Trenton Gardens Rehabilitation and Nursing Center

Inspectors wroteComplaint #2974086 Based on interviews, review of medical records, and review of other pertinent facility documents on 4/14/26, 4/16/26 and 4/17/26, it was determined that the facility failed to provide a safe environment and adequate supervision to prevent the elopement of a resident (Resident #3) who was identified as an elopement risk. Resident #3 eloped from the facility on 4/1/26, and was later found in the neighborhood near the facility by the local police. During the survey a finding that constituted an immediate Jeopardy (IJ) was identified under CFR 483.12(a) (1) for F689. The facility failed to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. On 4/1/26, at approximately 3 PM, Resident #3's assigned nurse, Licensed Practical Nurse (LPN #1), observed the resident seated in a wheelchair in the main lobby, near the front door. [...]

Inspectors wroteCOMPLAINT #297096, 2971506, & 2980872 Based on interviews, review of medical records and other pertinent facility documentation on 4/15/26, 4/16/26, and 4/17/26, it was determined that the facility failed to maintain accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to: a) consistently document toileting and bowel & bladder elimination in the Documentation Survey Report v2 (DSR) (Resident #4 and Resident #9) and b) provide documentation that a resident's request for a specific roommate was addressed (Resident #6). This deficient practice was identified for 3 residents of 9 reviewed (Resident #4, Resident #6, & Resident #9) and was evidenced by the following:a). A review of the admission Record revealed that Resident #4 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 policy, it was determine that the facility failed to ensure standard food safety practices were put in place to prevent food borne illness by ensuring a.) the dish machine and the three-compartment sink were maintained in safe operating conditions in accordance with manufacturer's specifications; b.) adherence to sanitary requirements to ensure all dishware was properly sanitized to prevent potential foodborne illness or potential exposure to hazardous chemicals; and c.) a monitoring system was in place and staff were competent to record the temperature and the chemical concentrations of the sanitizing agent. This deficient practice had the potential to affect all 185 residents. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure the dietary staff were competent to maintain the kitchen in a manner to ensure that appropriate sanitation measures were in place to prevent potential food borne illness or potential exposure from hazardous chemicals. This deficient practice had the potential to affect all residents and was evidenced by the following:On 2/5/26 at 8:10 AM, the surveyor toured the Second-floor nursing unit and observed that all the residents were being served their breakfast meal on disposable dishware with disposable utensils. During an interview with the Nurse on the floor at that time, she stated that that she could not comment why residents were eating on disposable ware and that the surveyor would have to ask the kitchen staff. [...]

Inspectors wroteBased on observations and interviews on 2/5/26, in the presence of the facility's Licensed Nursing Home Administrator (LNHA), it was determined that the facility failed to provide privacy curtains in resident rooms to ensure each resident was afforded full visual privacy. This deficient practice had the potential to affect all eight residents who resided in the rooms (4 rooms). The deficient practice was evidenced by the following:On 2/5/26, between 9:00 AM to 10:45AM, the surveyor toured the 5th floor of the facility where eight out of 40 residents were transferred from another facility. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documents on 2/5/26, in the presence of the Maintenance Assistant, it was determined that the facility failed to ensure that residents were provided with direct communication system in which residents' calls were received and answered by staff. This deficient practice was identified for 2 of 40 residents reviewed (Resident #1 and Resident #2), and was evidenced by the following: According to the admission Record (AR), Resident #1 was transferred to the facility on 2/3/26 with diagnoses which included but were not limited to: Sciatica left side, Depression, Parkinson's disease and peripheral vascular disease. Resident #1 was dependent on staff for care. Resident #2 was transferred also to the facility on 2/3/26 and had diagnoses of bipolar disorder, hyperkalemia and generalized anxiety disorder. [...]

Inspectors wroteComplaint # 2673152 Based on observation, interview, and record review, it was determined that the facility failed to ensure adequate supervision was provided to a cognitively impaired resident with a history of being restless and impulsive and a history of falls, who sustained a fracture during an unreported episode of restlessness. On 11/18/25, Resident #114 was grimacing in pain and guarding their left arm. An x-ray revealed an acute non-displaced fracture of the left clavicle (broken collarbone), and it was determined that the facility did not implement care plan interventions prior to the discovery of the fracture when the resident was restless. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #114). The evidence was as follows: [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documentation it was determined the facility failed to have a process in place to ensure that resident personal needs account (PNA) funds were available for distribution the same day as requested by the residents seven days per week. This deficient practice was identified for 3 of 3 residents (Resident #31, #40 and #130) who maintained PNA funds and attended a Resident Council (RC) group meeting. The deficient practice was evidenced by the following:Complaint #2595473On 12/04/25 at 11:04 AM, the surveyor conducted RC with four alert and oriented residents. During the RC meeting, three of three residents stated that they only had access to their money Monday through Friday, and every other weekend. [...]

