Rosewood Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure enteral nutrition was labeled according to professional standards and facility policy for 1 of 18 sampled residents (Resident #12). This deficient practice had the potential to compromise patient safety by increasing the risk of contamination and infections, and improper hydration management, potentially leading to adverse health outcomes.Findings include:Resident #12Resident #12 was admitted on [DATE] with diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, cerebral aneurysm, and required assistance with personal care.On 12/10/2025 at 4:24 PM, during an observation of enteral feeding administration, the tube feeding pouch (secondary container to hold formula) was hanging in Resident #12's room without required labeling. The tube feeding pouch was not labeled with the resident's name, formula name, date and time hung, or expiration/beyond-use time.A physician order, dated…

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, clinical record review, and document review, the facility failed to ensure the oxygen was administered and saturation levels were monitored according to a physician order for 1 of 18 sampled residents (Resident #8). This deficient practice had the potential to cause exacerbation of the resident's underlying health conditions.Findings include:Resident #8Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic diastolic (congestive) heart failure, cognitive communication deficit, and atherosclerotic heart disease of native coronary artery without angina pectoris.On 12/08/2025 at 9:45 AM, Resident #8 was observed seated in a wheelchair next to the resident's bed. An oxygen concentrator was located on the opposite side of the bed and was running. The tubing from the oxygen concentrator was traced across the bed but was not connected to the resident via nasal cannula, and oxygen was not being administered. A physician's order dated…

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 clinical record review, interview, and document review, the facility failed to maintain completed dialysis communication forms for 1 of 18 sampled residents (Resident #116). This deficient practice had the potential to result in a lack of critical information shared between the facility and the dialysis provider with the potential to have lead to delays and errors in care, adversely having affected resident health and safety.Findings include:Resident #116Resident #116 was admitted to the facility on [DATE], with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus, liver transplant status, altered mental status, unspecified, and end stage renal disease.A physician's order dated 12/06/2025, documented Resident #116 was to receive dialysis treatment at a dialysis center every Monday, Wednesday, and Friday. Special instructions: Vital signs before and after each session. Send/receive communication form with patient. Medical records to scan upon return.Resident #116's clinical…

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, clinical record review, and document review the facility failed to ensure a resident with a documented history of trauma received trauma informed care based on the triggering factors identified in the trauma assessment for 1 of 10 residents sampled for facility reported incident and complaint investigations (Resident #11). This deficient practice had the potential to result in a resident experiencing re-traumatization and experiencing an intense reaction causing psychosocial harm.Findings include:Resident #11Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, and schizophrenia, unspecified. A facility reported incident, dated 07/23/2025, documented the resident had reported receiving a bed bath the night before from a male Certified Nursing Assistant (CNA). The resident reported feeling as if the CNA had been invasive when cleaning around the…

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, clinical record review and document review, the facility failed to ensure staff received training and were deemed competent by the facility to provide care to Peripherally Inserted Central Catheters (PICCs) prior to being assigned to care for 1 of 18 sampled residents (Resident #96). This deficient practice had the potential to result in insertion site and blood stream infections for residents due to lack of knowledge of correct technique for dressing changes and signs and symptoms of potential complications.Findings include:Resident #96Resident #96 was admitted to the facility on [DATE], with diagnoses including sepsis, unspecified organism and bacteremia.On 12/08/2025 at 11:22 AM, Resident #96 had a PICC line in the resident's left upper arm. The insertion site was covered with a transparent dressing. The dressing lacked a date the dressing was changed and initials indicating who placed the dressing. Resident #96 verbalized the resident was receiving antibiotics for an…

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, clinical record review, and document review, the facility failed to 1) ensure a medication ordered for the relief of shortness of breath and pain was available for a resident receiving hospice services for 1 of 10 residents sampled for facility reported incident and complaint investigations (Resident #86), This deficient practice had the potential to result in a resident not receiving timely relief from pain or shortness of breath and experiencing unnecessary and prolonged suffering at the end of life, and 2) maintain accurate controlled substance logs for four unsampled residents (Resident #81, # 1, #7, and #63) in 2 of 2 reviewed narcotic logs. This deficient practice had the potential to result in medication errors, inaccurate documentation of controlled substances, and increased risk of harm to residents due to improper handling of medications.Findings include: Resident #86 Resident #86 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including…

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 document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility by not honoring diets, preferences, and not notifying residents of a menu change.Findings include:On 12/10/2025 at 9:07 AM, during a resident council meeting, 8 of 8 residents verbalized the facility would often serve the residents food not on the menu. The staff would not provide any notification to the residents and serve whatever the facility felt like serving.Resident #44 verbalized for breakfast on 12/10/2025, the residents were supposed to receive waffles for breakfast. Some residents received waffles and some received French toast. Resident #44 explained no notification was given to the residents of the change and the resident was looking forward to waffles, but was instead served French toast with no explanation from the staff. The resident verbalized this concern had previously been brought to the staff's attention.The Resident Council Meeting Minutes from 09/26/2025, documented…

