Rosewood Rehab and Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were counting the residents' narcotic medications (a drug that relieves pain, dulls the senses, and induces sleep) at the beginning and end of each shift, failed to ensure the residents' prescribed medications that had been discontinued were returned to the pharmacy in a timely fashion, and failed to ensure a resident's narcotic medication had been disposed of timely for a resident who had passed away more than a week previously out of 16 sampled residents The facility census was 250 residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate a report of missing resident narcotics for one sampled resident (Resident #15) out of 16 sampled residents. The facility census was 250 residents. Review of the facility's policy, Incident Investigation, dated October 24, 2022 showed:-Purpose: To ensure the facility tracks incidents that take place at the facility in an effort to increase the quality of care provided to the residents.-In the event of an incident, a Licensed Nurse or the individual who first encountered or witnessed an incident would have completed Form A Incident/Accident Report Form or a substantively similar form which would have included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep one sampled resident (Resident #17) out of 23 sampled residents safe from physical abuse. On 3/5/26 Resident #18 struck Resident #17 multiple times in the face, resulting in bruising and cut above Resident #17's left eye. The facility census was 251 residents. The Administrator was notified on 3/19/26 of Past Non-Compliance which occurred on 3/5/26. An all-staff in-service on Abuse and Neglect was completed by 3/6/26. The deficiency was corrected by 3/6/26. Review of the facility's Abuse Prevention and Prohibition Program revised 10/24/22 showed each resident had the right to remain free from abuse and neglect, including abuse from other residents. 1. [...]

Inspectors wroteThe Administrator was notified on 3/19/26 of Past Non-Compliance which occurred on 3/5/26. An all-staff in-service on Abuse and Neglect, as well corporate administrative staff completed education with the facility Administrator on 3/6/26. The deficiency was corrected by 3/6/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #72 and #238 were free from abuse when the residents got into a resident to resident altercation. Staff failed to separate the residents in accordance with their policy after the altercation and the residents remained roommates for 48 hours. Both residents reported being scared of the other resident. Staff failed to ensure Resident #240 was free from abuse when the resident entered Resident #215's room leading to an altercation. Resident #240 had significant facial bruising and family reported the resident to be sad and would not come out of his/her room after an altercation with Resident #215. The facility failed to ensure five sampled residents (Resident #26, #38, #187, #238, and #240) were free from physical abuse from Resident #307 who had a known history of verbal and physical aggression. [...]

Inspectors wrote4. A policy for Pharmacy Services was requested and not received by the exit date. Review of Resident #14's admission record showed he/she was admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 4/18/25, showed he/she was cognitively intact. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: -The order for Metformin 750 mg administer once daily. -The pharmacy dispensed Metformin 1000 mg administer one tablet daily. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed Metformin 750 mg had been signed off as given daily from 5/1/25 through 5/22/25. [...]

Inspectors wrote4. Review of the facility's policy, Standard and Enhanced Precautions, dated July 1, 2023 showed: -Standard precautions were to be used in the care of residents regardless of their diagnoses or suspected or confirmed infection status. -Standard precautions presume that blood, body fluids, secretions, and excretion, non-intact skin and mucous membranes may contain transmissible infectious agents. -Hand hygiene refers to hand washing with soap or using alcohol-based hand rub that did not require access to water. -Gloves (clean, non-sterile) were to be worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material was anticipated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light in one sampled resident's room (Resident #15) was within reach of the resident, out of 35 sampled residents. The facility census was 259 residents. Review of the facility's Communication Call System policy, dated 10/24/22, showed: -The purpose of the policy was to provide a mechanism (Call Light-a bedside button typically tethered to the wall in a residence room that provided signals to the nursing station when a resident had a need or required attention) for residents to promptly communicate with nursing staff. -The facility provided a call system to help residents alert the nursing staff from their beds and toileting facilities. -Call light cords were placed within the resident's reach in each residents room. -Nursing staff answered call lights promptly. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident with an appropriate discharge notice and failed to allow one supplemental resident (Resident #307) to return to the facility after having been transferred to the hospital or found an alternate facility to accept him/her out of 31 supplemental residents. The facility census was 259. Review of the Transfer and Discharge Planning policy, dated 10/24/22, showed: -The purpose of the policy was to ensure adequate preparation and assistance was provided to residents prior to transfer or discharge from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and retain a Level 1 Nursing Facility Preadmission Screening and Resident Review (PASARR - a federally mandated program that requires all states to prescreen all people regardless of payer source or age seeking admission to a Medicaid certified nursing facility) which assured appropriate placement of persons known or suspected of having mental impairment(s) and that the individual needs of mentally impaired persons could be and were being met in the appropriate placement environment) for one sampled resident (Resident #140) out of 35 sampled residents