Inspectors wroteBased on interview and review of pertinent facility provided documents it was determined that the facility failed to a) ensure that within 30 days of a resident's death, the resident's funds, and a final accounting of those funds were conveyed to the resident's responsible party for 2 of 2 expired residents reviewed (Resident #163 and Resident # 164) Personal Needs Account (PNA) accounts; and b) ensure the resident or resident's responsible party was notified that the funds in their PNA account reached the $2,000 maximum Supplemental Security Income (SSI) or $200 less of the maximum which could jeopardize their eligibility for SSI or Medicaid. This was identified for 5 of 5 (Resident #59, Resident # 68, Resident # 69, Resident # 101, Resident #136 and Resident #165) PNA accounts reviewed. [...]

Inspectors wroteComplaint # NJ 2587050Based on observation, interview and document review, it was determined that the facility failed to maintain a clean, comfortable and homelike environment by failing to ensure a) resident rooms, including personal belongings and common areas were kept clean, sanitary, free of pests and ensuring soiled meal trays were removed in a timely manner, b) furniture and resident rooms and common areas were maintained in a clean and homelike manner, and c) resident excrement was cleaned up timely to limit odors. The deficient practice was identified for 4 of 4 residents who attended a resident council meeting and observed on 3 of 3 resident units (2nd, 3rd and 4th floor). [...]

Inspectors wroteComplaint #s NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993Based on observation, interview and record review, it was determined that the facility failed to ensure that sufficient staff were available at all times to ensure residents maintained their highest practical physical and mental well-being by failing to ensure: a) residents were provided with timely incontinence care for 2 of 2 residents reviewed (Resident #81 and #135), b) medications were administered per standards of practice (Resident #121) , c) adequate staff were available to clean up resident excrement in a timely manner, and d) the mandatory New Jersey staffing requirements were consistently adhered to. The deficient practice had the potential to affect all residents who resided on 3 of 3 units and was evidenced by the following: a. Resident #81:On 12/02/25 at 8:02 AM, the surveyor observed Resident #81 in bed. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 5 of 5 Certified Nurse Aides reviewed and the deficient practice was evidenced by following: A review of the facility-provided CNA annual performance evaluations revealed that 5 of the 5 CNAs did not have an annual performance evaluation for 2024. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document performance evaluations for the requested CNAs. The DON and could only provide checklists for the CNAs. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure the Facility Assessment identified competencies and skill sets that were necessary to provide the level and types of care needed for the resident population. This deficient practice affected all residents who resided on 3 of 3 resident units and was evidenced by the following: On 12/2/25, during the entrance conference, the facility provided a copy of the Facility Assessment which revealed under Services and Care Provided: Other Special Care Needs: dialysis, chemotherapy, radiation, ostomy care, tracheostomy, ventilator care .On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the amount of hourly training and/or performance evaluations for the requested CNAs. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a comprehensive, data-driven Quality Assurance Program (QAPI) was implemented and sustained during leadership transition and focused on resident outcomes and quality of life to ensure for an ongoing infestation of cockroaches that was documented as observed on the 3rd floor beginning 6/1/24, and affected 3 of 3 resident units. The deficient practice was evidenced by the following:Refer to 584F, 925F, and 880F The surveyors observed cockroaches during the following observations:- On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. [...]

Inspectors wroteBased on observation, interview and document review it was determined the facility failed to develop and implement an infection prevention and control program (IPCP) to limit the potential transmission of bacteria during a facility wide infestation of cockroaches, ensuring clean linens were protected from pests, and ensure water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems were developed and implemented. The deficient practice affected all residents who resided on 3 of 3 resident units and was evidenced by the following: Reference: Guidelines for Environmental Infection Control in Health- Care Facilities; Recommendations of CDC (Centers for Disease Control) and the Healthcare Infection Control Practices Advisory Committee; 2003; Updated July 2019. Refer to F584 and F925Fa. [...]