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 document review, the facility failed to ensure an opened bottle of hand sanitizer was removed from a resident food storage area. This deficient practice had the potential to affect all residents in the facility by increasing the risk of food contamination and illness.Findings include:On 12/08/2025 at 8:23 AM, an open bottle of FLTR Pure Protectant hand sanitizer gel (75% ethyl alcohol, 16.9 fluid ounces) was observed on a shelf in the resident food storage area. The hand sanitizer was placed on a tray with a coffee pot, cups, creamer, and sugar.On 12/08/2025 at 8:25 AM, the [NAME] confirmed an open bottle of hand sanitizer was being stored with the resident dry food. The [NAME] explained the hand sanitizer was kept on a tray containing a coffee pot, and accessories to serve hot coffee to residents, because when staff would take the tray out into the hallways, if residents wanted coffee, staff were using the hand sanitizer prior to giving the residents coffee. The cook verbalized chemicals were not to be stored with food to be served to…

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, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen at a nursing station facing a public area. This deficient practice had the potential to result in unauthorized access to residents' Protected Health Information (PHI).Findings include:On 12/09/2025 at 10:01 AM, a nurse walked away from the medication cart and left a computer screen open displaying resident information, including medications for the resident in room [ROOM NUMBER]-B.On 12/09/2025 at 10:03 AM, one staff member walked by the unlocked computer screen.On 12/09/2025 at 10:05 AM, the nurse walked behind the nurse's station.On 12/09/2025 at 10:05 AM, the Licensed Practical Nurse (LPN) returned to the medication cart. When asked if the computer should have been locked prior to leaving the cart, the LPN verbalized, I guess so, and explained locking the computer when walking away was required to protect PHI under Health Insurance…

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 document review, the facility failed to ensure education regarding the facility's Antibiotic Stewardship Program (ASP) was provided to residents and residents' representatives/families. This deficient practice had the potential to affect all residents in the facility and placed residents at risk of developing antibiotic-resistance. Findings include:On 12/11/2025 at 12:04 PM, the IP verbalized the purpose of the IP role was to facilitate the infection control program and provide education regarding the facility's policies and infection control plan. The IP explained if an antibiotic was prescribed for a resident, the IP would visit the resident and provide education regarding the facility's ASP. The IP would later call the resident's representative/family member to provide education regarding the ASP. The IP explained the education was provided verbally and denied the IP had documented evidence the IP provided the education.The IP confirmed education regarding the ASP was only provided to residents and representatives/families of residents who were prescribed…

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 employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 1 of 20 sampled employees (Employee #11). The deficient practice had the potential to place residents at risk for abuse and neglect. Findings Include: Employee #11 Employee #11 had a title of Licensed Practical Nurse (LPN) and a hire date of 04/01/2025. Employee #11's record lacked documented evidence abuse training had been completed. On 12/10/2025 at 12:37 PM, the Human Resources Payroll Representative confirmed Employee #11 had worked 29 shifts as a contract LPN and had not completed abuse training, as required. The Human Resources Payroll Representative verbalized having been responsible for ensuring contract employees obtained the required abuse training but did not ensure the training was completed. The facility policy titled, Freedom from Abuse, Neglect, Exploitation, revised 10/2022, documented staff would receive training…

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 interview, clinical record review, and document review the facility failed to ensure an allegation of neglect was thoroughly investigated for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential for physical and/or emotional harm to residents due to allegations of neglect not being thoroughly investigated and protections not put in place to prevent future neglect. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including wedge compression fracture of T7-T8 vertebra, subsequent encounter for fracture with routine healing and encounter for other orthopedic aftercare. An initial Facility Reported Incident (FRI) Report submitted by the facility on [DATE], documented the type of incident as neglect. The FRI Report documented a Certified Nursing Assistant (CNA) reported a Blood Pressure (BP) reading for Resident #2 of 118/65 around 6:00 AM. The resident was found in the resident's room with no pulse, cold to touch, and with signs…

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, clinical record review, and document review the facility failed to ensure tube feeding was administered to a resident per physician order and a physician's order for tube feeding was complete prior to administration for 1 of 10 sampled residents (Resident #8). This deficient practice had the potential to result in malnutrition, dehydration, inadequate and inappropriate caloric intake. Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with a diagnosis of dysphagia following cerebral infarction. A Physician Order dated 03/09/2025, documented Enteral Feed Order at bedtime, 40 milliliters (ml)/ hour (hr). Hang at 8:00 PM and take down at 6:00 AM. The discontinue date was 04/22/2025 at 1:41 PM. A Physician Order dated 04/22/2025, with a start date of 04/23/2025, documented Enteral Feed Order one time a day, Jevity 1.2. On at 8:00 PM at 50 cubic centimeters (cc)/ hr for ten hours, off at 6:00 AM. On 04/23/2025 at 12:37 PM, a Licensed Practical Nurse 1…