and failed to submit a Level 1 timely for one supplemental resident (Resident #307) out of 31 supplemental residents. The facility census was 259 residents. Review of the facility PASARR policy, revised on 10/24/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was communication going to the dialysis center (a medical facility where dialysis treatment were provided to patients with end-stage renal disease to filter a patients blood when their kidneys no longer can) such as the resident's vital signs and receive communication from the dialysis center after a resident's treatment such as vital signs, pre and post treatment weights, and anything unusual that may have happened during the treatment for one sampled resident, (Resident #236) out of 35 sampled residents. The facility census was 259 residents. Review of the facility's Dialysis Care policy, dated October 24, 2022, showed: -The facility would be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and provide supportive interventions for two sampled residents (Resident #176 and #194), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 35 sampled residents. The facility census was 259 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and behavioral health services per policy for one sampled resident (Resident #307) who had a known history of physical aggression and wandering. The resident admitted on [DATE], with a history of post-traumatic stress disorder (PTSD-can develop after experiencing or witnessing a traumatic event in which symptoms can include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event) to a locked memory care unit. The facility staff failed to consistently implement a plan of care related to behavioral health services to reduce resident behavior and maintain resident safety. The facility staff failed to update the plan of care after incidents of aggression with new interventions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a 5% or lower error rate during medication administration by having an error rate of 6% that effected three supplemental residents (Resident #120, #14, and #501) out of 35 sampled residents and 31 supplemental residents. The facility census was 259 residents. Review of the facility's policy titled Medication Administration, revised October 2022, showed nursing personnel who were administering medications were to follow the following guidelines for safe administration: -The right medication. -The right amount. -The right resident. -The right time. -The right route. --Additional considerations included the Rule of 3, staff would perform 3 checks comparing the physician's order, the pharmacy label, and the Medication Administration Record (MAR). [...]

Inspectors wrote2. Review of Resident #216's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Suicide attempt (an act in which a person tries to kill themselves but survives). -Alcohol abuse (a pattern of drinking that interferes with day to day activities). -Depression. -Adjustment disorder (a mental and behavioral condition that exhibits an extreme reaction to stress). Review of the resident's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -He/She took scheduled and as needed pain medications. Review of the resident's POS, dated May 2025, showed: -The resident did not have an order to self administer medications. -Norco Oral Tablet (a strong pain medication with the risk for addiction with Tylenol- an over the counter pain medication) 5/325 milligrams (mg), give one tablet by mouth every four hours as needed for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 216) had a follow up dental appointment to have multiple teeth removed, out of 35 sampled residents. The facility census was 259. Review of the facility's policy, Dental Services, dated October 24, 2022, showed: -All residents would receive appropriate oral care including denture care. -Assessment of the oral cavity and teeth was performed upon admission and as necessary. -The facility would assist residents with referrals for dental services. -The facility would refer and or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident. -Emergency dental services include but were not limited to; -Acute pain in teeth, gums, or palate. -Broken or damaged teeth. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of one sampled resident (Resident #1) when on 11/29/24 at 5:37 A.M., Certified Nurses Aide (CNA) A argued and cursed at the resident out of three sampled residents The facility census was 258 residents. The Administrator was notified on 12/2/24 of Past Non-Compliance which occurred on 11/29/24. The facility had provided education to all staff prior to their next shift on customer service, abuse and neglect. The deficiency was corrected on 11/30/24. Review of the facility's policy titled Privacy and Dignity dated 10/24/22 showed: -The facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect, in full recognition of each resident's individuality. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program when staff failed to follow the facility's infection control policies and guidance by the Centers for Disease Control (CDC) related to Coronavirus Disease 2019 (Covid-19 - an infectious disease caused by severe acute respiratory syndrome) when staff failed to complete follow-up Covid-19 tests for two residents (Resident #2 and Resident #4) who had shared rooms with residents who became positive for Covid-19 and when staff failed to follow infection control practices related to hand washing and personal protective equipment (PPE - items such as masks, gowns,and gloves) usage when working in areas/rooms with Covid-19 positive residents. The facility census was 260. