Brookdale Rosehill

Inspectors wroteThe facility identified a census of 75 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure linens were stored in a sanitary manner, the facility further failed to ensure Bilevel Positive Airway Pressure (BIPAP- a device that helps with breathing), nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), and an oxygen cannula were stored in a sanitary container when not in use. The facility further failed to ensure the blood pressure cuff, pulse monitor, and temporal thermometer on a monitoring machine were sanitized after each resident's use.

Inspectors wroteThe facility identified a census of 75 residents. The sample included 18 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's plate guard was applied to his breakfast plate.

Inspectors wroteThe facility identified a census of 75 residents. The sample included 18 residents, with five residents reviewed for medication administration. Based on observation, record review, and interviews, the facility failed to meet professional standards when staff failed to administer Resident (R) 21's medication.

Inspectors wroteThe facility identified a census of 75 residents. The sample included 18 residents, with one resident reviewed for tube feeding complications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 8's tube feeding bags were marked with the date, time, and contents in the feeding bag.

Inspectors wroteThe facility identified a census of 75 residents. The sample included 18 residents, with six residents reviewed for unnecessary medications. Based on interviews, observation, and record review, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 10.

Inspectors wroteThe facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to ensure staff accurately transcribed orders from the hospital on admission and failed to follow the physician's orders for Resident (R) 1. This deficient practice placed R1 at risk for unwarranted physical complications and less-than-therapeutic effects related to medication use.

Inspectors wroteThe facility identified a census of 76 residents. The sample included three residents reviewed for medications. Based on record review and interviews, the facility failed to address the admission medication regimen review for Resident (R) 1 when the Consultant Pharmacist (CP) found irregularities with her admission orders. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use for R1.

Inspectors wroteThe facility identified a census of 78 residents. The sample included 18 residents. Based on record review, interviews, and observations, the facility failed to ensure sufficient staffing was provided to maintain the residents' physical and psychosocial wellbeing. This placed the residents at risk for impaired quality of life. Findings Included: - The Payroll Based Journaling (PBJ) report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 1 and 3 indicated the facility had excessively low weekend staffing. Review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. (The complaint of slow call lights was not on the 01/23, 03/23, and 08/2023 council minutes). [...]

Inspectors wroteThe facility identified a census of 76 residents. The facility identified one main kitchen and five satellite kitchenette areas. Based on observation, record review and interview, the facility failed to ensure kitchen staff appropriately sanitized a probe-type thermometer used to check food temperatures prior to meal service. The facility failed to ensure staff cleaned and maintained a satellite kitchen ice machine. This deficient practice left residents at risk for food borne illnesses and cross-contamination.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents. The facility identified two COVID-19 (highly contagious, potentially life-threatening respiratory virus) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection control standards were followed related to COVID-19 isolation precautions, clean supply/equipment storage, and hand hygiene during cares. This deficient practice placed the residents at risk for infectious diseases.

Inspectors wroteThe facility reported a census of 76. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life.

Inspectors wroteThe facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: - On 12/18/23 at 07:05AM an inspection of the facility revealed no designated grievance drop -box or alternative system available accessible to the residents and visitors of the facility to allow submission of grievances anonymously On 12/18/23 at 02:00PM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported Social Services X was responsible for complaints or grievances. The council stated they would contact staff or social services. [...]

Inspectors wroteThe facility reported a census of 76 residents. The sample included 18 residents. Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR- a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures.

Inspectors wroteThe facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

Inspectors wroteThe facility identified a census of 76 resident. The facility had three medication storage rooms and five medication carts. Based on observation, record review and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R) 47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with two residents reviewed for transfers. Based on observation, record review and interview, the facility failed to provide written notification of facility-initiated transfers with the required information to Resident R165 or their family/durable power of attorney (DPOA) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with one resident reviewed for baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan to include an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) for Resident (R) 115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide adequate care and services for activities of daily living (ADL) when staff failed to provide supervision with eating during meals for Resident (R)43. This deficient practice placed R43 at risk for complication related to aspiration (inhaling liquid or food into the lungs) and decline of overall abilities.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with four reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, The facility failed to provide consistent bathing opportunities for Residents (R)19, R13, and R37. This deficient practice placed the residents at risk for complications related to hygiene and infections and impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure staff physician ordered daily weights were obtained and monitored for Resident (R) 164 who had congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The facility also failed to ensure staff applied R52's thrombo-embolic deterrent (TED - a stocking that helps prevent blood clots and swelling in your legs) hose. This deficient practice placed R164 at risk for unwanted weight/fluid gain and R52 at risk for swelling and possible complications.

Inspectors wrote- The Diagnoses tab of R34's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), injury of lumber spinal cord, and difficulty in walking. The Quarterly Minimum Data Set (MDS) dated 11/14/23, documented R34 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The MDS documented R34 used a wheelchair and required substantial assistance from staff for bathing and toileting. The MDS further documented R34 was dependent on staff to transition from seated to lying or lying to seated position and for chair to bed transfers. The Pressure Ulcer/Injury Potential Care Area Assessment (CAA) dated 10/28/23, documented R34 was at risk for skin breakdown due to weakness, decreased mobility, and incontinence. [...]

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with five reviewed for bowel and bladder management and/or urinary catheter (tube inserted into the bladder to drain urine). Based on interviews, observations, and record review, the facility failed to identify changes in Resident (R) 47's bowel and bladder incontinence patterns and implement individualized toileting interventions. The facility additionally failed to ensure R115's indwelling catheter had an appropriate indication and physician's order to provide catheter and related care. This deficient practice placed both residents at risk for complications related to bladder management and incontinence.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations for physician documented rationale for the continued use of the antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R) 37 were addressed by the physician. This deficient practice placed R37 at risk for unnecessary psychotropic medication and related complications.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 52. This deficient practice R52 at risk for unnecessary medication use and physical complications for the affected resident.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication or documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R)115 and R37. This deficient practice placed these residents at risk for unnecessary psychotropic medication and related complications.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory test results for Resident (R) 37 were included the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with five reviewed for influenza (highly contagious viral infection) and pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)13 and provide influenza vaccinations or informed refusals for R53. This deficient practice placed the residents at risk for complication related to infectious diseases.

Inspectors wroteThe facility identified a census of 76 residents. The sample included 18 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure they issued the correct CMS (Center for Medicare/Medicaid Services) form 10055 Advance Beneficiary Notice of Non-coverage (ABN) form for Resident (R) 25 and R53.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services for one sampled resident, Resident (R) 62. This placed the resident at risk for poor hygiene.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to provide supervision and assistance for one of four residents reviewed for accidents, Resident (R) 230 who was at risk for falls. This placed R230 at risk of injury.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents, with one reviewed for urostomy (an artificial opening in an organ of the body) care. Based on observation, record review, and interview, the facility failed to provide urostomy care for one sampled resident, Resident (R) 178. This placed the resident at risk for inappropriate care and unecessary complications.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents, with three reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor hydration status for one sampled resident, Resident (R) 69, who was on a physician ordered fluid restriction, and failed to establish a fluid restriction as ordered for R176. This placed the residents at risk for dehydration or fluid overload.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents, with three reviewed for pain. Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to one sampled resident, Resident (R) 62. This placed the resident at risk for pain and discomfort.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (a hormone which regulates the amount of sugar in the blood) for Resident (R) 40 when blood sugars were lower than the physician ordered parameter, did not provide interventions when R22 had five days without a bowel movement, and did not hold blood pressure medication for R69 when blood pressures were out of the physician ordered parameters. This deficient practice placed three of six residents at risk for adverse side effects from medications.