Inspectors wroteComplaint # NJ 2587050Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure the ice machines were maintained in a clean and sanitary manner, and per manufacturers' instructions. The deficient practice was identified for 3 of 3 ice machines located on the 2nd, 3rd and 4th floor resident units, and was evidenced by the following: On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:36 AM, the ice machine located in the resident dining room, had a plastic type ice chute that was heavily soiled inside with white and black colored substances. The drain cover had a rust like build and the molding around the ice machine was peeling off. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to have an effective pest management program to irradicate an infestation of German cockroaches. The deficient practice occurred on 3 of 3 resident units and was evidenced by the following:Refer to 584F and 880F On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. The bathroom floor was covered with various debris, which included used plastic bags, a broken toilet seat was also observed on the floor. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. The surveyor then asked the CNA's what the protocol was if staff observed cockroaches. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure a system was in ensure annual competency evaluations were completed for Certified Nurse Aides (CNAs) and they were educated based on the outcome, and a system was in place to ensure CNAs were provided with at least 12 hours of education per their annual date of employment. The deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. [...]

Inspectors wroteBased on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training for 5 of 5 CNAs education reviewed. This deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the hourly training and/or performance evaluations for the requested CNAs. The DON and could only provide checklists for the CNAs. [...]

Inspectors wroteComplaint #s NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents who were dependent on staff for care were provided with a) routine and appropriate incontinence care and b) provided with care to maintain their fingernails in a clean manner. This deficient practice was identified for 3 of 4 residents reviewed for Activities of Daily Living (Resident #11, #81 and Resident #135. The deficient practice was evidenced by the following: 1. On 12/02/25 at 7:50 AM the surveyor observed Resident # 11 lying in bed, the resident was awake and alert and the surveyor further observed that the resident's fingernails were long and jagged with a black substance underneath all of the nails. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the required Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) for 1 of 2 residents (Resident #114) reviewed for change in insurance coverage status and remained in the facility. This deficient practice was evidenced by the following:On 12/09/25 at 9:09 AM, the Social Worker returned 2 of 3 requested beneficiary forms to the surveyor and stated, I don't have Resident #114, they didn't have a beneficiary form completed, as the resident had a guardian. The Social Worker stated that she should have informed the guardian regarding Medicare coverage ending but she did not, and stated, it fell through the cracks. On 12/09/25 at 9:11 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (BPNR) forms for Resident #114, provided by the facility. [...]

Inspectors wroteComplaint Intake NJ #2594199Based on interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure an allegation of misappropriation of property was investigated. The deficient practice was identified for 1 of 1 sampled resident (Resident #154) reviewed for misappropriation property and was evidenced by the following:On 12/09/25 at 12:00 PM the surveyor reviewed Resident #154's medical record which revealed the following:The diagnoses included but not limited to; Schizoaffective disorder, Bipolar type (mental health disorder), Epilepsy (seizure disorder) and Hemiplegia (loss of voluntary movement on one side). A review of the Significant Change Minimum Data Set, an assessment tool, dated 9/29/25, indicated the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident was cognitively intact. [...]

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 Form 222) were completed with sufficient detail to enable accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention)medications ordered and received for 1 of 6 forms provided, and the facility failed to ensure medications were administered to a resident according to standards of practice (Resident #121). The evidence was as follows: a. [...]

Inspectors wroteComplaint # 388773Based on interviews, record reviews and reviews of other facility documentation, the facility failed to ensure that staff received behavioral health training to assist them in coping effectively with residents who had maladaptive behavior of being disruptive, cursing and spitting at staff. This deficient practice was identified for 1 of 2 residents reviewed for behavior, Resident #157, and was evidenced by the following:A review of a Facility Reportable Event Record (RER). dated 2/13/25 revealed a Narrative: Resident #157 picked up a piece of cake that the aide (Certified Nurse Aide) was going to give to another resident, and the aide explained that the cake was not for Resident #157, and took a bite out of the cake and spit it at the aide, and gestured to hit the aide, who then raised a hand to protect herself. [...]

Inspectors wroteCOMPLAINT #2620207 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/07/2025, it was determined that the facility failed to ensure a resident (Resident #2) whose smoking privileges were revoked did not have cigarettes in their possession or smoke in the facility in the presence of oxygen to prevent accidental explosion and fire from unsafe smoking. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for accidents. During an interview with the Nursing Supervisor (NS) on 10/07/2025, she stated that while conducting her rounds on 09/16/2025, at approximately 8:00 P.M., she observed Resident #2 seated in a wheelchair, smoking a cigarette in Resident #1 and Resident #3's room. The NS stated that Resident #2 did not reside in that room; they were talking to Resident #3; [...]

