Rosewood Center

Inspectors wroteBased on record review and interviews, the facility failed to employ a qualified social worker to provide and oversee social services from 10/14/25 through the time of survey, resulting in a failure to ensure appropriate follow-up, documentation, and resident support related to an allegation of misappropriation of property, abuse, neglect, reporting, and investigation. Resident identifiers: #54, #36, #32, #30, #3. Facility census: 67. Findings Include: a) Resident #32 Record review and staff interview revealed the facility did not employ a qualified social worker from 10/14/25 through the time of survey. During an interview on 03/25/26, facility administration confirmed there had been no qualified social worker employed during this time period. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were disposed of in accordance with professional standards of practice for one (1) of one (1) medication storage rooms observed. The facility failed to remove and properly dispose of 11 discontinued medications that remained in the storage room in various random drawers. This failure created a potential for medication errors or unauthorized access to medications. Facility Census:

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to establish and 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 with regards to the resident's personal products. This failed practice was a random opportunity for discovery. Resident identifiers: #12, #7, #39, and #68. Facility Census: 68. Findings Included:a) Resident #12During an interview with Resident #12, on 03/22/26 at 12:08 PM, a wheelchair near the resident's bed had rips and holes in the plastic cover on the left side of the head rest, and both of the arm rests covering and plastic trim, exposing the inner padding. [...]

Inspectors wroteBased on resident interview, staff interview, and policy review, the facility failed to ensure residents were free of verbal abuse from staff. This failed practice was true for (1) one of (2) two residents reviewed for abuse during the Long-Term Care Survey Process. Resident identifier #3. Facility census: 67. Findings Included: A review of the policy titled, OPS300 Abuse Prohibition, revealed verbal abuse defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. [...]

Inspectors wroteBased on resident interview, staff interviews, and policy review, the facility failed to report a resident allegation of verbal abuse within two (2) hours of facility staff being aware of the allegation. Additionally, the facility failed to complete and/or submit a 5-day follow-up for an allegation of abuse for Resident #77. This failed practice was found true for two (2) of two (2) residents reviewed for abuse during the Long-Term Care Survey Process. Resident identifier #3. Facility census: 67. Findings Included:A review of the policy titled, OPS300 Abuse Prohibition, revealed verbal abuse defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one (1) of one (1) resident reviewed (Resident #32). The facility failed to maintain sufficient documentation to determine the extent of the alleged financial exploitation and failed to follow up on the outcome of the investigation, potentially placing residents at risk for continued or unaddressed misappropriation of property. Resident Identifier: #32. Facility Census: 67. Findings Included:a) Record ReviewA record review was completed on 03/24/26. The record review revealed that on 09/10/25, Resident #32 reported unknown charges on her debit card. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to implement a care plan related to oral hygiene. This failed practice was found true for (1) one of (1) one residents reviewed under the dental pathway during the Long-Term Care Survey Process. Resident identifier: #70. Facility census: 67. Findings Included: a) Resident #70 The initial observation, on 03/22/26 at 12:15 PM, revealed Resident #70 in the dining room, waiting for her lunch tray. Resident #70's teeth were covered in debris and had a thick white substance around her gum lines. An observation, on 03/24/25 at 2:30 PM, revealed Resident #70 in her bed. Resident's teeth were covered in debris and had a thick white substance around her gum lines. A record review, completed on 03/24/25 at 2:40 PM, revealed an oral health care plan that included the following intervention, revised 03/19/25: [...]

