Rose Lane Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, review of the facility policy and review of the resident handbook, the facility failed ensure a clean, sanitary and homelike environment. This affected 12 residents (#32, #37, #40, #70, #77, #109, #110, #129, #131, #148, #149 and #159) out of 30 residents residing on the 300-hall (memory care). The facility census was 167.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 160 residents who ate meals prepared by the facility's kitchen, as two residents (Resident #3 and #23) were ordered nothing by mouth and did not receive meals from the kitchen. The facility census was 162.

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide a dignified dining experience on the Memory Care Unit (MCU), and failed to ensure Resident #9 was provided dignity and respect at all times This affected ten residents (#10, #18, #32, #49, #69, #83, #105, #125, #139 and #142) out of 22 residents observed in the dining room, and one (Resident #9) of one resident reviewed for abuse.

Inspectors wroteBased on record reviews, interviews with families and staff and observations on the Memory Care Unit (MCU) the facility failed to provide meaningful activities to Resident #18. This affected Resident #18 and had the potential to affect all 27 residents on the MCU.

Inspectors wroteBased on interviews, observation and resident handbook the facility failed ensure a clean homelike environment. This affected three residents (Resident #51, #172, and #178) out of five residents reviewed for physical environment. The facility census was 162. Findings Include:1. On 01/27/26 at 10:44 AM Resident #178 room revealed the bedside commode (BSC) had a small amount of urine and bowel movement (BM) in it dried and when the bathroom door was opened there was BM all around the toilet riser, toilet base and on the floor by the toilet. Resident #178 was not in the room at that time. At 10:53A.M. Resident #178 came back from getting her hair done At10:55 A.M. with Register Nurse #821unit manager and Licensed Practical Nurse (LPN) #902 stated Resident #178 takes herself to bathroom. [...]

Inspectors wroteBased on record reviews, interviews and observations the facility failed to assist Resident #32 with his meal per his care plan. This affected one resident (Resident #32) of one residents reviewed for meal assistance. The census was 162.

Inspectors wroteBased on observation and interviews the facility failed to ensure resident's received timely assistance to meet their needs. This affected two of two residents (Resident #180 and Resident #181) observed for call lights. The facility census was 162. Findings Include:Observation on 01/28/26 at 11:25 A.M. of the call light monitor on the 500-hall nurse's station revealed Certified Nurse Assistant (CNA) #909 was seating at the desk charting on the computer right next to the call light monitor. CNA #909 then got up and stated she had to answer the call lights. Call lights for room [ROOM NUMBER] (Resident #181) had been on for 34:54 minutes and room [ROOM NUMBER] (Resident #180) call light had been on for 43 minutes. This was verified with Licensed Practical Nurse (LPN) #971. Interview with Register Nurse (RN) #821 on 01/28/26 at11:29 A.M. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #110 was assessed properly after they returned to the facility from the dialysis center. This affected one resident sampled for dialysis care. The facility census was 162.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure enhanced barrier precautions were followed while providing Resident #181 catheter care. This affected one resident (Resident #181) of one resident reviewed for catheter care.

Inspectors wroteBased on interview, record review, facility policy, and self-reported incident (SRI) review, the facility failed to timely report an injury of unknown origin. This affected one resident (Resident #175) of three residents reviewed for abuse. The facility census was 151.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, interview, and facility policy review, the facility failed to provide Resident #49 adequate assistance when transferring resulting in a fall with major injury. Actual harm occurred on 01/13/24 when Resident #49, who required assistance of two people for transfers, was transferred from the toilet to a shower chair by one person, resulting in a fall and non displaced fracture on left metacarpal and closed fracture of radius and ulna in left forearm, requiring orthopedic surgery. This affected one (Resident #49) of three residents reviewed for falls. The census was 159. Findings Include: Resident #49 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record reviews, policy review, observations, and interview, the facility failed to ensure services were provided to maintain or improve a resident's range of motion. This affected four (Residents #58, #91, #125 and #127) of five residents reviewed for limited range of motion.

Inspectors wroteBased on observation, medical record review, review of schedules and time punches, and interview, the facility failed to ensure there was sufficient staff to consistently provide restorative programs and to respond to call lights in a timely manner. This affected two (Residents #58, #127) of six residents reviewed for activities of daily living and two (Residents #58 and #127) of five residents reviewed for range of motion and one additional resident (Resident #140) who was identified as not having the call light responded to timely. This had the potential to affect all residents.