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to provide a safe, functional, sanitary, and comfortable environment for all residents, staff, and public when staff failed to maintain two beds and failed to keep flooring cleanable and sanitary. The facility census was 260. Review of the facility's policy titled Maintenance Services, revised 10/24/22, showed the following: -Purpose of the policy was to protect the health and safety of residents, visitors, and facility staff; -The Maintenance Department maintained all areas of the building, grounds,and equipment; -The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #1 and #6) out of ten sampled residents received adequate supervision and assistance. On [DATE], staff did not check on Resident #1, who had a diagnosis of dementia and a known history of pulling his/her indwelling catheter, from 12:00 A.M. until 7:00 A.M. At 7:05 A.M., the resident was found lying on his/her side in a pool of blood, urine, and feces. EMS pronounced the resident deceased . On [DATE], CNA A transferred Resident #6 with a Hoyer lift (mechanical lift) by him/herself resulting in the resident sustaining an abrasion to the resident's foot. The facility census was 275 residents. The Administrator was notified on [DATE] at 5:18 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there were enough staff present to meet the care needs for one sampled resident (Resident #1) out of 10 sampled residents, when on [DATE] Resident #1 had not been checked on for approximately seven hours due to the lack of enough staff on 3 North, was found in his/her room with a large amount of blood and feces smeared all over the room, the indwelling catheter on the floor with the bulb inflated, and the resident was deceased with rigor mortis present. The facility census was 275 residents. Review of the Facility Assessment, dated 12/2023, showed: -The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free from accident hazards, when one resident (Resident #2) was not secured appropriately with a lap belt in the facility van during transport on 5/20/24. The van abruptly stopped and the resident flew out the wheelchair onto the floor of the van and suffered a femoral fracture of the right leg that required surgical repair. There were 14 residents selected for sample. The facility census was 260. The Administrator was notified on 6/17/27 at 5:30 P.M. of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 5/20/24. Prior to any further facility transports, immediate in-servicing was completed for proper placement in the van and safety belt use with each transport. The IJ was corrected 5/21/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was clean, safe, and comfortable when on 6/13/24 odors, stains, and debris were noted in the common carpeted areas on the second floor, third floor, and fourth floor and failed to keep the trim in good repair in resident common areas, and one resident's room maintained for cleanliness and sanitation. The facility census was 260 residents. A policy was requested regarding cleaning the carpets and flooring but not provided. 1. Observation on 6/13/24 at 8:40 A.M., showed an musty odor in the air as exiting off the elevator on the second floor. Observation on 6/13/24 at 9:35 A.M., showed the carpeted floors on the fourth floor south had debris scattered over the carpet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to consistently measure and document hot food temperatures at the ovens and/or stoves to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility failed to provide residents refunds of their personal funds from the operating account in a timely manner for eight supplemental residents (Resident #656, #657, #658, #659, #660, #661, #662, #663). The total amount of personal funds withheld and not returned to the resident or responsible parties was $17,450.34. The facility census was 250 residents at the time of survey. 1. Review of the facility's maintained Accounts Receivable (A/R) Aging report for the period 1/2023 to 8/21/2023, showed personal funds still being held in the facility's operating account for the following residents: -Resident #656 had $125.00 held in the facility operating account. -Resident #657 had $791.00 held in the facility operating account. [...]

Inspectors wroteBased on interview and record review the facility failed to document participation of the resident and/or the resident's representative(S) regarding care plan development for one sampled resident (Resident #201): to ensure three sampled residents (Resident #247, #18 and #230) were invited to his/her care plan meeting; and to invite the resident's responsible party to care plan meetings for one sampled resident (Resident #37) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Care Planning Policy, dated 10/24/22, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Activities of Daily Living (ADL), bathing/showering, for four sampled residents (Resident #27, #47, #93 and #138,) out of 35 sampled residents by not providing scheduled baths or showers, causing poor hygiene. The facility census was 250 residents. Review of the facility's Showering a Resident policy, dated 10/24/22, showed: -A bath/shower was given to the residents to provide cleanliness, comfort and to prevent body odor. -Residents were offered a shower a minimum of once weekly and given per resident request. -Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. -Update the resident's care plan as needed. -Note: No procedure for documentation of bathing/showering and/or resident refusal was noted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of meaningful activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for eight sampled residents (Residents #37, #39, #75, #98, #151, #232, #233 and #505) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Activities Program policy dated as revised 10/24/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered, if applicable, by the State in which practicing and was eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or was a qualified occupational therapist or occupational therapy assistant; or had completed a training course approved by the State. The facility census was 250 residents. Review of the facility's Activities Director Job Description dated 6/1/05 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled residents (Resident #140 and #241) or the resident's family members were offered the right to formulate and/or obtain existing advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 35 sampled residents. The facility census was 250 residents. Review of the facility Advanced Directives policy dated 10/24/22 showed: -If a resident did not have an Advanced Directive, the Facility would provide the resident and/or resident's next of kin with information about advanced directives upon request. -An Advanced Directive was defined as a resident's written preference regarding treatment options. [...]