Inspectors wroteBased on record review, surveyor observation and intervention, as well as resident and staff interviews, the facility failed to provide necessary care and services to maintain or improve resident's ability to perform activities of daily living (ADL), such as mobility for one (1) of one (1) residents reviewed (Resident #60). The facility failed to follow up on the outcome of the resident receiving new custom made Hip Knee Ankle Foot Orthosis to resume Physical Therapy, placing resident at risk for continued decline in mobility. Resident Identifier: #60. Facility Census: 67.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Physician orders related to medications changes and instructions for Atorvastatin, Digoxin, and Lidocaine patches were not found in the electronic record. This was a random opportunity for discovery. Resident Identifier: #4. Facility Census: 67. Findings Included: a)Resident #4's Record Review Atorvastatin:On 03/24/2026 at 12:29 PM, during Resident #4's record review, the Medical Regimen Review, dated 07/25/25, recommended Atorvastatin 40mg HS to be discontinued. The physician agreed and signed off on the discontinuation. On 03/24/2026, it was found this order still active in the electronic record. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the daily Nurse Staff Posting had the correct date. This failed practice was a random opportunity for discovery and the potential to effect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 67. Findings Included:a) Nurse staff posting:Upon facility entrance, on 03/22/26 at 11:30 AM, a review of the Nurse Staff Posting found the posting had the incorrect date of 03/20/26, revealing it had not been updated for two (2) days. During an interview on 03/22/26 at 11:39 AM, The Nurse Manager on staff stated, Yes, we had a call off and I haven't gotten to that yet.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure Medicaid residents receive routine dental services. This deficient practice was found for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Resident identifier: #70. Facility census: 67. Findings Include: The facility policy titled, Dental Services, directs: Center will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. The policy defined routine dental services as follows: [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain a complete and accurate medical record related to intellectual disability. This failed practice was found true for one (1)of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #8. Facility census: 67. Findings Include: a) Resident #8 A record review, on 03/23/26 at 2:25 PM, revealed Resident #8's most recent Pre-admission Screening and Resident Review (PASARR) dated 03/06/26, indicated Resident #8 has a diagnosis of Mental Retardation (intellectual disability). Further record review revealed a History and Physical (H&P), dated 01/28/26, under the History of Present illness section, the last sentence read, Patient has underlying mental retardation unable to communicate much. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure staff was educated/ informed on the Covid Vaccine. The facility failed to provide education on the benefits, risks, and potential side effects of the COVID-19 vaccine to staff. This was true for one (1) of one (1) staff members selected. Census: 67.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to ensure resident call lights were within reach. This was a random opportunity for discovery resident identifier: #27. Facility Census: 67. Findings Included: a) Resident #27 During an interview with Resident #27, on 03/23/2026 at 11:50 AM, he stated he couldn't find his call button. The staff forgot to put it back after my bed bath today. They usually clip it to my shirt. Surveyor pushed the roommate's call button. Employee #84 came into the room to answer the call light. She found the call bell behind the back of the bed and reclipped it to his shirt. b) Staff Interviews In an interview with Employee #84, on 03/23/26 at 12:02 PM, she acknowledged the call bell was not within resident's reach and clipped it to his shirt. [...]

Inspectors wroteBased on review of the resident council minutes, resident council meeting, and staff interview, the facility failed to inform residents both orally and in writing in a language that the residents understood of their rights and all rules and regulations governing resident conduct and responsibilities on a yearly basis. Resident identifiers: #9, #18, #22, #26, #31, #38, #40, #48, and #51. Census: 64.

Inspectors wroteBased on the resident council meeting, observation, and staff interviews, the facility failed to post notice of the availability of the most recent survey results in areas of the facility that were prominent and accessible to the public. This was a random opportunity for discovery. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of two (2) residents reviewed during the annual survey process. Additionally, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of two (2) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #218, #317, and #318. Facility census: 64. Findings Included: a) SNF ABN On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for two (2) residents who remained at the facility. - Resident #218 began Medicare Part A skilled services on 09/05/24. [...]

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business. This was a random opportunity for discovery. Resident identifiers: #9, #18, #22, #26, #31, #32, #38, #40, #48, and #51. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were free from resident-to-resident abuse. This was true for six (6) of six (6) facility reported incidents reviewed. Resident identifiers: #54, #30, #216, #48, #218, #32, and #12. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to complete their self-identified corrective action which was intended to protect residents following an investigation into a resident-to-resident physical altercation that was verified as abuse. The facility failed to oversee the complete implementation of staff being retrained on the facility's 1:1 Supervision policy. This failed practice had the potential to affect more than a limited number of residents in the building. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan regarding Resident #219's activities preferences, weights, and dental issues, Resident #220 anticoagulation therapy, Resident #42's behavior and side effect monitoring of medications as well as activities, Resident #8's leave of absence and Resident #54's physical behavior. This is true for (5) five of 32 residents reviewed during the survey process. Resident identifiers: #219, #220, #42, #8 and #54. and Facility census: 64.

Inspectors wroteBased on record review and staff interview the facility failed to ensure they provided care to facility residents based on their comprehensive assessment and that residents received treatment and care in accordance with professional standards, a comprehensive care plan and the resident's choices for three (3) of 32 residents. The facility failed to follow physician's orders regarding medication administration, weight orders, and medical appointments for Resident #129, correct diagnosis for an antipsychotic medication for Resident #42 and Resident #7's choice to be placed in bed. Resident identifiers: #219, #42 and #7. Facility Census: 64. Findings Include: a) Resident #219 On 02/25/25 at 10:48 AM, a record review was completed regarding medication administration and treatments. [...]

Inspectors wroteBased on observation, record review and staff and resident interview, the facility failed to ensure they followed the recipe for the meal served. This had the potential to affect more than isolated number of residents. Facility census: 64.