Inspectors wrote2. On 11/14/23 at 12:10 P.M., observation of the medication room in the 400 hall revealed one box of Multistix urinalysis dip sticks to test for urinary tract infections with an expiration date of 08/31/23. Licensed Practical Nurse (LPN) #410 verified the urinalysis test strips were expired. Observation of the medication cart in the 400 hall revealed a bottle of Biotene mouth wash, labeled for Resident #46, had an expiration date of 08/03/22. At the time of observation, LPN #410 verified the Biotene was expired. 3. On 11/14/23 at 2:55 P.M., observation of the medication room in the 100 hall revealed an open one milliliter vial of Tubersol (a multi-dose solution used for tuberculosis testing) in the refrigerator. The vial of tubersol was not labeled as to when it was opened. [...]

Inspectors wroteBased on observations and interviews the facility failed to maintain a clean, sanitary environment This had the potential to affect eight residents (Resident #7, #29, #36, #84, #87, #100, #103, #125) for environment and all 18 residents (Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143) on the 200 unit who used the shower room. The facility census was 155. Findings Included: 1. Observations on 11/13/23 at 9:05 A.M., 1:46 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. On 11/13/23 at 3:00 P.M. an interview with State Tested Nursing Assistant (STNA) #406 verified the fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. [...]

Inspectors wroteBased on observation, medical record review and interview with staff the facility failed to ensure Resident #36's call light was within reach. This affected one resident (Resident #36) of 36 residents observed for call lights.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected two residents (Resident #410 and #411) of two residents reviewed for funds conveyance. The facility census was 155. Findings Include: 1. Resident #410 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, generalized anxiety disorder, schizophrenia, and major depressive disorder. Resident #410 expired at the facility on [DATE]. Review of the business records for Resident #410 revealed a check in the amount of $50.13 was dispersed to the State of Ohio Treasurer on [DATE]. 2. Resident #411 was admitted to the facility on [DATE] with a readmission date of [DATE] with diagnoses including, but not limited to, Alzheimer's Disease, major depressive disorder, diabetes mellitus. [...]

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure restorative programs for ambulation and/or transfers were consistently implemented and evaluated for two (Residents #58 and #127) of six residents reviewed for activities of daily living. The facility identified nine residents on restorative ambulation or transfer programs. The census was 155.

Inspectors wroteBased on observation, review of the medical record, and interview the facility failed to ensure Resident #134 was transported to a non-emergent emergency room visit for evaluation after a fall and wound dressings were applied as ordered for Resident #46. This affected one resident (Resident #134) of eight residents reviewed for accidents and one resident (Resident #46) of three residents reviewed for pressure ulcers. The census was 155.

Inspectors wroteBased on observations, review of the medical record and interview the facility failed to ensure fall interventions were in place for Resident #36, and failed to ensure medications were not left at the bedside for Residents #147 and #355. This affected three residents (Resident #36, #147 and #335) of eight residents reviewed for accidents.

Inspectors wroteBased on observation, medical record review, review of the narcotic count sheet and interview the facility failed to ensure residents were free from unnecessary psychotropic medications and failed to ensure medications were administered per physician orders. This affected one resident (Resident #66) of five residents reviewed for unnecessary medications. The census was 155.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records. This affected three (Residents #96, #125 and #138) of 34 resident records reviewed for accurate medical records The census was 155.

Inspectors wroteBased on medical record review, review of transfer notices, policy review, and interview, the facility failed to ensure information regarding the reason for hospital transfer was documented on the transfer notice. This affected four residents (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey. The census was 155.

Inspectors wroteBased on medical record review, review of transfer notices, and interview, the facility failed to ensure information was provided regarding the length of time a resident's bed would be held or the cost to do so when residents were transferred to the hospital. This affected four (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey.

Inspectors wroteBased on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo, review of the facility COVID-19 policy, observations and interviews, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the administration used its resources effectively and efficiently to ensure comprehensive and effective infection control policies and practices were developed and implemented to prevent the spread of COVID-19. This affected all 150 facility residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure identified concerns were timely and appropriately addressed through the Quality Assurance and Performance Improvement committee. This had the potential to affect all 150 residents residing at the facility.

Inspectors wroteBased on observations, interview, and review of manufacturer information for sanitizer use, the facility failed to prepare puree food under sanitary conditions. This affected 12 residents (Residents #14, #26, #36, #55, #56, #74, #88, #91, #105, #120, #127, and #142) of 12 residents who received puree diets. The facility identified 148 residents who received diets from the kitchen.

Inspectors wroteBased on record review, interview and observation the facility failed to ensure adequate incontinence care was provided for two residents (#27 and #56) of two reviewed for incontinence care. The facility census was 150.

Inspectors wroteBased on observation, record review and interview, the facility failed to discard expired insulin. This affected one (Resident #3) of three residents (Resident #3, #13 and #30) reviewed for insulin medication in the 500 medication cart. The facility census was 150.