Rose View Rehab And Care Center

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for three of 25 residents reviewed (Residents 6, 40, and 83). Findings include: Clinical documentation review for Resident 40 revealed a Fall Risk Evaluation dated November 27, 2023, at 2:52 AM that indicated the resident was documented as having one to two falls in the past three months under the history of falls section. A review of clinical documentation for Resident 40 revealed no evidence of any falls within the past three months as the above Fall Risk Evaluation noted. A request by the surveyor for any fall investigations for Resident 40 during a meeting with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 2:30 PM revealed no evidence of any falls as indicated. An interview with the Director of Nursing on December 1, 2023, at 9:51 AM confirmed the resident did not have any falls as the Fall Risk Evaluation had indicated. The Director of Nursing further believed the documentation was an error in staff…

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 and staff interview, it was determined that the facility failed to ensure accurate completion of assessments for three of 25 residents reviewed (Residents 4, 30, and 66). Findings include: Clinical record review for Resident 4 revealed a Level I PASRR (Preadmission Screen and Resident Review, assessment used to identify evidence of serious mental illness and/or intellectual or developmental disabilities in all individuals seeking admission to Medicaid- or Medicare-certified nursing facilities) dated November 16, 2018, that indicated Resident 4 had a positive screen for serious mental illness in Section II-D and Section VII indicated that Resident 4 was in a Target Group requiring approval from the Program Office prior to admission. A letter from Office of Mental Health Department of Human Services program offices dated November 20, 2018, determined that Resident 4 had evidence of a mental health condition that met the criteria for a Program Office review and the resident may be…

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 and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of two residents reviewed (Resident 30). Findings include: A clinical record review revealed the facility admitted Resident 30 on July 21, 2021. Further review of Resident 30's clinical record revealed the following weight assessments: July 18, 2023, 137 pounds August 14, 2023, 127.4 pounds (a 9.6 pound, a 7.1 percent significant weight loss) A nutrition progress note dated August 15, 2023, recommended staff monitor Resident 30's weights weekly, and administer Ensure Clear (a nutrition drink that contains high-quality protein and essential nutrients) three times a day with her meals. Further review of Resident 30's weight assessments revealed staff did not complete weekly weights as recommended by the registered dietician. A review of Resident 30's MAR (Medication Administration Record, a form utilized by the facility to document the administration of medications) dated August 2023, revealed no evidence 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, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 56). Findings include: Review of a physician's order for Resident 56 dated August 21, 2023, indicated staff to administer oxygen 2 liters per minute (lpm) via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) continuously. Review of a nursing progress note for Resident 56 dated November 5, 2023, at 6:13 AM revealed the resident had an oxygen saturation (percentage of oxygen in the blood, normal usually is 95-100 percent) of 64 percent. Resident 56's oxygen was bumped up to 4 lpm and his oxygen saturation came up to 90 percent. Review of the treatment administration records for Resident 56 dated November 2023, revealed that the oxygen was administered continuously at 2 lpm. Observation of Resident 56 on November 28, 2023, at 1:45 PM revealed that the resident's oxygen was set at 3.5 lpm. Concurrent interview with…

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 review of active nurse aides and staff interview, it was determined that the facility failed to complete a performance evaluation of every nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 5 and 6). Findings Include: Review of the facility's list of nurse aide staff revealed Employee 5 with a hire date of June 1, 2007, and Employee 6 with a hire date of July 7, 2015. A request to review the annual performance evaluations for Employees 5 and 6 revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with the Nursing Home Administrator on December 1, 2023, at 10:24 AM confirmed that performance evaluations were not completed. 28 Pa. Code 201.19 Personnel policies and procedures