Inspectors wroteBased on observation and interviews the facility failed to provide food that was appetizing and appealing to residents. This issue had the potential to affect more than an isolated number of residents. Resident identifiers: #55 and #20. Facility census: 64.

Inspectors wroteBased on staff and resident interview and resident council meeting interview, the facility failed to offer bedtime snacks to all residents. Resident identifiers: #51 and #35. Facility census: 64.

Inspectors wroteBased on observation and staff interviews, the facility failed to wear hair covers in accordance with professional standards for food service safety. This has the ability to affect all residents that get their nutrition from the kitchen. Facility census: 63. Findings Included: a) Kitchen An observation on 02/19/25 at about 3:35 PM found the Cook/Aide #53 preparing resident drinks without a beard covering. During an interview 02/19/25 at about 3:35 PM, Cook/Aide #53 verified a beard net should be in place. At this time, he put a beard net on. b)The facility failed to wear hair nets during meal preparation. During observation of food preparation on 02/18/25 at 11:12 AM Kitchen aide #200 was observed with her hair not fully contained in her hair net. This was brought to the attention of the District Manager #68 who acknowledged and directed KA #200 to readjust her hair net. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to properly contain kitchen waste in kitchen waste receptacles. This practice had the potential to affect more than an isolated number of residents. Facility census: 64.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This has the potential to affect all residents residing in the facility. Facility census: 63.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe and homelike environment regarding packaged terminal air conditioner (PTAC). This has the potential to affect all residents living in the facility. Room Numbers: #104, #210, #118, #123, #124. Facility census: 63.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 63.

Inspectors wroteBased on resident interview and observation, the facility failed to promote dignity by not serving residents who reside in the same room their meals at the same time. Resident identifier: #20. Facility census: 64.

Inspectors wroteBased on interviews and record reviews, the facility failed to inform the resident of the reason they were receiving hospice care. This was true for one (1) of eight (8) residents interviewed. Resident identifier: 40. Facility census: 64.

Inspectors wroteBased on record review and interview, the facility did not notify or include the resident in the planning of their care. This included the right to be involved in the planning process, the right to request meetings, and the right to ask for revisions to their care plan. Resident identifier: #40. Facility census: 64.

Inspectors wroteBased on the interview and record review, the facility failed to assess the resident's potential for independent ambulation, and failed to provide him with the assistance necessary to accomplish his choices. The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident identifier: #22. Facility Census: 64.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #1's room was not in good repair. This was true for one (1) of 32 residents reviewed during the long term care survey process. Room identifier: 210-A. Resident identifier: #1. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure allegations of resident-to-resident abuse were reported within two (2) hours to the appropriate state agencies. The failure to make a timely report was true for one (1) of nine (9) sampled resident-to-resident altercations involving abuse that were reviewed during the Long-Term Care Survey Process as well as complaint investigations. Resident identifiers: #54, #216. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan regarding the amount of assistance needed for activities of daily living (ADLs) for Resident #45. This was true for one (1) of five (5) residents reviewed under the care area of activities. Resident identifier: #45. Facility Census: 64.

Inspectors wroteBased on interview and record review, the facility failed to assess the resident's potential for independent ambulation, and to ensure that appropriate treatments and services could be provided to maximize the resident's functional abilities. Resident Identifier: #22. Facility Census: 64. Findings Include: a) Resident #22 During an interview on 02/19/25 at approximately 11:11 AM, the resident stated that he wanted to ambulate. He further stated that he has attempted to ambulate by walking behind his wheelchair, but staff stop him and ask him to sit in his wheelchair. Resident further stated that if there was any reason why he was not allowed to ambulate by himself, He would like to be evaluated by occupational therapy. Record review on 02/19/25 at approximately 12:15 PM, revealed resident has been on hospice since 11/11/24. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide activities of daily living for a dependent resident (Resident #45). This was true for one (1) of five (5) residents reviewed under the care area of activities of daily living. Resident identifier: #45. Facility Census: 64.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide hearing, and vision care for two (2) residents. Resident Identifiers: #40, #219. Facility Census: 64.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure an environment that was free from accident hazards over which the facility had control. This was true for one (1) of 32 residents reviewed in the annual Long-Term Care Survey Process. Resident identifier: #1. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that pain management was provided in a manner consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed under the pain pathway during the Long-Term Care Survey Process. Resident identifier: #19. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure care and services, in addition to professional standards to address the needs of a trauma/post-traumatic stress disorder (PTSD)survivor for Resident #27. This is true for one (1) of four (4) residents reviewed under the care area of mood and behavior. Resident identifier: #27. Facility Census: 64.

