Rowan Community, Inc

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 14 sample residents were treated with respect, dignity and care in a manner that promoted quality of life or recognized the residents' individuality. Specifically, the facility failed to:-Knock prior to entering Resident #2's room, introduce themselves and the care they were going to be providing; and,-Respect Resident #2's wish to have staff enter her room wearing a face mask.

Inspectors wroteBased on observations and interviews, the facility failed to facilitate resident self-determination for one (#4) of five residents reviewed for choices and preferences out of 14 sample residents. Specifically, the facility failed to honor Resident #4's choice to return to his room.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a dependent resident received the necessary services to maintain activities of daily living (ADL) for two (#4 and #5) of five residents out of 14 sample residents. Specifically, the facility failed to:-Ensure timely repositioning and incontinence care for Resident #4; and,-Ensure timely repositioning for Resident #5.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#51) of five residents reviewed out of 32 sample residents. Resident #51, who was at risk for falls and had a history of falls, experienced 21 falls between 1/13/25 to 5/15/25. The facility's interdisciplinary team (IDT) met after the falls to determine a root cause for the resident's falls and implement interventions. However, the facility's review of the falls was not always timely. The root cause identified for 19 of the resident's 21 falls was poor safety awareness, however, the facility did not identify a more specific root cause in order to determine if the fall interventions were appropriate and effective for preventing further falls. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for one (#16) of three residents reviewed for mental health out of 32 sample residents. Resident #16, was admitted on [DATE] and readmitted on [DATE], with diagnoses of bipolar disorder and dissociative disorder. The resident had a previous reported history of suicidal ideation with self-harm. Resident #16 had documented behaviors of becoming easily agitated, verbally reactive and frequently calling emergency medical services (EMS) for all issues. Resident #16 had a behavioral care plan in place, which included monitoring mood/behavior and consulting with behavioral health services. [...]

Inspectors wroteIII. Resident #6 A. Resident status Resident #6, age [AGE] years, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included multiple sclerosis (chronic progressive disease of the central nervous system), depression, peripheral vascular disease (blood circulation to the body's tissue is restricted due to blocked blood vessels), contracture of muscle in multiple sites, psychotic disturbance, mood disturbance and left elbow contracture. The 2/18/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and personal hygiene. The assessment revealed she had an impairment to one upper extremity and an impairment to both lower extremities. B. Resident interview and observation Resident #6 was interviewed on 5/20/25 at 11:02 a.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain a system of documenting grievances and demonstrating prompt actions for one (#6) of two residents out of 32 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #6.

Inspectors wroteBased on interviews the facility failed to ensure one (#51) of five residents were free from abuse out of 32 sample residents. Specifically, the facility failed to protect Resident #51 from verbal and physical abuse from two staff members.

Inspectors wroteBased on observations, record review and interviews the facility failed ensure residents were free from chemical restraints for one (#18) of five residents out of 32 sample residents. Specifically, the facility failed to ensure Resident #18, who was on an antipsychotic medication, received appropriate and timely monitoring before and after the resident developed signs and symptoms of tardive dyskinesia (involuntary movements).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of 32 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put into place for Resident #6's right foot.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#18) of three residents out of 32 sample residents received dental services timely. Specifically, the facility failed to arrange a referral for a dental surgical appointment to remove the permanent implants on Resident #18's lower gums so she could be fitted with new lower dentures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for two (#48 and #38) of four residents reviewed for hospice care services out of 32 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #48 and Resident #38; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and have consistent documentation of hospice care visits in Resident #48 and Resident #38.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of two units. Specifically, the facility failed to: -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff changed cleaning rags between different sides in a double occupancy resident room; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms; and, -Ensure housekeeping staff performed appropriate hand hygiene with glove changes.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection at the facility. Specifically, the facility failed to; -Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (light switches and door handles); -Ensure housekeeping staff performed hand hygiene when appropriate; -Clean the mechanical lift and vitals machine between each use with a resident; -Perform hand hygiene during medication administration; -Offer hand hygiene to each resident before meals; and, -Perform hand hygiene between each resident when assisting with meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored according to professional standards in one of three medication carts, one of two medication treatment carts and one of two medication rooms. Specifically, the facility failed to ensure medication rooms and medication/treatment carts were locked properly when unattended by a licensed nurse.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt action was taken to honor a request for the resident's personal and medical records by the resident and legal representative for one (#52) of one resident reviewed for medical records requests out of 33 sample residents. Specifically, the facility failed to allow Resident #52 and the resident's legal representative the right to obtain a copy of the resident's medical records or any portions of the electronically maintained record upon request and within two (2) working days of a verbal or written request for the resident's medical records.

Inspectors wroteBased on record review and interview, the facility failed to ensure two (#209 and #52) of two residents out of 33 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -Ensure Resident #209' s complaint about meals not being served at a palatable temperature; -Support Resident #52' s right to file any grievance (written or verbally) without the fear of feeling retaliation; [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#13) of one resident reviewed out of 33 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure Resident #13 was assisted and encouraged to shower and maintain personal hygiene; and, -Ensure Resident #13's care plan addressed his refusals of showers and provided person-centered interventions to ensure the resident had appropriate hygiene.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (#3) of five residents reviewed for ADL care assistance out of 33 sample residents. Specifically, the facility failed to assist and provide Resident #3 with her scheduled showers and wash her hair with the prescribed medicated shampoo.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident receiving enteral feeding (nutrition delivered directly to the stomach or intestinal tract) received appropriate care and services to prevent complications of enteral feeding for one (#49) of one resident out of 33 sample residents. Specifically, the facility failed to: -Administer Resident #49's medications per professional standards by properly liquifying the medication. administering each medication separately with adequate water flushes between medications in order to prevent clogging of the resident's gastric tube; and, -Check gastric residual (amount of undigested feeding left in the stomach) prior to starting Resident #49's enteral gastric tube feeding per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#16) of two residents reviewed for pain out of 33 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #16 was offered effective pain management to include non-pharmacological interventions.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of foodborne illness in one of one kitchen and two of three medication carts. Specifically, the facility failed to ensure: -Food holding temperatures were at appropriate levels to prevent the growth of foodborne pathogens; -Moisture was not between stacked pans; and, -Proper chemical concentrations for the sanitation bucket.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases for two out of three units. Specifically, the facility failed to: -Ensure professional standards of infection control were followed while cleaning a resident room where the resident in the room was on transmission-based precautions, specifically droplet precautions for a COVID-19 infection; -Ensure that different rags were used to clean and disinfect different potentially contaminated surfaces; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that its medication error rate was not five percent or greater for observed medication administration for five residents (#32, #260, #2, #18, and #25). Specifically, the facility had a medication error rate of 20 percent, which was five errors out of 25 opportunities for error. Cross-reference F760 failure to ensure residents were free from significant medication errors.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for two residents (#32 and #260) out of 34 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration for Residents #32 and #260. Cross-reference F759 failure to ensure the medication error rate was less than five percent.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for one resident (#110) of three residents in two allegations of abuse reviewed out of 34 sample residents. Specifically, the facility failed to provide adequate supervision to prevent Resident #110 form being a victim of sexual abuse by Resident #23.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure activities of daily living (ADL) were performed for one resident (#49) of one dependent resident out of 34 sample residents. Specifically, the facility failed to provide oral care for Resident #49, who was dependent on staff for care.