Inspectors wroteComplaint #2620207Based on interviews and review of other pertinent facility documentation on 10/07/2025 and 10/14/2025, it was determined that the facility failed to: a.) ensure that the facility-wide assessment (FA) evaluated its resident population and b.) identified the resources needed to provide the necessary care and services required for residents admitted with a history or current use of, tobacco or drug and alcohol abuse. This deficient practice had the potential to affect all residents and was evidenced by the following:Refer to F689A review of the facility's Facility Assessment provided by the Director of Nursing (DON), indicated that the assessment was completed on 05/03/2025. [...]

Inspectors wroteComplaint #: 2562900 Based on interviews, medical record reviews, and review of pertinent facility documentation on 7/22/25 and 7/23/25, it was determined that the facility failed to ensure the safety of a resident (Resident #3) with a known history of illicit drug use with multiple overdoses in the facility who overdosed in the facility on 7/11/25, by: A) monitoring and supervising the resident to ensure illicit drugs were not obtained or used and B.) developing and/or implementing care plan interventions to protect the resident from obtaining illicit drugs and preventing overdoses. This deficient practice was identified for 1 of 14 residents reviewed (Resident #14). On 7/11/25 at approximately 4:30 PM, the Registered Nurse (RN) Supervisor was called to main lobby regarding Resident #3 being found unresponsive with pinpoint pupils by the main elevator. [...]

Inspectors wroteComplaint #: NJ185458 Based on interviews, medical record reviews, and review of pertinent facility documentation on 5/8/25 and 5/9/25, it was determined that the facility failed to: A) ensure the residents' safety by failing to implement interventions to prevent drugs from entering the facility and overdose incidents from occurring while in the facility, B) conduct a thorough investigation into a resident's (Resident #6) drug overdoses, and C) notify the police and the New Jersey Department of Health (NJDOH) of the residents' drug overdoses. 1. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. [...]

Inspectors wroteComplaint #: NJ185458 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #6) who had multiple drug overdose incidents while at the facility and b.) follow the facility's policy titled Policy on Resident Care Planning. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. On 2/22/25, Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. [...]

Inspectors wroteComplaint #: NJ185458Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) and the administrative staff failed to ensure resident safety and well-being by failing to A) prevent illicit drugs from entering the facility and drug overdose incidents from occurring, B) ensure a thorough investigation was completed for a staff to resident sexual abuse allegation involving Resident #3 and multiple drug overdoses that occurred in the facility involving Resident #6, and C) ensure that the police and the New Jersey Department of Health (NJDOH) were notified of any drug overdoses that occurred in the facility. [...]

Inspectors wroteComplaint #: NJ182907, NJ185458, NJ186028 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to: a.) report a to the New Jersey Department of Health (NJDOH) on 10/12/24 when Resident #15 was observed to have bruising, swelling and a scratch to her/his face. b.) report to law enforcement when a resident (Resident #2) reported witnessing an alleged sexual abuse between Licensed Practical Nurse (LPN #1) and another resident (Resident #3), and c.) report a staff to resident verbal abuse allegation involving LPN #7 and Resident #1 to the NJDOH in a timely manner. The facility also failed to follow its policy titled Abuse, Resident Behavior and Facility Practice. The deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint #: NJ182907, NJ186028 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to complete thorough investigations when A) Resident #15 was observed to have bruising, swelling and a scratch to her/his face. B) when a resident reported witnessing an alleged sexual abuse between another resident (Resident #3) and the Licensed Practical Nurse (LPN #1). The facility also failed to ensure its policy titled Abuse, Resident Behavior and Facility Practice was implemented for the alleged physical abuse and alleged sexual abuse allegations. 1. On 10/12/24 at approximately 8:30 P.M, the Unit Manager (UM) was notified by LPN #6 that Resident #15 had a scratch on his/her face. [...]