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 clinical record review, interview, and document review the facility failed to ensure a clinical record was complete for 1 of 10 sampled residents (Resident #1). This deficient practice had the potential for care provided to residents, resident response to care provided, and refusals of care to not be documented and available for review as necessary. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including multiple fractures of ribs, bilateral, subsequent encounter for fracture with delayed healing and mild protein-calorie malnutrition. Resident #1's Documentation Survey Report for September 2024, documented an intervention/task of bathing. The report documented Resident #1 received a shower on 09/02/2024 and 09/16/2024, and a full-body bath on 09/14/2024. The intervention/task had a blank space for the PM shifts on 09/06/2024, 09/11/2024 and 09/15/2024. An intervention/task titled shower/bathe self documented the resident received partial/moderate…

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 interview, clinical record review, and document review, the facility failed to ensure residents were informed both orally and in writing prior to or upon admission of the rules related to leaving on pass. This deficient practice had the potential to affect the entire facility population of 87 residents. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of type two diabetes mellitus without complications. On 12/17/2024 at 10:24 AM, Resident #3 verbalized the resident was informed the resident was unable to leave the facility premises because he was unable to walk. Resident #3 verbalized being in the facility felt like being in a prison. On 12/18/2024 at 10:48 AM, a Certified Nursing Assistant (CNA) verbalized residents who wanted to leave the facility property on pass would need to get approval with a physician's order. On 12/18/2024 at 11:16 AM, a Licensed Practical Nurse (LPN) verbalized residents who wanted to go out on…

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 and interview, the facility failed to ensure the ice machine was free of buildup and refrigerated foods were covered, labeled and dated. The deficient practice could potentially expose residents to foodborne illnesses. Findings include: Ice Machine On 10/07/2024 at 8:18 AM, the ice machine in the kitchen had black buildup on the plastic visor above the ice. On 10/07/2024 at 8:35 AM, the Dietary Manager (DM) verbalized the ice machine was cleaned every three months. The expectation was the staff would clean any visible buildup in the machine. The DM confirmed the buildup in the ice machine and should have been cleaned. Uncovered Food On 10/09/2024 at 11:22 AM, three cups of fruit cocktail were uncovered in the trayline refrigerator. On 10/09/2024 at 11:27 AM, the [NAME] verbalized food stored in the refrigerator would be covered and labeled with the date. The [NAME] confirmed three cups of fruit cocktail were uncovered in the refrigerator. On 10/09/2024 at 11:30 AM, the DM verbalized the expectation was food in refrigerator was covered and labeled with the date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was informed in advance of the menu options and alternative meal choices for 1 of 18 sampled residents (Resident #44). This deficient practice had the potential to result in a resident experiencing frustration due to a lack of choice and the resident having to wait longer to eat due to not wanting the offered meal and needing to request an alternative after the meal had been delivered. Findings include: Resident #44 Resident #44 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, hypothyroidism, unspecified, and neuromuscular dysfunction of bladder, unspecified. On 10/07/2024 at 10:17 AM, Resident #44 verbalized the resident frequently had to send the resident's meal trays back to the kitchen and request a bowl of soup. The resident verbalized the resident was not aware of an alternative menu, but the facility was usually able to bring the resident a bowl 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview, and document review, the facility failed to report resident to resident abuse to the State Agency (SA) within the required timeframes for 1 of 18 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including vascular dementia, severe, with psychotic disturbance, and unspecified mood (affective) disorder. Resident #57 Resident #57 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with agitation, and unspecified mood (affective) disorder. A Behavior Note dated 10/05/2024, for Resident #57 documented upon walking into the resident's room, Resident #57 was seen slamming their wheelchair into their roommate, Resident #23's legs. A Facility Reported Incident (FRI) was submitted to the SA on 10/07/2024, documenting the resident to resident abuse between Resident #23 and Resident #57. On 10/10/2024 at 10:05 AM, the Abuse Coordinator…

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, clinical record review, and document review, the facility failed to ensure a care plan was developed to address side effects and necessary monitoring for a resident receiving an anticoagulant and experiencing symptoms of a gastrointestinal bleed and low hemoglobin (a protein carrying oxygen in red blood cells) and hematocrit (a measurement of the proportion of red blood cells in the blood) levels for 1 of 18 sampled residents (Resident #71); and failed to develop a care plan for a resident's diagnosis of hypoxemia and the administration of oxygen for 1 of 18 sampled residents (Resident #134). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for further signs of active bleeding. Findings include: Resident #71 Resident #71 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left…

