Rossville Healthcare and Rehabilitation Center

Inspectors wroteBased on record review, interview, and observation, the facility failed to maintain infection control designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for Residents (R)1, R2, R3, R4, and R5.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents received the required assistance with activities of daily living (ADL) when staff failed to provide Resident (R) 1 with the necessary oral care to keep R1's mouth free from mucus.

Inspectors wroteThe facility reported a census of 74 residents, with 19 residents sampled. Based on observation, interview, and record review, the facility failed to ensure a safe care environment related to environmental hazards. On 04/21/25 at 07:15 AM, an inspection of the facility's open kitchenette area off the main entry revealed the kitchenette's oven/stove top power shut-off was not activated. An inspection of the electric oven/stove top revealed working stove top burners and oven, and the counter to the left of the oven revealed a working bread toaster. On 04/21/25 at 07:30 AM, an inspection of the 200-hallway revealed an unlocked maintenance closet which contained 15 bottles of disinfectant cleaner. [...]

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 74 residents with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food and equipment storage. This deficient practice placed the residents at risk related to foodborne illnesses and food safety concerns. Findings Included: - On 04/21/25 at 07:00 AM, a walkthrough of the facility's kitchen was completed: An inspection of the kitchen's reach-in freezer unit revealed 13 uncovered cups of chocolate ice cream open to the air in the freezer. The cups were unlabeled and undated. An inspection of the plate and utensil storage area revealed stacked bowls in a plastic bin facing upward. An inspection of the kitchen's reach-in refrigerator located in the dry food storage office revealed an opened, but unlabeled/undated chocolate pie. [...]

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 74 residents residing in the facility. Findings Included: - On 04/21/25, Administrative Staff A provided a Facility Assessment updated 12/19/24. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shifts for the weekends and staffing needed for the specialized Memory Care Unit. [...]

Inspectors wroteThe facility had a census of 74 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). This placed the residents at risk for impaired care due to unidentified staffing issues.

Inspectors wroteThe facility identified a census of 45 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to address quality deficiencies prior to the survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: - The facility identified a census of 74 residents. The sample included 19 residents, with three reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 59 during meals. This deficient practice placed the residents at risk for impaired dignity and quality of life. (Refer to F550) The facility identified a census of 74 residents. The sample included 19 residents, with four reviewed for reasonable accommodation of needs related to assistive devices. [...]

Inspectors wroteThe facility had a census of 74 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with four reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) 23, R65, R10, and R281 had a way to communicate their needs due to their call lights being left out of reach. The facility additionally failed to ensure safe transport for R44, R71, and R76 due to them being pushed in their wheelchairs without foot pedals. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/21/25 at 07:04 AM, an inspection of R23's bed revealed no call light within her reach. She attempted to locate the light but was unable to find it. R23's bed was pushed against the wall and her call light was on the floor underneath her bed. [...]

Inspectors wroteThe facility identified a census of 74 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). [...]

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with three reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 59 during meals. This deficient practice placed the resident at risk for impaired dignity and quality of life. Findings Included: - The Medical Diagnosis section within R59's Electronic Medical Records (EMR) included diagnoses of aphasia (difficulty speaking), dementia (a progressive mental disorder characterized by failing memory and confusion), and hypertension (high blood pressure). R59's admission Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. [...]

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 2's medical record. This placed this resident at risk for impaired right to confidentiality.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's footrest was down on her wheelchair and her feet had appropriate footwear, and further failed to ensure R6 was provided with assistance while eating. This defiant practice placed R10 and R6 at risk of impaired activities of daily living (ADL) and unmet care needs.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 6 and R10, who were at risk for the development of pressure ulcers. This deficient practice placed R6 and R10 at risk for complications related to skin breakdown.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's resting splint and R41's cockup splint were applied for contractures (abnormal permanent fixation of a joint or muscle) and dysphagia (swallowing difficulty). This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 18 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 13's continuous positive airway pressure (CPAP - a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner. This placed R13 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address Resident (R) 37's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis. This deficient practice placed R37 at risk of ineffective treatment and decreased quality of care.

Inspectors wroteThe facility identified a census of 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 2, R37, and R67 antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication lacked a Centers for Medicare and Medicaid (CMS) approved indication for use. These deficient practices placed R2, R37, and R67 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the physician provided an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use of Resident (R) 2 and R67's prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. These deficient practices placed R2 and R67 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 74 residents. Based on record review and interviews, the facility failed to maintain the posted daily nurse staffing data for the required 18 months.

Inspectors wroteThe facility identified a census of 71 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required effective communication education. This deficient practice placed residents at risk for impaired care.

Inspectors wroteThe facility identified a census of 71 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from staff to resident verbal abuse. This deficient practice placed R1 at risk for further abuse and a decline in her psychosocial well-being.

Inspectors wroteThe facility identified a census of 70 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure the required information was provided on an involuntary notification of discharge to Resident (R) 1 and/or his representative. This deficient practice placed R1 at risk for an inappropriate discharge and impaired resident rights.

Inspectors wroteThe facility identified a census of 72. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents. On 12/05/23 R1 fell forward from her wheelchair while being lowered on the facility bus lift, after staff failed to ensure the brakes were fully engaged and no staff were present on the ground monitoring the lift. This deficient practice resulted in an emergent transfer of R1 to the hospital where she was diagnosed with a subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). This deficient practice also placed R1 at further risk for injury and pain.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to implement interventions to prevent the development of pressure injuries and promote healing for existing pressure injuries for Resident (R)22 and R38 who developed facility acquired pressure ulcers.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24 had the appropriate fall interventions when an unwitnessed fall occurred. The facility failed to collect staff statements regarding the event, failed to investigate to rule out abuse and neglect, and failed to ensure all interventions were in place. The facility failed to identify causative factors for a fall, which resulted in a subdural hematoma (serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain) for R24.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with six reviewed for nutrition. Based on observation, record review, and interview, the facility failed to follow up and implement the nutritional interventions to prevent further weight loss and promote weight gain for Resident (R)6, who had a significant weight loss despite having enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food). The facility further failed to monitor weights as ordered and failed to identify and implement interventions to address refusals and complications related to the tube feeding for R6, who had a significant weight loss of 10.9 percent in three months, and/or 7.77 percent in one month.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, for the 70 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and assessment.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year.

