Rosepine Retirement & Rehab Center, LLC

Based on observation, interview and record review, the facility failed to ensure prompt efforts to resolve grievances/complaints, voiced in The Resident Council, were addressed and acted upon for 2 (11/2025 and 12/2025) of 3 months reviewed for grievances/complaints. The facility census was 88. Findings: Review of an undated facility policy on 01/22/2026 at 4:04 p.m. titled, Grievances/Complaints revealed the following .4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; ensure that immediate action is taken if necessary to prevent further violations of any resident rights while the allegation is under investigation. Review of an undated facility policy on 01/21/2026 at 10:49 a.m. titled, Smoking Policy revealed the following .5. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas. 6. Smoking is not allowed in resident rooms or any other non-designated smoking area. Smoking areas will be designated. Review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident's comprehensive care plan was revised to reflect the resident's current Advanced Directive status for 1 (Resident #11) of 18 sampled residents.Findings:Review of Resident #11's electronic medical record revealed an admission date of 09/25/2025, with diagnoses including, in part . Unspecified Mycosis; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; Anorexia, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of Resident #11's electronic record bed board, orders, and LaPost (Louisiana Physician Orders for Scope of Treatment) signed on 10/09/2025 by the resident's physician and Personal Health Care Representative revealed the resident had an advanced directive designation of DNR (Do Not Attempt Resuscitation Allow Natural Death). Review of Resident #11's current comprehensive care plan revealed, in part .Code Status: Full Code, with a revised date of 10/02/2025. Interview on 01/22/2026 at 12:37 p.m., with S2 DON confirmed that Resident #11's care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure an advanced directive was properly reflected in the resident's medical record for 2 (Resident #3 and Resident #44) of 18 sampled residents reviewed for advanced directive status. Findings:Resident #3 Review of Resident #3's medical record revealed an admit date of 12/29/2025 with diagnoses that included: Encounter for Other Orthopedic Aftercare; Chronic Obstructive Pulmonary Disease with (Acute) Lower Respiratory Infection; Hypertensive Heart Disease with Heart Failure; Major Depressive Disorder, Single Episode, Moderate. Review of Resident #3's electronic record dashboard/orders revealed the resident was a Full Code status. Review of Resident #3's 01/2026 physician's orders revealed the code status as Full Code signed on 01/05/2026. Review of Resident #3's care plan with the revision date of 01/11/2026 revealed the code status as Full Code. Review of Resident #3's LaPost (Louisiana Physician Orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (#11) of 2 (#11 and #23) residents reviewed for nutrition. The facility failed to provide ordered dietary supplements for a resident with significant weight loss. Findings: Resident #11 Review of the Resident #11's medical record revealed an admit date of 09/04/2021 with a reentry date of 03/18/2022. Diagnoses included .Parkinson's Disease, Mild Protein-Calorie Malnutrition, Dysphagia - Oropharyngeal Phase, and Muscle Wasting and Atrophy. Review of Resident #11's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #11 required extensive assistance by one person with eating. Review of Resident #11's medical record revealed the resident was care planned for a nutritional problem related to a diagnosis of Protein Calorie Malnutrition, no salt on tray, and mechanical soft diet. Interventions included in part: Monitor, record, and report to Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, to help prevent the development and transmission of infection for 3 (#26, #45, and #72) of 4 (#26, #45, #72, and #83) residents reviewed for infection control. The facility failed to: 1. Ensure staff wore proper PPE while providing wound care to Resident #26; 2. Ensure staff wore proper PPE while proving personal hygiene to Resident #45; and 3. Ensure staff performed proper hand hygiene and maintained a clean technique while performing wound care for Residents #26 and #72. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions read in part . It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 46. Enhanced Barrier Precautions - a. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: i.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to implement the comprehensive person-centered care plan for 1 (#83) of 4 (#17, #21, #76 and #83) sampled residents reviewed for care plans. The facility failed to monitor a medication that was self-administered by a resident. Findings: Review of the facility's policy titled, Medication - Self-Administration with no date, revealed the following, in part: .The nurse will check with the resident each day and document on the MAR if the medication was taken as reported by the resident . Review of Resident #83's medical record revealed an admit date of 09/02/2024 with diagnoses that included in part .Major Depressive Disorder, Hypertensive Heart Disease without Heart Failure, Obstructive and Reflux Uropathy, Shortness of Breath and Pain. Review of Resident #83's admission MDS with an ARD of 09/09/2024 revealed a BIMS summary score of 15, indicating Resident #83 was cognitively intact. Review of Resident #83's current care plan with a start date of 09/07/2024, revealed Resident #83 may keep Albuterol inhaler at bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #47 Based on observation, record review and interview, the facility failed to ensure a resident received proper treatment and an assistive device to maintain and/or improve hearing for 1 (#47) resident reviewed for communication and sensory problems out of a total sample of 21 residents. Findings: Review of Resident #47's Medical Record revealed an admission date of 06/21/2023 with diagnoses that included in part . Benign Paroxysmal Vertigo, Unspecified Ear, Age-related Cataracts, Bilateral, Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus, Parkinson's disease and Speech and Language Deficits following unspecified Cerebrovascular Disease. Review of Resident #47's Quarterly MDS with an ARD of 07/25/2024 revealed a BIMS score of 15, indicative of intact cognition. Review of MDS revealed resident with moderate difficulty with ability to hear and speaker has to increase volume and speak distinctly. Resident did not use a hearing aid or other hearing appliance. Review of Resident #47's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