Inspectors wroteThe facility failed to ensure the daily nursing posting was completed accurately for three (3) days throughout the long-term care survey process. This was a random opportunity for discovery. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure routine dental care was provided for Resident #219. This was true for one (1) of one (1) residents reviewed under the care area of dental services. Resident Identifier: #219. Facility Census: 64.

Inspectors wroteBased on record review, the facility failed to provide an accurate and complete record regarding anticoagulation therapy for Resident #220. This was true for one (1) of one (1) residents reviewed under the care area of anticoagulation. Resident Identifier: #220. Facility Census: 64. Findings Include: a) Resident #220 On 02/19/25 at 2:20 PM, a record review was completed for Resident #220. The review found a physician's order dated 02/18/25 for Warfarin (Coumadin) 3mg (milligrams) by mouth in the evening. The physician's order did not list a diagnosis for the use of Warfarin. On 02/19/25 at 3:15 PM, the Administrator confirmed the physician's order did not include a diagnosis for the use of the medication.

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. This practice affected one (1) of three (3) residents reviewed for urinary catheters. Resident identifier #59. Facility census: 63.

Inspectors wroteBased on record review, facility reported incident review, and staff interview the facility delayed initiating Cardiopulmonary Resuscitation (CPR) to Resident #63 after staff identified he did not have a heart beat or breath sounds but was still warm to the touch. The residents record contained no documentation to indicate if he did or did not want to have CPR. The standard of care is when there is an absence of an advance directive CPR should be given. Resident #63 was found unresponsive with no pulse or respirations by facility staff at approximately 6:45 am on [DATE]. CPR was no initiated until 7:19 am which was approximately 34 minutes after he was round unresponsive with no pulse or respirations. The emergency medical squad arrived at 7:30 am and assumed care of the code. They received authorization to call the time of death around 7:55 am on [DATE]. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the staff abuse and neglect training contained training related dementia management and resident abuse prevention. This was true for five (5) of five (5) nurse aides reviewed. This failed practice had the potential to affect more than an isolated number of residents. Nurse Aide (NA) Identifiers: #10, #11, #12, #13, and #14. Facility Census: 62. Findings Include: a) Abuse Training Review A review of the following nurse aides personnel record found the following: -- NA #10 had a hire date of 03/23/22. Her training record was reviewed from 01/01/23 until 12/31/24. This review found she had the following abuse training: Protecting residents from assault and abuse for a total of 40 minutes. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Nurse Aide (NA) # 14 had a performance evaluation completed every 12 months as required. This was true for one (1) of five (5) nurse aide files reviewed. This failed practice had the potential to effect more than isolated number of residents. Staff identifier: NA # 14 Facility Census: 62.

Inspectors wroteBased on record review, facility reported incident review, and staff interview the facility failed to ensure the resident record was complete and accurate. Resident #63 expired at the facility on [DATE] and cardiopulmonary resuscitation was initiated but failed. The medical record contained no information regarding the events of [DATE]. Resident identifier: #63. Facility Census: 62.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate infection control standards for the storage of clean linen in the shower room. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 83.

Inspectors wroteBased on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment for rooms 114, 130 and 131. Facility also failed to ensure a resident was free of urine odor in her wheelchair and in her bed. This was a random opportunity for discovery. Resident identifiers #32.

Inspectors wroteBased on record review and staff interview the facility failed to revise a care plan to reflect a change from eternal tube feeding to a by mouth diet. This failed practice was a random opportunity for discovery. Resident identifier #55.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #67. This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #67. Facility Census: 65.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to assess and treat Resident #210's pain stemming from an unstageable pressure ulcer to his left heel resulting in actual physical and psychosocial harm. The resident rated his pain as a 8 (very strong pain) on 01/30/23. The surveyor notified the resident's nurse of his pain. The resident again rated his pain as a 10 (worst pain possible) on 02/01/23 during his pressure ulcer treatment. The facility failed to provide any pain medication on 01/30/23 despite surveyor intervention. Pain medication was not provided until the surveyor again alerted staff on 02/01/23. The facility failed to monitor the effectiveness of the pain medication administered within one (1) hour after administration on 02/01/23. This practice caused unnecessary suffering for the resident. [...]

Inspectors wroted) Resident #24 Record review found the resident is receiving Hospice services for chronic medical conditions. Diagnoses included: PVD, History (HX) of Cardiac Ischemia, HX of alcohol dependance, HX of tobacco dependance, hypertension, atrial fibrillation, and Cerebral infarction. A review of the medical records for Resident #24 revealed the following information: The facility uses a system called Swift, this a program using a camera to measure and document all wounds. On 01/31/23, Registered Nurse 54 stated the facility began using the SWIFT on 09/29/22. In addition, the facility staff do weekly skin checks. Record review found the facility documented the resident had an Arterial wound on his right foot, 2nd digit. Date: 12/01/22 Location: Right foot, 2nd digit (second toe) New- Age unknown Acquired: In-House Acquired Length: 9.66 cm Width: [...]