Inspectors wroteComplaint # NJ 185458, NJ179424 Based on observations, interviews, and review of other facility documentation on 5/7/2025, it was determined that the facility failed to maintain a clean and homelike environment for the residents. The deficient practice was identified for 2 of 3 units, (floor 2 and floor 4) and was evidenced by the following: During a tour of the 2nd floor unit on 5/7/2025 at 11:08 AM, the surveyor observed the following: 1. Inside 2nd floor Central Bath, sink filled with isolation gown, black pad, wash sponge, and grey basin. 2. Inside 2nd floor Central Bath, shower bed noted to have hair clippings, toilet paper, shaving cream can, a covered razor, a shampoo and a lotion bottle on it. 3. Inside 2nd floor Central Bath, visible water on the floor outside of the shower stall and in the shower stall. 4. [...]

Inspectors wroteComplaint #NJ184250 Based on interview and record review it was determined that the facility failed to appropriately discharge a resident from the facility. This deficient practice was identified for 1 of 18 residents who was discharged without a 30-day discharge notice. This deficient practice was evidenced by the following: According to Resident #16's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Polyneuropathy, Bipolar, Chronic PTSD, Frontotemporal Neurodegenerative Disorder, Neuroleptic Induced Parkinsonism. According to the Minimum Data Set (MDS), an assessment tool dated 1/27/25, Resident #16 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteC#175920 Based on interviews, medical record reviews, and other pertinent facility documentation on 5/7/2024, 5/8/2024, and 5/9/2024, it was determined that the facility failed to follow a Physician's Order (POs) for a treatment to the Resident's (Resident #5) wound. The facility also failed to follow its policies titled P&P Physician Order and Medication Administration Policy and Protocol. This deficient practice was identified for 1 of 18 residents and was evidenced by the following: Reference: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks, and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a Registered Nurse, or otherwise legally authorized Physician or Dentist. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; and c.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 5/2/24 at 8:49 AM, the surveyor with the Dietary Director (DD) toured the kitchen and observed the following: 1. The handwashing sink had no paper towels. The DD acknowledged there should be paper towels by the sink at all times. 2. In the walk-in refrigerator, one gallon of ranch dressing dated opened 3/30/24. The rim of the bottle, lid, and outside of the container all contained ranch dressing spillage. The DD acknowledged the bottle should have been cleaned after use to prevent bacterial growth. 3. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) perform hand hygiene during and after medication administration; b.) perform hand hygiene before and after serving residents meals; and c.) maintain enhanced barrier precautions to maintain infection control standards. This deficient practice was identified on 2 of 3 nursing units (Second and Third Floor), and was evidenced by the following: 1. On 5/8/24 at 10:29 AM, the surveyor observed Unit Manager/Licensed Practical Nurse (UM/LPN #1) perform tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) care on Resident #47 and observed the following: UM/LPN #1 performed hand hygiene with soap and water lathering outside the flow of running water for thirteen seconds and put on a pair of gloves. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents it was determined that the facility failed to ensure the smoking policy was followed to screen and assess a resident for the ability to safely smoke cigarettes. The deficient practice occurred for 1 of 5 residents reviewed for accidents (Resident #127) and was evidenced by the following: On 4/30/24 at 10:18 AM, during the entrance conference, the facility provided a Smoking Policy and Procedure and the Smoking Schedule which revealed that Resident #127 was listed as smoking during shift #1 from 9:00 AM-9:10 AM, 10:30 AM-10:40 AM, 2:00 PM-2:10 PM, 5:00 PM-5:10 AM. On 5/2/24 at 8:40 AM, Resident #127 was observed self-propelling from the designated smoking area onto the elevator. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 3 of 4 entree meals observed on 1 of 3 nursing units (Third Floor). This deficient practice was evidenced by the following: On 5/3/24 at 10:07 AM, the surveyor conducted a Resident Council meeting which included four residents (Resident #13, #27, #46, and #48). Resident #46 stated lunch and dinner were served cold and in takeout containers and not on hot plates since February of 2024. On 5/8/24 at 11:32 AM, the surveyor informed the Dietary Director (DD) they wanted to observe the lunch meal for the day including food temperatures. The surveyor asked the [NAME] to calibrate two thermometers in their presence; which the [NAME] completed using an ice bath, and the thermometers reached 32 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to a.) inform and offer educational material regarding advance directives (written instruction including but not limited to living will, medication restrictions, and treatment restriction for the provision of healthcare when an individual is incapacitated) with a resident's legal representative, and b.) ensure life-sustaining treatment wishes were reviewed with the residents or their representatives and documented consistently within the medical record. This deficient practice was identified for 2 of 2 residents (Resident #96 and #62) reviewed for advance care planning and directives and was evidenced by the following: On [DATE] at 9:12 AM, the surveyor observed Resident #96 in a recliner chair in the 3rd unit day room. [...]

