Rose Meadows Health & Rehab Center

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

Inspectors wroteBased on review of the observations and staff interviews, it was determined that the facility failed to maintain an effective pest control program in the Main Kitchen.

Inspectors wroteBased on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for three of six residents (Residents R5, R66, R102).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for one of five residents reviewed (Resident R38).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of two residents reviewed (Resident R37).

Inspectors wroteBased on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of five residents (Resident R66).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization (Resident R1 and R4). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a left humerus (upper arm) fracture for one of six residents reviewed (Resident R1). This was identified as harm for past non-compliance.

Inspectors wroteBased on review of facility policies and documents, clinical record review and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in the actual harm of a left humerus (upper arm) fracture for one of six residents (Resident R1). This was identified as past noncompliance.

Inspectors wroteBased on review of facility policies, facility provided documents, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for two of three residents reviewed (Resident R190 and R400).

Inspectors wroteBased on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate and/or report potential abuse and/or neglect for four of five residents (Resident R4, R13, R57 and R116).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for three of six residents reviewed (Residents R6, R20, and R72), and failed to document results accurately in blood glucose summary and medication administration record for three of five residents (Residents R52, R69, and R91).

Inspectors wroteBased on review of facility policy, manufacturers recommendations,resident interviews, clinical records, and staff interviews, it was determined that the facility failed to make certain medications were administered as ordered by the physician for two of five residents (Residents R52 and R69) and failed to make certain that residents are free of significant medication errors for two of three residents observed (Resident R301, and R24.)

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change.

Inspectors wroteBased on a review of facility policy, resident interviews, clinical record reviews, family interview, and staff interviews it was determined the facility failed to ensure the resident's right to voice grievances and to act promptly in the resolution of grievances for two of two residents (Resident R55 and Resident R163).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for six of eight residents reviewed (Residents R34, R69, R70, R97, R106 and R134).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for food borne illness during trayline service in the Main kitchen.

Inspectors wroteBased on review of facility policy, observation and staff interviews, it was determined the facility failed to provide privacy and confidentiality of resident health information on one of two electronic health records systems (B2 Unit).

Inspectors wroteBased on a review of facility policy, resident record review, and staff interview, it was determined the facility failed to review and revise a resident care plan to reflect current status and needs for one of eight residents (Resident R47).

Inspectors wroteBased on a review of facility policy, resident record reviews, resident interviews, observations, and staff interviews, it was determined the facility failed to ensure that a resident who is unable to carry out activities of daily living in eating receives the necessary services to maintain good nutrition for one of four residents (Resident R47). Findings Include: Review of facility policy titled Routine Resident Care last reviewed 6/23/23, informed it is the policy of this facility to provide resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and to provide routine daily care by a certified nursing assistant including but not limited to maintaining adequate fluid and nutritional intake. Review of Resident R47's record indicated the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined the facility failed to secure medications in a locked compartment and allowed access to unauthorized persons and residents for one of two medication carts (B Unit).

Inspectors wroteBased on facility policy, facility submitted reports, clinical record review and staff interviews, it was determined that the facility failed to make certain that assistance for activities of daily living were consistently provided for 16 of 93 residents (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16 and R17). Review of the facility policy Routine Resident Care, last reviewed 8/21/23, indicated that routine care by a nursing assistant includes assisting or providing for personal care including timely incontinence care. Review of three facility provided documents indicated Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16 had not been provided assistance with incontinence care timely and Resident R17 had been left on a bedpan but had refused care when staff attempted to provide care. [...]

Inspectors wroteBased on review of facility records, resident and staff interview it was determined that the facility failed to respect resident rights in the handling and protection of personal property an packages being delivered upon receipt and unopened for one of three residents reviewed Resident R1.

Inspectors wroteBased on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse and/or neglect. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of 18 of 184 residents reviewed. This failure created an Immediate Jeopardy situation for 18 of 184 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18).

Inspectors wroteBased on review of facility provided policies and documentation, provided reports, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18).

Inspectors wroteBased on a review of nursing job description, facility policy, clinical record, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services to maintain safety for two of thirteen residents (Resident R19 and R20), and actual harm resulting increased pain during the provision of nursing care for one of thirteen residents. (Resident R20).

Inspectors wroteBased on review of state laws, facility policies, police reports, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion, observation, or knowledge of staff to resident neglect for thirteen of eighteen residents (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).

Inspectors wroteBased on a review of nursing job description, facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide treatments as ordered by the physician for seven of twelve residents (R23, R36, R47, R13, R48, R42, and R10).

Inspectors wroteBased on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 31 of 63 residents (R2, R11, R12, R21, R22, R23, R24, R25, R26, R27, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R50, R51, and R52). Findings Include: Review of the Facility Assessment Tool dated 10/1/23, indicated the facility will have the overall number of facility staff needed to ensure enough qualified staff are available to meet each resident's needs. During an interview on 11/4/23, at 9:57 a.m. Resident R21, when asked if he felt the facility maintained sufficient staff stated, There could be more. [...]

Inspectors wroteBased on review of Federal regulation, facility documents, and staff interviews, it was determined that the facility failed to develop, implement, and permanently maintain a training program for all staff which included training on abuse and neglect, as determined by staff need for 121 of 204 employees (Employees E4, E5, E8, E12, E13, E16, E20, E21, E27, E33, E35, E36, E37, E38, E39, E40, E41, E42, E43, E44, E45, E46, E47, E48, E49, E50, E51, E52, E53, E54, E55, E56, E57, E58, E59, E60, E61, E62, E63, E64, E65, E66, E67, E68, E69, E70, E71, E72, E73, E74, E75, E76, E77, E78, E79, E80, E81, E82, E83, E84, E85, E86, E87, E88, E89, E90, E91, E92, E93, E94, E95, E96, E97, E98, E99, E100, E101, E102, E103, E104, E105, E106, E107, E108, E109, E110, E111, E112, E113, E114, E115, E116, E117, E118, E119, E120, E121, E122, E123, E124, E125, E126, E127, E128, E129, E130, E131, E132, E133, E134, [...]