CNA#1, #2, #3, #4, and #5. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for six (6) of ten (10) newly hired staff reviewed, (Staff #1, #2, #6, #7 #8, and #9). This deficient practice was evidenced by the following: On 9/28/23 at 8:30 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 10/24/21, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. [...]

Inspectors wroteBased on interviews, and review of the facility provided documents, it was determined that the facility failed to revise a care plan to address the discharge plan for one (1) of three (3) residents reviewed for closed record, (Resident #90) reviewed for a comprehensive person-centered care plan. This deficient practice was evidenced by the following: The surveyor reviewed Resident #90's medical records. The admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to diffuse traumatic brain injury without loss of consciousness (following trauma, secondary diffuse brain injury), major depressive disorder, recurrent severe without psychotic features, chronic obstructive pulmonary disease unspecified (COPD; [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility staff failed to follow a physician's order for one (1) of nineteen (19) residents reviewed (Resident #5). This deficient practice 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 stated, 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 interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that: a) a physician order for discharge (d/c) was obtained for two (2) of two (2) residents (Resident #84 and #142) and b) d/c summary was completed by the physician for one (1) of two (2) residents who were transferred to another facility (Resident #142) reviewed for d/c. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident #84. The admission Record (or AR; face sheet; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a communication device for a resident identified as having language barrier. This deficient practice was identified for one (1) of one (1) resident (Resident #39) reviewed for language and communication deficits and was evidenced by the following: On 9/18/23 at 10:54 AM, the surveyor observed the resident lying in bed, who waived to the surveyor. The surveyor observed the menu in the Resident's room was written in both English and Chinese. The English Activities Communication Calendar in Resident #39's room was dated September 2023, and the Chinese Activities Communication Calendar was dated June 2023. On 9/18/23 at 12:08 PM, the surveyor called the family for interview and did not receive a response. [...]

Inspectors wroteBased on the interviews, review of the facility closed record, and the review of facility provided documents, it was determined that the facility failed to: a) follow the physicians' orders for consultation for two (2) of 22 residents (Residents# 12 and #89) and b) ensure that the physician documented a recapitulation (a summary) of resident's stay at the facility and visit progress notes in accordance with the resident's care and professional standards of clinical practice for two (2) of 22 residents, (Residents#12 and #89) reviewed for quality of care 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: [...]

Inspectors wroteBased on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of one (1) resident reviewed for falls (Resident #2). This deficient practice was evidenced by the following: On 9/18/23 at 11:09 AM, the surveyor observed Resident #2 seated in a wheelchair in the dayroom. Resident #2 did not speak English. The surveyor interviewed the resident via an interpreter that was an employee of the facility and the resident stated that he/she was very good. The surveyor reviewed Resident #2's medical record. The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) monitor residents returning from the dialysis center for hemodialysis access site and vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and b) complete the Hemodialysis Communication Record (HCR), post dialysis treatment according to standard of practice, policy, and facility practice. The deficient practice was observed for one (1) of two (2) residents (Resident #7) reviewed for hemodialysis. The deficient practice 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents' highest practical wellbeing by failing to: a.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey (NJ) and b.) ensure that 7 AM-3 PM, 3-11 PM, and 11-7 shifts were staffed to provide the ADLs (activities of daily living) for three (3) of 16 residents, (Residents#2, #35, and #67) according to facility practice, required minimum direct care staff-to-shift ratios as mandated by the state of NJ, and facility assessment. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted Resident Care Staffing Report (24-hour staffing report) was up to date and provided accurate information. This deficient practice was evidenced by the following: On 9/18/23 at 9:18 AM, the surveyors entered the facility and observed the posted 24-hour staffing report which was dated 9/15/23. The census listed was 90. The staffing report was not up to date and it was three days late. On 9/23/23 at 11:26 AM, the surveyors observed the posted 24-hour staffing report which was dated 9/19/23. The census listed was 91. The staffing report was not up to date and it was four days late. On 9/25/23 at 8:35 AM, the surveyor observed the posted 24- hour staffing report which was dated 9/22/23. The census listed was 90. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented including the approprite hours of sleep snacks (HS snacks) for one (1) of 19 residents, (Resident #7) reviewed. This deficient practice was evidenced as follows: On 9/19/23 at 10:24 AM, the surveyor observed Resident #7 seated on the edge of their bed with breakfast tray on the bedside table. There were no visible menus in the room for the resident to review. The residents breakfast meal was on his/her bedside table, the ticket only read, scrambled eggs, double portion. The preference and the dislike columns were blank. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain complete and accurate records for a resident. This deficient practice was identified for one (1) of 1 resident reviewed for Hospice and End of Life services (Resident #51) and was evidenced by the following: On 9/18/23 at 10:48 AM, the surveyor observed Resident #51 sleeping on their right-hand side and was covered with a thin blanket. The surveyor reviewed Resident #51's medical record. [...]

Inspectors wroteBased on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify a resident and offer a subsequent pneumococcal vaccine and b) revise the facility pneumococcal vaccine policy to reflect the current Pneumococcal vaccination guidelines in accordance with the CDC's (Centers for Disease Control and Prevention) guidelines for one (1) of five (5) residents, (Resident #14) reviewed for immunization. This deficient and was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: For adults who only received the Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23) regardless of risk and condition, should received one (1) dose of Pneumococcal conjugate vaccine (PCV 15 or PCV20) at least one year after the most recent PPSV23. [...]

Inspectors wroteBased on interviews and review of other facility documentation, it was determined that the facility failed to ensure the facility staff had the mandatory behavioral health training for two (2) of the five (5) Certified Nursing Assistants (CNA #3 and CNA #5) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files within a year according to their date of hire. A review of the facility form, Continuing Education Record for 2022 to 2023 revealed the log did not include the mandated behavioral health education training for CNA#3 and #5. On 9/27/23 at 12:06 PM, during an interview with the surveyor, the Licensed Practical Nurse / Assistant Director of Nursing (ADON) Infection Preventionist /Education Co-Ordinator (EC) stated she received an informal training from the previous ADON. [...]