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 interview, clinical record review, and document review, the facility failed to ensure laboratory (lab) results were monitored for timely completion and staff caring for a resident were informed of the resident's signs and symptoms of active bleeding while on anticoagulant therapy for 1 of 18 sampled residents (Resident #71). This deficient practice had the potential to result in a resident suffering a severe adverse health outcome because of blood loss. Findings include: Resident #71 Resident #71 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery, chronic kidney disease, stage 3B, and acute cystitis without hematuria. On 10/07/2024 at 2:01 PM, the resident verbalized the resident had been on blood thinner medication and the resident had low blood. An order dated 09/04/2024, documented apixaban oral tablet 2.5 milligrams (mg), give one tablet by mouth two times a day for atrial fibrillation. A Change in…

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 clinical record review, interview, and document review, the facility failed to provide care to prevent Moisture Associated Skin Damage and a pressure injury for 1 of 4 closed records reviewed (Resident #184). This deficient practice led to a skin injury. Findings include: Resident #184 Resident #184 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and type two diabetes mellitus with foot ulcer. The resident was discharged on 07/15/2024. Resident #184's Daily Skilled Note dated 07/05/2024, documented no active skin conditions. Resident #184's Nursing Note dated 07/09/2024, documented a Certified Nursing Assistant (CNA) was doing rounds and noticed redness and an open area on the resident's coccyx . The nurse told the CNA to put cream on the resident and ensure the resident was being changed every two hours. Resident #184's Licensed Nurse Skin Evaluation dated 07/09/2024,…

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 clinical record review, observation, interview, and document review, the facility failed to ensure a known tripping hazard was corrected to prevent potential falls by residents and visitors using the outside courtyard. Findings include: The Facility Reported Incident (FRI) #NV00071929, dated 08/13/2024, documented a resident was witnessed tripping over an irrigation sprinkler head in the courtyard, resulting in a fracture to the right elbow and patella. FRI #NV00071929 Final Report, dated 08/16/2024, documented the action taken to prevent future occurrences included education to the resident on mobility and safety outdoors. The Final Report lacked language to include the corrective measure(s) taken to prevent future occurrences of tripping caused by the sprinkler heads in the courtyard. On 10/09/2024 at 1:55 PM, the sprinkler heads located in the courtyard, between the grass and a concrete walkway, were in the off position. Five of the sprinkler heads were raised above the level of the ground approximately 1-2 inches. On 10/09/2024 at 1:55 PM, the Director of Environmental…

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 clinical record review, observation, interview, and document review, the facility failed to obtain a physician's order for the administration of oxygen for 1 of 18 sampled residents (Resident #134). Findings include: Resident #134 Resident #134 was admitted to the facility on [DATE], with a diagnosis of hypoxemia. On 10/07/2024 at 12:49 PM, Resident #134 was sitting in a wheelchair next to the bed. An oxygen concentrator, reading two liters-per-minute, next to the resident was on and the resident was receiving oxygen via a nasal cannula. Resident #134's clinical record lacked documented evidence of a physician order for the administration of oxygen. On 10/08/2024 at 2:16 PM, Resident #134 verbalized not having used oxygen prior to being admitted to the facility and was unsure if the resident needed it. On 10/08/2024 at 2:42 PM, the Director of Nursing confirmed Resident #134 had been receiving oxygen since admission and confirmed Resident #134's clinical record lacked a physician order for oxygen. The…

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 document review the facility failed to ensure medications were not left unsecured in a medication cart. The deficient practice could have facilitated unauthorized access to medications in the cart. Findings include: On 10/09/2024 at 11:44 AM, a medication cart located outside of the nurse's station was unlocked and unattended while a resident and visitors were in the hallway. On 10/09/2024 at 11:46 AM, the Director of Nursing (DON) approached the medication cart and verbalized the expectation was medication carts remain locked when unattended. The DON confirmed the medication cart was unlocked and a resident and visitors were present. The facility policy titled Storage of Medication, dated 2007, documented only licensed nurses and those lawfully authorized to administer medications were allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and interview, the facility failed to ensure a resident's diet order was followed for 1 of 18 sampled residents (Resident #134). Findings include: Resident #134 Resident #134 was admitted to the facility on [DATE], with diagnoses including acute kidney failure and chronic kidney disease, stage four. On 10/07/2024 at 12:18 PM, Resident #134 was sitting in a wheelchair next to the bed. A tray table was in front of the resident with the resident's lunch meal of pureed cheese enchiladas, pureed Spanish rice and refried beans. A meal ticket, dated 10/07/2024 for lunch, documented Resident #134's name and room number, with a diet order of mechanical soft, low fiber. The resident appeared to have their own teeth. On 10/07/2024 at 12:20 PM, Resident #134 verbalized not knowing why the resident had been receiving meals with pureed or mechanically altered foods. The resident verbalized the food tasted good but did not like the texture of the soft food. A physician's order dated…