Inspectors wroteBased on interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by not completing grievance investigations timely for two sampled residents (Resident #9 and #102) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Grievances and Complaints Policy, dated 10/24/22, showed: -Any resident was able to file a grievance or complaint concerning theft of property. -Any alleged misappropriation of property was to be reported to the administrator immediately (not more than 24 hours after the alleged incident). -The facility identified a Grievance Official who was responsible for: --Oversight of grievance process. --Tracking grievances through to their conclusion. --Led any necessary investigations by the facility. --Issued written grievance decisions to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) for three sampled residents (Residents #84, #247 and #39) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's PASRR Policy, dated 10/24/22, showed: -The purpose of the policy was to achieve placement of individuals in the least restrictive environment possible and be able to receive all services required by their physician and mental condition. -The facility ensured all Level I PASRR's were completed by the transferring facility, upon admission, or as soon as possible, by the facility for all applicants. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one sampled resident (Resident #247) with a summary of his/her baseline care plan and to include the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 35 sampled residents. The facility census was 250 residents. Review of the facility Care Planning policy dated 4/24/22 showed: -The facility would develop a person-centered baseline care plan for each resident within 48 hours of admission. -The baseline care plan would include the initial goals of the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to have parameters listed in the medication orders for Acetaminophen containing medications for one sampled resident (Resident #5) of out of 35 sampled residents. The facility census was 250 residents. Review of the facility policy titled Medication-Administration revised October 24, 2022 showed: -The licensed nurse would know the following information about any medication he/she would have administered any precautions or special considerations. -The residents Medication Administration Record (MAR) would be reviewed for special considerations for administration including acceptable professional standards and principles. 1. Review of Resident #5's Medication Review Report dated 8/21/23 showed the following orders: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct setting for a Low Air Loss mattress (LAL - a mattress that provides airflow to help keep skin dry as well as to relieve pressure with alternating air cells that expand and contract to shift pressure) for one sampled resident (Residents #190) with a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; dead tissue may be present on some parts of the wound bed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hydration opportunities and assistance was provided to three sampled residents (Residents #75, #98, and #232) who were dependent upon staff for their hydration needs out of 35 sampled residents. The facility census was 250 residents. Review of the facilities Nutrition/Hydration Management policy and procedure, revised 10/24/22, showed nutrition management included: -Maintaining acceptable parameters of nutritional status. -Developing, implementing and on-going assessment of the nutrition/hydration program through the Interdisciplinary process. Review of the facility census, dated 8/16/23 showed 48 residents were living on the 2 South secured unit. 1. Review of Resident #75's admission Record showed he/she was originally admitted with the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff clarified orders with the physician for use of either Bi-level Positive Airway Pressure (BiPAP a machine set to use two levels of mild air pressure, one for inhalations and one for exhalations, delivered by mask to keep breathing airways open during sleep) or Continuous Positive Airway Pressure (CPAP the same as the BiPAP machine with settings to deliver continuous mild air pressure rather than bi-level pressure to keep breathing airways open during sleep) and for oxygen concentrator use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were provided to address loose teeth in a timely manner for one sampled resident (Resident #140) out of 35 sampled residents. The facility census was 225 residents. Review of the facility Dental Services policy dated 10/24/23 showed: -Instruction to refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident, if needed or requested and arranging transportation to and from the dentist's office. 1. Review of Resident #140's physician's order dated 10/27/22 showed an order for a regular diet, regular texture, regular consistency. Review of the resident's physician's order dated 4/3/23 showed dental consult related to a loose tooth. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow its policies and procedures to ensure residents were free from sexual abuse. The facility failed to assess residents to determine risks, including capacity to consent to sexual contact. The failure impacted one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia. Twice the resident was found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205), who was also unclothed, and once was found on top of Resident #126. The failure also impacted one unknown resident, when Resident #290, a resident with a diagnosis of dementia with behavioral disturbances, was found on top of him/her in bed. [...]