FACILITY QAPI and QAA Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's quarterly committee meetings. Findings: Review of the facility's 4th Quarterly Quality Assessment and Assurance (QAA) committee sign in sheet conducted on January, 06, 2024 revealed staff in attendance was the facility's Medical Director, Infection Preventionist, staff RN and a staff LPN. Interview on 10/16/2024 at 2:40 p.m. with S2 DON revealed that she was present as a staff RN at the time of the 4th Quarterly QAA meeting was held but the DON at that time was not present. During an joint interview on 10/16/2024 at 2:43 p.m., S1 Administrator and S2 DON indicated that the other members were not available at the time of the QAA meeting scheduled with the facility's Medical Director. S1 Administrator confirmed the required staff members were not in attendance for the Quarterly QAA meetings and should have been.

Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The Facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 70 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facility's approved Menu Matrix revealed: Lunch: Fried Chicken 4oz. Instructions read in part Serve 4oz breaded portion=3oz meat 1 Breast or 1 Thigh + 1 Drumstick An observation on 10/30/2023 at 12:00 p.m. in the dining room during lunch revealed dietary staff preparing resident plates in the kitchen area. The meal included fried chicken. An observation of a resident plate revealed 1 drum stick as the only meat serving on the plate. The plate was covered and placed on the meal cart for facility residents dining in their room. An interview on 10/30/2023 at 12:05 p.m. with S3 Dietary Manager revealed there was no scale in the facility to weigh serving sizes and that staff usually just eye ball the food items that was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #223) of 2 (Resident #12 and Resident #223) Residents sampled for dignity, by failing to ensure she was free of facial hair. Total sample size was 23. Findings: Review of Resident #223's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, Depression Unspecified, Mild-Protein Calorie Malnutrition, Anemia, Age-Related Physical Debility and Unspecified Atrial Fibrillation. Review of Resident 223 #'s Annual MDS with an ARD of 09/26/2023 revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #223 required two person physical assistance with bed mobility and transfers; total dependence with toilet use, bathing and personal hygiene and one person physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure a resident's right to be free from unsolicited sexual abuse (touching) for 1 (Resident #60) of 1 sampled residents. The facility failed to protect Resident #60 from sexual abuse by Resident #48 on 07/01/2023. Total sample size was 23. Findings: The review of the facility's policy titled Abuse Prevention and Investigation read in part . Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #60 Review of Resident #60's clinical record revealed an admit date of 03/31/2023 with diagnoses which included: Major Depressive Disorder, Unspecified Dementia, and Vascular Dementia. Review of Resident #60's Quarterly MDS with an ARD of 08/14/2023 revealed a BIMS score of 3 (indicating severe cognitive impairment). Review of Resident #60's Care Plan with a review date of 11/14/2023 revealed a problem of Altered Cognition related to diagnosis of Dementia, Depression and Suicidal Ideations with interventions that included: Ask simple questions with visual cues if possible and to assist with decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 1 (#60) of 1 residents reviewed for abuse in a total of 23 sampled residents. Interview on 10/30/2023 at 2:48 p.m. with S1 ADM revealed on 07/01/2023 at 6:00 p.m. Resident #60's groin area was touched by Resident #48. S1 ADM revealed this incident of resident to resident non- consensual sexual contact was witnessed by S10 CNA. S1 ADM confirmed Resident #60 was not cognitively intact to consent to being touched by Resident #48. Review of the SIMS (Statewide Incident Management System) report dated 07/11/2023 revealed the allegation of sexual abuse for Resident #60 had been substantiated by the facility. Documentation on the SIMS report reflected the discovery date and time of sexual abuse for Resident #60 was on 07/01/2023 at 6:03 p.m. The SIMS entry time was noted as 07/02/2023 at 2:31 p.m. Interview on 10/31/2023 at 2:48 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a magnifying glass was followed for 1 (Resident #52) resident. Total sample size was 23. Findings: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Legal Blindness Review of Resident #52's Annual MDS with an ARD of 07/26/2023 revealed resident had a BIMS score of 12 (which indicated moderately impaired cognition), and exhibited no behaviors or rejection of care. The MDS revealed Resident #52's vision was coded as being moderately impaired-limited vision, not able to see newspaper headlines but can identify objects. Review of Resident #52's Care Plan with a Review date of 01/11/2024 read in part .resident had impaired vision: Legally blind in right eye, left eye vision adequate, does not wear glasses with interventions that included provide large print materials and a magnifying reading glass to read…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 3 (Resident #2, Resident #18 and Resident #52) of 6 (Resident #2, Resident #11, Resident #18, Resident #26, Resident #35 and Resident #52) residents reviewed for ADL care. Findings: Review of the Facility's Nail Care read in part . Policy: The Purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail Care will be provided between scheduled occasions as the need arises. #2 Review of Resident #2's Care plan with a review date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.