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 document review, the facility failed to ensure water samples were collected and submitted for Legionella testing on a five-year basis as per the facilities water management policy. This deficient practice had the potential to result in resident illnesses from undetected bacteria in the facility water lines. Findings include: On 10/09/2024 at 4:19 PM, the Director of Environmental Services (Director) verbalized the maintenance department was responsible for the water management program within the facility. The Director verbalized the facility did not have results of Legionella testing and the Director did not know when testing was last conducted. The Director verbalized the facility did not have a plan to conduct testing at a future date. The Director confirmed the current practice was not following the facility policy for Legionella testing frequency. The facility policy titled Rosewood Rehabilitation Center Control Measures, undated, documented control areas would have random water samples collected and submitted for Legionella testing on a five-year basis,…

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 personnel record review, interview and document review, the facility failed to ensure annual elder abuse training was completed for 1 of 25 sampled employees (Employee #9). Findings include: Employee #9 Employee #9 was hired as a Registered Nurse on 12/10/2015. Employee #9's personnel record documented elder abuse training completed on 08/27/2023 but lacked documented evidence elder abuse training was completed in 2024 On 10/09/2024 at 11:18 AM, during an interview for review of personnel records, the Human Resources Representative (HRR) verbalized all staff were required to complete elder abuse training upon hire prior to starting on the floor, and annually thereafter. The HRR confirmed Employee #9's personnel record lacked annual elder abuse training in 2024. A facility policy titled Abuse: Prevention of and Prohibition Against, revised 05/2023, documented the facility would engage in training and orienting its new and existing nursing staff on topics to include prohibiting and preventing all forms of abuse, identifying what constitutes abuse, recognizing signs of abuse,…

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, record review and document review the facility failed to ensure a Care Plan related to an indwelling catheter and catheter care was developed and implemented for 1 of 19 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease and benign prostatic hyperplasia, without lower urinary tract symptoms. A Physician's Order dated 02/12/2024, documented to provide indwelling catheter care every shift. A Physician's Order dated 02/12/2024, documented indwelling catheter: 18 French 5 cubic centimeters balloon, change every night shift every 30 days. A care plan focus dated 02/09/2024, documented Resident #1 had bowel/bladder incontinence related to impaired mobility and prostate enlargement. Resident #1's comprehensive care plan lacked documented evidence a care plan related to an indwelling catheter and catheter care. On 08/01/2024 at 4:52 PM, the Director of Nursing (DON) confirmed…

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 document review, the facility failed to ensure a high temp dishwasher was operating appropriately, and expired food items were discarded. This had the potential to affect the entire facility census. Findings include: Sanitizing Dishwasher On 10/30/23 at 8:10 AM, during the initial kitchen tour, the dishwasher was making a noise and the dishwasher final rinse cycle rinsed at 178 degrees Fahrenheit. On 10/30/23 at 8:12 AM, a [NAME] verbalized all dietary staff was responsible for dishwashing. The [NAME] verbalized the lower dishwasher sprayers were not working correctly and would get stuck together due to being loose. The [NAME] was unsure if a work order had been submitted. On 10/30/23 at 8:43 AM, the Dietary Supervisor verbalized there was no work order for the dishwasher and explained the need to ensure the dishwasher was working properly to sanitize all dishes to avoid illness in the facility. The Dietary Supervisor confirmed the dishwasher final rinse was not getting to 180 degrees Fahrenheit and confirmed the dishes were not being sanitized…

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 clinical record review, interview, and document review the facility failed to ensure 1) 2 of 5 sampled residents (Resident #308 and #55) were administered a pneumonia vaccine after the vaccine was requested by the residents, 2) 25 of 82 residents residing in the facility were screened for eligibility to receive a pneumococcal vaccination, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined, and 3) 12 of 82 residents requesting to receive an influenza vaccine were administered the vaccine. The failure resulted in 45.11 percent (%) of the facility's residents either not being screened and offered the vaccine or not receiving the vaccine after eligibility was determined and the vaccine was requested. This failure had the potential to result in a facility wide outbreak of influenza. Findings include: Pneumonia Resident #308 Resident #308 was admitted to the facility on [DATE], and readmitted on…

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, clinical record review, and document review, the facility failed to ensure the privacy of resident health information was maintained for 3 of 3 residents whose names were visible under the wounds tab of the electronic health record (EHR) on an unstaffed and open computer screen (Residents #300, #309, and #311). Findings include: Resident #300 Resident #300 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute kidney failure, unspecified, type two diabetes mellitus with hyperglycemia, and unspecified asthma, uncomplicated. Resident #309 Resident #309 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounter for other orthopedic, aftercare, and emphysema, unspecified. Resident #311 Resident #311 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, acute and chronic…