Inspectors wroteThe facility had a census of 70 residents. Based on record review and interview the facility failed to employ a designated, certified Infection Preventionist who was responsible for the facility's Infection Prevention and Control Program. This placed the 70 residents of the facility at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents. Based on record review and interview, the facility failed to complete ensure certified nurse aides (CNA) received the required 12 hours of in-service which included dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) training and abuse prevention training. This deficient practice placed the residents at risk for impaired quality of care and abuse.

Inspectors wrote- On 08/17/23 at 09:00 AM, observation of Hall 200 medication cart revealed the following: Omeprazole (antacid or used to treat low magnesium) 20 milligrams (mg) 14 tablets expired 06/2023. On 08/17/23 at 09:15AM, observation of the Hall 100 medication cart revealed the following: R40's Humulin R 100 (short acting insulin) vial lacked an open date and expiration date. On 08/17/23 at 09:15 AM, Certified Medication Aide (CMA) S verified the staff were to discard expired stock medications. On 08/23/23 at 09:45 AM, Administrative Nurse D verified the nurses should label and date the vials with the resident's name and discard expired vials and expired medications. [...]

Inspectors wroteThe facility had a census of 70 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide a CMS form 10055 for Resident (R) 54, R68, and R223. This placed the residents at risk for uninformed decisions regarding skilled services.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents, with one reviewed for restraints. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 6 was free from physical restraints when they failed to ensure he could release a safety seatbelt while in his wheelchair as directed by the physician. This placed the resident at risk for complications related to physical restraints.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified an unwitnessed fall resulting in a serious head injury as an allegation of potential abuse and/or neglect and report to the state agency as required. This placed the residents at risk for ongoing abuse and/or neglect.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified an unwitnessed fall resulting in a serious head injury as an allegation of potential abuse and/or neglect and intiate an investigation as required. This placed the residents at risk for ongoing abuse and/or neglect.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with one reviewed for hospitalization. Based on observation, interview and record review the facility failed to provide a Notice of Bed Hold to Resident (R) 5, or their representative, upon transfer/discharge to the hospital. This deficient practice placed R5 at risk to not be allowed to return to their same room upon discharge from the hospital.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents. Based on observation, record review and interview, the facility failed to review and revise Resident (R) 38's care plan with effective interventions to prevent the development of future pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and promote healing for her right inner heel pressure ulcer. The facility failed to update R45's care plan after a fall and failed to update R4's care plan regarding side rails. These deficient practices placed the residents at risk for decreased quality of care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to provide ongoing communication and assessment of the resident's dialysis treatment, including monitoring for Resident (R)71. This placed the resident at risk for complications and health decline.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)38, R5, R17, R22, R4, and R42. This placed the affected residents at risk for injury.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with four reviewed for dementia (group of thinking and social symptoms that interferes with daily functioning). Based on observation, interview, and record review the facility failed to provide dementia related psychosocial services to attain the residents highest practicable health and wellbeing, including initial and ongoing mental health assessment for Resident (R) 28 who initiated sexual contact with another impaired resident on the dementia unit. The facility failed to assess the resident for capacity to consent, and failed to initiate ongoing monitoring to ensure the intimate relations did not impact R28 in a negative manner, due to her inability to express her feelings as a result of dementia. [...]

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist (CP) notified the facility of Resident (R) 28's as needed (PRN) lorazepam (medication isued to treat anxious or restless mood) which lacked a stop date as required. This deficient practice placed R28 at risk for adverse side effects related to continued psychotropic (altering mood or mind) medication use beyond 14 days.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure Resident (R) 28's as needed (PRN) lorazepam (medication isued to treat anxious or restless mood) had a stop date as required. This deficient practice placed R28 at risk for adverse side effects related to continued psychotropic (altering mood or mind) medication use beyond 14 days.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents. Based on observation, record review and interview the facility failed to serve Resident (R) 60, on the memory unit, food at the appropriate temperature for food safety and palatability. This placed R60 at risk for food borne illness and/or decreased intake and nourishment.

Inspectors wroteThe facility had a census of 70 residents. The sample included 21 residents with one reviewed for urinary catheter (tube inserted into the bladder to drain urine) care. Based on observation, interview, and record review the facility failed to practice proper infection control when providing care for Resident (R)17's urinary catheter. This deficient practice placed R17 at risk for urinary infections.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards when staff left chemicals in an unlocked cabinet in the activity room.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to change gloves during incontinent care, carried unbagged soiled lines against their clothing down the hall to the dirty utility room, and failed to disinfectant a shared glucometer (medical device that helps to measure glucose or sugar levels in the blood).

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents with one reviewed for discharge. Based on observation, record review, and interview the facility failed to follow up on Resident (R) 23's request to be transferred to another facility closer to his guardian.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain grooming, and personal hygiene for two sampled residents, Resident (R) 16 and R42.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, physician and medical director medication concerns for one of five sampled residents. Resident (R) 10's medication not held when pulses were out of physician ordered parameters.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to hold amiodarone hcl (a medication for heart rhythm problems) when pulses were out of parameter for one of five sampled residents, Resident (R) 10.