Inspectors wroteBased on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures that addressed resident care and safety. This failure had the potential to affect all 250 residents who currently live in the facility. 1. Record review of the facility policy, revised 01/2008, showed: -The quality improvement committee was appointed to provide oversight for the quality assurance program. -The functions of the quality improvement committee: --Determine quality improvement programs. -Assess effectiveness of staff in designing, measuring, assessing, and improving the resident care and organizational functions by: ---Reviewing the clinical outcome benchmark data. ---Reviewing data relevant to the needs and expectations of our customers. ---Reviewing customer complaints. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 250 with a licensed capacity for 300. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair or replace three kitchen appliances to maintain safe operating condition according to manufacturers' specifications for the preparation of meals for the residents. This deficient practice had the potential to affect all residents who ate food from the kitchen. The facility's census was 250 residents with a licensed capacity for 300 residents. 1. Observations during the initial kitchen inspection on 12/6/21 at 9:40 A.M., showed the facility's electric convection oven, an electric combi oven (a combi has a combination mode which uses both dry heat and steam to maintain exact humidity levels, thus providing more control of the moisture levels in food), and an electric pass-thru refrigerator were not in proper working order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician and family were notified of possible sexual abuse for two sampled residents (Resident #126 and #205); for one closed record resident (Resident #290) and for sexually inappropriate behaviors for one sampled resident (Resident #222) out of 37 sampled residents and six closed sample residents. The facility census was 250 residents. Record review of the facility's Abuse Prevention Program policy, dated 3/18, showed: -Any allegation of abuse will be reported immediately to the facility Administrator or his/her designee, who will follow Federal requirements for reporting to the state licensing agency, law enforcement, resident's representative and resident's primary physician. Record review of the facility's Physician Communication policy, dated 5/09 and reviewed 2/13, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to report sexual abuse to the State Agency (SA) or local law enforcement when one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia, was twice found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205). Resident #205 was also unclothed, and once was found on top of Resident #126. The facility also failed to report abuse when Resident #290, a resident with a diagnosis of dementia with behavioral disturbances, was found on top of an unknown resident in bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures to ensure a thorough investigation of resident to resident sexual contact was completed to determine whether sexual abuse occurred. This deficient practice affected one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia, was twice found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205). Resident #205 was also unclothed, and once was found on top of Resident #126. The facility also failed to thoroughly investigate when Resident #290, a resident with a diagnosis of dementia with behavioral disturbances, was found on top of an unknown resident in bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff maintained current cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure consisting of chest compressions, often combined with artificial breathing, to manually preserve intact brain function, circulation and breathing to an unresponsive person) certification, failed to know if CPR certified staff were available each shift who could provide CPR to residents who needed it, and failed to monitor which staff had maintained CPR certification. The facility census was 250 residents. Record review of the facility's Cardiopulmonary Resuscitation/Emergency Response Policy dated 4/2012 and revised 6/2016 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities to meet the interests of and support the physical, mental, and psychosocial well-being of five sampled residents residing on the 200 North Secure Care Unit (SCU)(Residents #42, #71, #90, #188, and #207) out of 37 sampled residents; and failed to provide activities for residents residing on the 200 North SCU. The facility census was 250 residents. There was no record of activities scheduled or posted for the 200 North SCU. Record review of the facility's Activity Program Policy, original date of August 1998 and most recently reviewed in May 2016, showed: -The Activity Program was designed to provide therapeutic benefit and maintenance of normal activity which support the individual resident's needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a coordination of care between Hospice (end of life) and the facility and failed to ensure staff were instructed where and how to retrieve the Hospice providers electronic documentation for eight sampled residents (Residents #10, #71, #73, #125, #146, #176, #209, and #211) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Hospice Care policy, revised on 10/15, showed: -Hospice services are provided to augment the services provided by the facility. The facility retained protective oversight of the resident and continued to provide services for the resident as before the Hospice admission. -Hospice services provided a comprehensive, individualized care plan based on the current needs of the residents and will be placed in the clinical record once admitted . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accident hazards by not keeping two medication carts locked when unattended and failed to ensure fall interventions were put into place for one sampled resident (Resident #146) out of 37 sampled residents. The facility census was 250 residents. A policy for medication carts was requested and was not received at time of exit. 1. During an observation on 12/8/21 at 3:52 P.M., on the Three North unit showed: -A medication cart unlocked in the common area near the Nurses Station. -Two nurses and two Certified Nursing Assistants (CNA) at the Nurses Station. -Two residents in wheelchairs who could maneuver themselves in the common area near the unlocked medication cart. -One resident in a chair who moved him/herself from the wheelchair to the chair in the common area near the unlocked medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post complete staffing information to include the the facility census and the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), and Certified Medication Technicians (CMTs) directly responsible for resident care for each shift, in locations throughout the facility that are easily accessible to residents and visitors. The facility census was 250 residents. 