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 clinical record review, interview and document review, the facility failed to prevent resident to resident abuse for 2 of 6 Facility Report Incident (FRI) residents (Resident #45 and #79) and failed to prevent resident neglect for 1 of 6 FRI residents (Resident #47). Findings include: FRI #NV00069544 documented on 09/28/23 a resident grabbed the arm of and tried to hit another resident. Resident #45 Resident #45 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, anxiety disorder and unspecified convulsions. Resident #79 Resident #79 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, unspecified dementia, and anxiety disorder. A Nursing Progress Note dated 09/27/23, documented Resident #45 was slamming a door and cussing at Resident #79. Resident #45 tried to grab the arm and hit Resident #79. Both residents were separated. Resident #79 would be moved to a different room. On 11/02/23 at 8:18 AM, the Director of Nursing…

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 document review and interview, the facility failed to submit a Facility Reported Incident (FRI) final report to the State Survey Agency (State) within the five-day requirement for 1 of 7 FRIs investigated. Findings include: FRI# NV00069177 with the allegation a Certified Nursing Assistant had force fed a resident was submitted to the State on 08/09/23. A final investigation report was submitted to the State on 08/17/23, three days past the five-day requirement. On 11/02/23 at 8:33 AM, the Director of Nursing (DON) confirmed having been responsible for submitting the initial and final FRI reports to the State. The DON confirmed the final report for FRI# NV00069177 had been submitted late due to a miscalculation of the dates. The facility policy titled, Abuse: Prevention of and Prohibition Against, reviewed 10/2022, documented the facility would follow the applicable reporting timeframes and regulations of the State or Federal agency for all reports of resident abuse. FRI# NV00069177

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interview and document review, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 5 of 5 sampled residents reviewed for Resident Assessment (Resident #8, #9, #11, #41, and #46). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with a diagnosis of cerebral palsy. Resident #8's quarterly MDS assessment documented a start date of 09/26/23 and a completion date of 10/16/23. On 11/02/23 at 9:17 AM, the MDS Coordinator confirmed Resident #8's quarterly MDS assessment dated [DATE] should have been transmitted on 10/23/23 but had not yet been transmitted. Resident #9 Resident #9 was admitted to the facility on [DATE], with a diagnosis of dementia. Resident #9's quarterly MDS assessment documented a start date of 09/20/23 and a completion date of 10/10/23. On 11/02/23 at 9:19 AM, the MDS Coordinator confirmed Resident #9's quarterly MDS assessment dated [DATE] should have been transmitted on 10/17/23 but 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 clinical record review, interview and document review, the facility failed to ensure 1) care planned interventions related to cognitive functioning were completed and person centered, and care planned interventions related to communication were implemented for 1 of 18 sampled residents (Resident #26), 2) care planned interventions regarding psychotropic medications were medication specific and included the behaviors to be monitored for 1 of 18 sampled residents (Resident #40), 3) a care plan related to the use of bedrails was developed for 1 of 18 sampled residents (Resident #31), and 4) care plans were developed following resident abuse and neglect for 2 of 18 sampled residents (Resident #47 and #45). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of type II diabetes mellitus. Resident #26's Comprehensive Care Plan included a care plan related to impaired cognitive function/dementia initiated on 05/25/23. Care planned…

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, clinical record review, and document review, the facility failed to ensure professional standards of practice were followed during medication preparation and administration for 2 of 3 residents observed during medication administration (Residents #56 and #7) and the practitioner adhered to professional standards of quality for assessing and diagnosing a resident with schizoaffective disorder for 1 of 18 sampled residents (Resident #40). Findings include: Resident #56 Resident #56 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified osteoarthritis, unspecified site and opioid dependence, uncomplicated. On 11/01/23 at 7:30 AM, Resident #56 asked a Licensed Practical Nurse (LPN) for oxycodone. The LPN administered 10 milligrams (mg) of oxycodone to Resident #56. The LPN then asked the resident to rate the pain and where the pain was located. An Order Review History Report for Resident #56 documented oxycodone oral tablet 10 mg, give…

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, clinical record review and document review, the facility failed to offer a non-English speaking resident a communication device and/or provide translation services for 1 of 18 sampled residents (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of type II diabetes mellitus. Resident #26's Comprehensive Care Plan documented Resident #26 had limited English proficiency (LEP) and interventions included use of a language (phone) line. On 11/02/23 at 8:22 AM, a Hospitality Aide (HA) verbalized the HA tried to speak as much of the resident's language as possible and used short sentences. The HA explained a member of the resident's family visited almost daily and helped some with communication but was rarely at the facility for very long. The HA did not use a language line. On 11/02/23 at 8:25 AM, a Certified Nursing Assistant (CNA), verbalized the CNA communicated with Resident #26 by using hand…

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, clinical record review, and document review, the facility failed to ensure resident care was coordinated with a hospice agency for a resident receiving hospice services for 1 of 18 sampled residents (Resident #34). Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including tubulo-interstitial nephritis, not specified as acute or chronic, quadriplegia, unspecified, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. On 10/30/23 at 10:50 AM, Resident #34 expressed concern the facility did not do what hospice told them. A Physician's order for Resident #34, dated 07/10/23, documented to admit to hospice. The Task: Bathing documented Not Applicable for the dates of 10/20/23 through 10/29/23, in response to the question What type of bathing activity was completed?. A hospice Plan of Care Update Report, dated 10/05/23, documented the resident was receiving home health aide…