Inspectors wroteBased on observation, staff interview, record review and resident interview, the facility failed to ensure residents with pressure ulcers received the routine necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four (4) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifiers: #210 #27, #111 and #24. Facility census: 64.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide appropriate before and after hemodialysis care and services. This was true for one (1) of one (1) reviewed for end-stage renal disease requiring hemodialysis. This had the potential to affect all residents receiving hemodialysis services. Resident identifier: #111. Facility census: 64.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure nursing staff had the competencies and skill sets necessary to provide nursing and related services to meet the residents needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. The facility failed to ensure staff administered medication as directed (before meals) and timely (within one hour before or one hour after scheduled times). Staff failed to identify and follow physician orders for skin conditions (non-pressure). Additionally, the staff failed to assess, identify and treat pressure ulcers per professional standards. Resident identifiers: #13, #37, #21, #24, #27, #210, and #111. Facility census: 64.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure systems were in place to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. The facility's Quality Assessment and Assurance committee failed to identify pressure ulcers that were not identified/assessed, measured and treated. This had the potential to affect more than a minimal number of residents at the facility. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee consisted of the required members. The infection preventionist was not present for the QA&A meetings during the first and second quarter of 2022. Facility census: 64.

Inspectors wroteBased on resident interview, staff interview and record review the facility failed to ensure one (1) of two (2) residents reviewed for the care area of choices was afforded the opportunity to exercise her autonomy regarding those things that are important in her life, specifically health care options/decisions. Resident identifier: #4. Facility census:

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to notify the ombudsman when the facility discharged Resident #40 and Resident #25 to the hospital. This was true for two (2) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #40 and #25. Facility census: 64.

Inspectors wroteb) Resident #24 Record review found the resident was transferred to the hospital on [DATE]. 01/26/2023 3:40 am- General Note: Found resident unresponsive in room. (Name of on call physician) contacted and ordered to send resident to (name of hospital) ER (emergency room) for eval (evaluation.) Message left for (name of family), emergency contact. Report called into (name of hospital). The resident returned to the facility on [DATE]. The facility failed to notify the resident and the resident's representative(s) of the bed hold agreement. On 02/01/23 at 12:07 PM, the Director of Nursing (DON) confirmed the resident and the representative was not notified of the bed hold agreement when discharged to the hospital on [DATE]. She verified the notification was blank. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment of one (1) of twenty MDS assessments reviewed during the investigation process of the survey. The medication section of the MDS assessment for Resident #14, was not coded to include the date of last gradual drug reduction (GDR) for Zyprexa noted on 06/24/22. Resident identifier: #14. Facility census: 64.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure two (2) of two (2) residents reviewed for area of care plan during the long-term care survey process had the opportunity to participate in the development, review, and revision of his/her care plan. Resident Identifiers #40 and #13. Facility census 64.

Inspectors wroteBased on observation, record review and staff and family interview, the facility failed to ensure the head of the bed was at an appropriate level during continuous tube feeding administration for Resident #210. This was a random opportunity for discovery. Resident identifier: #210. Facility census: 64.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the consulting pharmacist's recommendations were answered in a timely manner for Resident #14 and additionally, the Director of Nursing (DON) failed to ensure a gradual dose reduction (GDR) for Resident #14 in a timely manner after the attending physician had approved the GDR. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident Identifier: #14. Facility Census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #14's drug regimen was free from unnecessary antipsychotic medications. The attending Physician agreed to do a gradual dose reduction (GDR) for Resident #14's Zyprexa on/or about 06/24/22, this medication was not reduced until 07/20/22. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #14. Facility Census: 64.

Inspectors wroteBased on observation and staff interview the facility failed to ensure foods were stored in accordance with professional standards for food service safety. This had the potential to affect a limited number of residents. Facility census 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of 20 residents reviewed, for the care area of advance directives, had a Physician Orders for Scope of Treatment (POST) that was accurate and complete. Resident identifier: #9. Facility census: 64.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the call system was accessible to one (1) of 20 residents reviewed during the long term care survey process. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate staff posting with the total number of staff and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. This was true for ten (10) out of 14 days reviewed from 09/04/22 through 09/17/22 and seven (7) of fourteen (14) reviewed from 01/15/23 through 01/28/23. Facility census 64.