1. Record review and observation of staff sheets, dated 12/10/21, 12/11/21, 12/12/21, and one undated showed: -The staffing sheet was posted at the receptionist's desk, under a glass countertop, on the first floor at the entry of the facility. -A copy of this staffing sheet was not posted in a prominent place accessible to residents on the second, third, or fourth floors where residents resided. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen, dry storage, walk-in refrigerator and walk-in freezer floors clean; failed to retain thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to change the deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to separate damaged food; and failed to ensure the proper refrigeration of food. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 250 residents with a licensed capacity for 300. 1. Observations during the Kitchen inspection on 12/7/21 between 10:10 A.M. and 11:26 A.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to update written contracts for the use of outside resources and/or sign and date contracts after a change of ownership occurred. The facility census was 250 residents. A policy was requested related to use of outside resources and the facility did not have a policy related to this. 1. Review showed the facility had a change of ownership on 10/19/2021. Record review of the facility's Medical Director Agreement showed: -An outlined agreement of the Medical Director to provide services to the facility. -The document was signed by the Medical Director on 4/15/10. Record review of the facility's Services Agreement for psychiatric services showed: -An outlined agreement to provide psychiatric services dated 10/11/19. -The contract was signed by the former facility Administrator on 10/14/19. [...]

Inspectors wroteBased on interview and record review, the facility failed to update an existing hospital transfer agreement after a change of ownership and to put forth a good faith effort to obtain other hospital transfer agreements for hospitals used by the facility. The facility census was 250 residents. A policy was requested related to transfer agreements and the facility did not have a policy related to this. 1. Review showed the facility had a change of ownership on 10/19/2021. Record review of the Facility Transfer Agreement, dated 8/20/18, showed: -A written transfer agreement signed by the former Administrator and the CEO of the hospital. -The transfer agreement outlined transfer of patients, responsibilities of the transferring facility and receiving facility, and billing. During an interview on 12/14/21 at 9:57 A.M., the DON and Administrator said: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the significant change in physical or mental condition timely after hospice admission for one sampled resident's (Resident #146) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Completion and Submission Timeframes, dated 2/2015, showed: -MDS assessments are conducted and submitted in accordance with current Federal and State submission timeframes. -The MDS Coordinator or designee is responsible for ensuring that the resident assessments were submitted to the Centers for Medicare and Medicaid (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with Federal and State guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Significant Change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) for two sampled resident (Residents #73 and #71) out of 37 sampled residents. The facility census was 250 residents. Requested policy on MDS accuracy and no policy received from facility. 1. Record review of Resident #73's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified Atrial Fibrillation (abnormal heart rhythm). -Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications. -Hyperlipidemia (high levels of lipids in the blood), unspecified. [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans to reflect residents' current condition and needs for two sampled residents (Residents #71 and #290) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Care Plans-Comprehensive policy, updated 7/18, showed: -Care plans were revised as information about the resident's condition change. -Changes in the resident's current condition must be reported to the Minimum Data Set (MDS) coordinator or Assistant Director of Nursing (ADON) so a review of the resident's assessment and care plan can be made. 1. Record review of the Resident #71's face sheet, printed on 12/14/21 showed the resident was admitted to the facility on [DATE] and had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents had baths or showers according to the resident's bath schedule and as needed for three sampled residents (Residents #80, #102, and 165) out of 37 sampled residents. The facility census was 250 residents. 1. Record review of Resident #80's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke affecting the right dominant side. -Acquired absence of Left leg above the knee. -End stage renal disease (ESRD- the kidneys have stopped working). -Dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate communication was maintained between the dialysis center and the facility for one sampled resident (Resident #80) out of 37 sampled residents. The facility census was 250 residents. A policy for dialysis communication was requested and not received at the time of exit. Record review of the undated facility and the dialysis center communication form showed the following areas to be filled out by the facility and the dialysis center: -The facility fills out the top half of the form with: --The resident's name and caregiver; --Primary care physician's name; --Date and time of arrival; --From what facility and the phone and fax numbers; --The resident's VS (vital signs- Blood Pressure, Pulse, Respirations, Temperature) and date and time taken; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medical-related social services for one sampled resident (Resident #126), who was severely cognitively impaired, out of 37 sampled residents. The facility census was 250 residents. The facility did not have a policy for Social Services. 1. Record review of Resident #126's face sheet showed: - The resident's diagnoses were: -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). [...]