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, clinical record review, and document review, the facility failed to ensure a resident's pain level and location was assessed prior to the administration of an as needed (prn) narcotic pain medication for 1 of 3 residents observed for medication administration (Resident #56). Findings include: Resident #56 Resident #56 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including polyneuropathy, unspecified, unspecified osteoarthritis, unspecified site, and opioid dependence, uncomplicated. On 11/01/23 at 7:30 AM, a Licensed Practical Nurse (LPN) administered 10 milligrams (mg) of oxycodone to Resident #56. After the resident had taken the medication, the LPN asked the resident for the pain level and location of the pain. An Order Review History Report and the November 2023 Medication Administration Record for Resident #56 documented the following: - oxycodone hydrochloride oral tablet 10 mg, give one tablet by mouth every three hours as needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents with bedrails had appropriate alternatives attempted and implemented prior to usage for 1 of 18 sampled residents (Resident #31). Findings include: Resident #31 Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified cirrhosis of liver, difficulty in walking and unsteadiness of feet. On 10/30/23 at 2:42 PM, Resident #31's bed had half bedrails up on both sides and was in the lowest position. On 11/01/23 at 3:51 PM, Resident #31 verbalized using the bed rails to get out of bed. Resident #31's physician's order dated 10/02/23, documented bilateral quarter size bed side rails for improved safety/stability during mobility and to decrease risk of falls. Resident #31's Bed Rail Safety Evaluation, dated 10/03/23, documented full bed precautions with low bed and fall mats for injury prevention given the resident's risk of falling. On 11/01/23 at…

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 interview, clinical record review, and document review, the facility failed to ensure a resident on a psychotropic medication had an assessment addressing why the medication was prescribed for 1 of 18 sampled residents (Resident #40). Findings include: Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, type 2 diabetes mellitus without complications and restless legs syndrome. Resident #40's Resident Information sheet, from the facility, documented on 03/29/23 the onset diagnosis of schizoaffective disorder. A Physician's Order for Resident #40 originally dated 02/02/23, and order renewed 10/25/23, documented Seroquel tablet, 50 milligrams (mg), give by mouth two times a day related to schizoaffective disorder, unspecified. The Care Plan for Resident #40 lacked documentation of the Seroquel, behaviors to monitor, completed assessments, and the diagnosis associated with Seroquel. Resident #40's clinical record lacked documented evidence 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate of less than 5 percent (%). There were 33 opportunities and 11 medication errors. The medication error rate was 33.33%. Findings include: Resident #56 Resident #56 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including polyneuropathy, unspecified, unspecified osteoarthritis, unspecified site, and opioid dependence, uncomplicated. On 11/01/23 at 7:30 AM, a Licensed Practical Nurse (LPN) administered 10 milligrams (mg) of oxycodone to Resident #56. After the resident had taken the medication, the LPN asked the resident for the pain level and location of the pain. An Order Review History Report and the November 2023 Medication Administration Record (MAR) for Resident #56 documented the following: - oxycodone hydrochloride oral tablet 10 mg, give one tablet by mouth every three hours as needed (prn) for chronic pain. On 11/01/23…

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, document review, and interview, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify influenza vaccines were not administered in a timely manner after receiving the influenza vaccine supplies. The facility's failure to identify areas in need of performance improvement related to resident vaccinations resulted in 45.11 percent (%) of the facility's residents not being vaccinated for influenza with the potential to affect the health and safety of the residents during the influenza season. Findings include: On 11/02/23 at 1:50 PM, the Administrator confirmed the QAPI committee failed to identify 45.11% of the facility's residents had not been screened for influenza vaccination or had been screened and desired to receive the influenza vaccine and the vaccine was not administered. The facility policy titled, QAPI Plan, dated 2022-2023, documented the QAPI plan was ongoing and comprehensive. The purpose was to correct identified deficiencies in quality series and put mechanisms in place to ensure performance 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 observation, interview, clinical record review, and document review the facility failed to ensure appropriate infection control practices were adhered to when preparing an insulin pen for insulin administration for 1 of 3 residents observed for medication administration (Resident #7). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic neuropathy, unspecified and type two diabetes mellitus with hyperglycemia. On 11/01/23 at 7:36 AM, a Licensed Practical Nurse (LPN) began preparing insulin for Resident #7. The LPN applied the needle to the insulin pen and did not scrub the rubber stopper with alcohol prior to applying the needle. On 11/01/23 at 7:38 AM, the LPN confirmed the LPN did not scrub the rubber stopper prior to applying the needle. The LPN verbalized the LPN believed the stopper to already be sterile. On 11/01/23 at 10:43 AM, the DON verbalized the rubber stopper on an…