Inspectors wroteBased on observation, interview, record review and review of other documentation, it was determined that the facility failed to implement a Care Plan (CP) intervention for a resident with an actual fall. This deficient practice was identified for 1 of 4 residents (Resident #96) reviewed for falls and was evidenced by the following: On 4/5/22 at 9:12 AM, the surveyor observed Resident #96 in a recliner chair in the 3rd floor day room. The surveyor attempted to interview the resident, but the resident did not respond. On 4/6/22 at 8:52 AM, the surveyor observed Resident #96 awake lying in bed. The bed was in the low position, there was a foot cushion at the foot board, a perimeter cover (a mattress cover used for fall prevention) on the mattress, but no floor mats. The surveyor noted there were no floor mats in the room. [...]

Inspectors wroteBased on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to update and revise the Care Plan (CP) for 1 of 4 residents (Resident #112) reviewed for falls and 1 of 1 resident (Resident #31) reviewed for urinary tract infections (UTI). This deficient practice was evidenced by the following: 1. On 3/31/22 at 10:20 AM, the surveyor observed Resident #112 in his/her room in bed with the head of the bed elevated and knees bent with call bell within reach. The surveyor attempted to interview the resident, and the resident shook their head yes to surveyor, however resident did not respond verbally to the surveyor's questions. On 4/1/22 at 12:17 PM, the surveyor observed the resident in bed, dressed in socks on their feet, head of bed elevated and knees bent. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure Peridex (a prescribed germicidal mouthwash) was administered and documented in accordance with professional standards of practice. This deficient practice was identified for 1 of 27 (Resident #39) sampled residents reviewed for medication management and was evidenced by the following: On 4/1/22 at 9:58 AM, the surveyor observed Resident #39 lying in bed asleep. At that time, the surveyor observed a graduated unit dose cup (used to administer medications) containing a light blue liquid on the resident's bedside table. At that time, the surveyor was unable to locate the nurse assigned to Resident #39. On 4/1/22 at 10:02 AM, the surveyor observed an ancillary staff walk through the hallway who informed the surveyor that she would call the unit manager (UM) to the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure an adaptive cup was provided to a resident during meal service. This deficient practice was identified for 1 of 4 residents (Resident #62) reviewed for nutrition and the evidence was as follows: On 3/31/22 at 10:00 AM, the surveyor observed Resident #62 seated in a wheelchair using their feet to propel themselves to the Nurse's Station. The resident then asked the nurse at the Nurse's Station to change their lunch meal to pork roll, French fries, and ginger ale. The surveyor observed both of the resident's hands appeared to be contracted. On 3/31/22 at 12:17 PM, the surveyor observed Resident #62 in their room with their lunch tray. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment and store/maintain food items to prevent microbial growth. This deficient practice was evidenced by: On 4/13/22 at 11:13 AM, the surveyor in the presence of the Food Service Director (FSD) conducted a follow-up kitchen tour and observed the following: 1. In the three compartment sink, the sink designated as the sanitizing sink, a black residue in the drain and a brown discoloration in the corner of the the sink. The FSD used a clean paper towel to wipe off the black residue in the drain which transferred onto the paper towel. The FSD stated the sanitizing chemical does that to stainless steel of the sink. The FSD further stated the three compartment sink was cleaned after every shift, and then he stated twice a day. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to track and securely document the COVID-19 vaccination status for all staff, both direct facility hires and contracted hires/outside vendors. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services (CMS) QSO-22-07 ALL, dated 12/28/21, included the following: Within 30 days after issuance of this memorandum 2, if a facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required Notice to Medicare Provider Non-coverage (NOMNC) for 2 of 3 residents (Resident #382 and #383) reviewed for change notifications. This deficient practice was evidenced by the following: On 4/5/22 at 9:00 AM, the surveyor reviewed three residents (Resident #79, #382, and #383) who were discharged from the Medicare Part A stay with benefit days remaining within the past six months and should have received Beneficiary Notices. Resident #382 was admitted to the facility in December 2021. The last documented covered day of Medicare Part A service coverage was 2/12/22 from a voluntary discharge when benefit days were not exhausted. The facility did not present the resident with the required NOMNC form to notify them their right to an expedited review of a service termination. [...]