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 clinical record review, interview, and document review the facility failed to ensure a COVID-19 (COVID) vaccine was administered as requested for 1 of 5 residents sampled for vaccination administration (Resident #308). Finding include: Resident #308 Resident #308 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encounter for orthopedic after care following surgical amputation, pulmonary hypertension, unspecified, and heart failure unspecified. A document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination, signed by Resident #308's representative on 10/27/23, documented the resident wished to receive a COVID vaccine. Resident #308's facility Immunization Report, dated 10/31/23, documented consent for vaccination with a COVID vaccine was obtained. The Immunization Report lacked documented evidence the vaccine was administered. On 11/01/23 at 9:58 AM, the Infection Preventionist (IP) confirmed Resident #308's Resident Representative…

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 personnel record review, interview, and document review, the facility failed to ensure elder abuse training was completed timely for 7 of 20 sampled employees (Employee #4, #12, #20, #21, #22, #23, and #24). Findings include: Employee #4 Employee #4 was hired as the Infection Preventionist on 01/31/23. Employee #4's personnel record documented elder abuse training was completed on 02/02/23. Employee #12 Employee #12 was hired as a Certified Nursing Assistant (CNA) on 04/06/23. Employee #12's personnel record documented elder abuse training was completed on 04/13/23. Employee #20 Employee #20 was hired as the Registered Dietician on 01/01/23. Employee #20's personnel record lacked documented evidence elder abuse training completed. Employee #21 Employee #21 was hired as a Registered Nurse on 01/20/23. Employee #21's personnel record documented elder abuse training was completed on 02/09/23. Employee #22 Employee #22 was hired as a Licensed Practical Nurse (LPN) on 03/24/23. Employee #22's personnel record documented elder abuse training was completed on 04/14/23. Employee…

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 interview, clinical record review, and document review, the facility failed to ensure a resident was not kicked by another resident and a resident was not threatened with harm by another resident for 2 of 11 sampled residents (Resident #8 and Resident #11). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and cognitive communication deficit. Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including disorganized schizophrenia and personal history of traumatic brain injury. A Facility Reported Incident (FRI) documented Resident #7 kicked Resident #8 in the knee on 08/08/23. The clinical records for Resident #7 and Resident #8 lacked documentation of the incident. The Care Plan for Resident #7, initiated 06/20/23, documented the staff would monitor for signs of agitation to provide redirection and would remove from situations causing high agitation. On 08/31/23 at 1:17…

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 interview, clinical record review, and document review, the facility failed to submit a final facility incident report to the State Agency within five days of the incident for 3 of 7 facility reported incidents (FRI) and failed to ensure an FRI was submitted for an incident of verbal abuse for 1 of 11 sampled residents (Resident #11). Findings include: An initial FRI #NV00069291 was submitted to the State Survey Agency on 08/24/23, with the following allegations: 1. A resident was asked to sign a document confirming pain medication administration and was in retaliation of a complaint. 2. A resident did not receive pain medication in a timely manner or as prescribed. A final investigation report had not been received by the State Survey Agency. On 08/31/23 at 11:20 AM, the Administrator confirmed the facility did not have documentation the final report was submitted to the State Survey Agency. The Administrator verbalized the Administrator had always assumed the submission for the final investigation…

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 interview and document review, the facility failed to initiate a care plan related to wound care for 1 of 11 sampled residents (Resident #5) and ensure a care plan related to pain was person-centered for 1 of 11 sampled residents (Resident #1). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, limitation of activities due to disability, spinal stenosis, and muscle weakness (generalized). Resident #5's physician order dated 07/28/23, documented sacral wound, cleanse with normal saline or wound cleanser, pat dry, apply medihoney, cover with foam dressing. Monitor for signs and symptoms of infection or worsening, notify provider of any changes. Every day shift every Monday, Thursday, Saturday and as needed. A care plan initiated for pressure ulcers on 07/13/23, documented Resident #5 had a pressure ulcer or potential for pressure ulcer development related to weakness. The…

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 #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, limitation of activities due to disability, spinal stenosis, and muscle weakness (generalized). A physician order for Resident #5 dated 07/14/23, documented lisinopril oral tablet 20 mg, give one tablet by mouth one time a day for hypertension, hold for Systolic Blood Pressure (SBP) less than (<) 110. Resident #5's Medication Administration Record (MAR) dated 07/01/23-07/31/23, documented Resident #5's SBP was 102 on 07/22/23. The medication was not held for a SBP of <110 and was administered to the resident on 07/22/23. A daily skilled note documented Resident #5 had a blood pressure of 102/60 and was taken on 07/22/23 at 6:25 AM. Vital Signs did not show any fluctuations from baseline that required intervention(s). On 08/31/23 at 2:46 PM the DON explained Resident #5 should not have received lisinopril with a SBP of 102. The DON confirmed the…

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.