Based on observations and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Second Floor Nursing Unit). Findings include: Observation of the Second Floor Nursing Unit medication cart with Employee 7 (licensed practical nurse) on November 30, 2023, at 8:40 AM revealed an accumulation of debris and dirt in the bottoms of the drawers on the cart. There were multiple unsecured and unidentified medication tablets on the bottom of several of the drawers that included: a small blue oblong pill, a large white capsule, two round white pills, an oblong white pill, half of a white tablet, two oblong pills, and two beige round pills. The above findings were discussed in a meeting with the Nursing Home Administrator and Director of Nursing on November 30, 2023, at 2:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the administration of a pneumococcal vaccine for one of five residents reviewed for immunization concerns (Resident 6). Findings include: Clinical record review for Resident 6 revealed that the facility admitted him on December 3, 2018. Review of Resident 6's immunization history revealed no evidence of a recommended pneumococcal vaccine. Review of a Pneumococcal Immunization Informed Consent dated November 6, 2023, revealed Resident 6's responsible party gave the facility permission to administer the pneumococcal vaccination. During an interview with Employee 4 (infection preventionalist) on December 1, 2023, at 1:57 PM it was confirmed that there was no documented evidence that Resident 6 was offered the pneumococcal immunization. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview it was determined the facility failed to store food and maintain the equipment in a sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on January 7, 2023, at 8:30 AM, revealed the following: A metal sink located in the coffee station area was covered in brown stains. A garbage can located under the sink had dried brown spills covering the lid. The garbage cans have a foot pedal mechanism for opening that was non-functional. Two light green colored wash racks were observed sitting on a shelf below the coffee station. The racks contained debris, dried brown spills, and a buildup of a white flaky substance on several areas of the racks. The racks contained several empty clear pitchers and lids that contained significant brown staining. Dried brown splatter was observed on the wall behind the shelf. The lower shelf of a metal stand with wheels located by the condiment/silverware station, holding metal beverage carafes on the lower shelf was observed dirty with dust and debris and sticky…

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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure documentation of what the resident and/or their responsible party received pertaining to the written notice of the facility bed hold policy at the time of transfer for five of six residents reviewed for hospitalization concerns (Residents 6, 38, 169, 105, and 116). Findings include: Clinical record review revealed nursing documentation dated October 27, 2022, at 1:47 AM noting the facility received a call from the lab indicating Resident 6 had a critical result of her potassium levels. Nursing staff obtained her vitals and notified the nurse practitioner and received an order to send Resident 6 to the emergency room for evaluation and treatment. Nursing documentation revealed that Resident 6 left the facility via an ambulance at 2:15 AM. Social service documentation dated October 28, 2022, at 6:58 AM revealed notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice…

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, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure reconciliation of medications upon discharge for two of three residents reviewed (Residents 15 and 116). Findings include: The policy entitled Transfer or Discharge Documentation, last reviewed on [DATE], indicates that when a resident is transferred or discharged from the facility, the disposition of the medications will be documented in the medical record. Review of Resident 15's closed clinical record revealed that she was discharged from the facility on [DATE]. Resident 15 had current physician orders for Morphine (a narcotic used to treat pain) 5 mg (milligrams) every four hours as needed for pain and Haldol (medication used to treat mental or mood disorders) 2 mg every four hours for agitation or restlessness. Review of Resident 15's controlled substance log for Morphine indicated that there was 12 milliliters of medication left when Resident 15 was discharged…

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, review of select facility policies, and staff interview, it was determined that the facility failed to ensure an appropriate and timely physician response to consultant pharmacist recommendations for four of five residents reviewed (Residents 38, 80, 104, and 105). Findings include: The policy entitled Consultant Pharmacist Monthly Reports, last reviewed without changes on January 22, 2022, revealed the consultant pharmacist provides administration a monthly report reviewing the facility's use of medication. Reports are acted upon by nursing and medical staff. After the reports are acted upon, administration reviews and reports to verify that sufficient action has been taken on the reports. Clinical record review for Resident 38 revealed a Consultant Pharmacist Medication Regimen Review dated February 17, 2022, that requested Resident 38's physician consider gradual dose reductions of Resident 38's Zyprexa (anti-psychotic) and Omeprazole (used to treat certain stomach and esophagus problems). Resident 38's physician responded on March 1, 2022, and…

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 review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement its established abuse prohibition policy regarding nurse aide registry verification for one of three newly hired licensed/certified employees reviewed (Employee 1). Findings include: Review of the facility policy entitled, Background Screening Investigations, last reviewed without changes on January 22, 2022, revealed that for any individual applying for a position as a certified nursing assistant, the facility ensures the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted. Review of the list provided by 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, clinical record review, and resident and staff interview, it was determined the facility failed to provide bathing per resident preference for one of four residents reviewed for activities of daily living (Resident 112). Findings include: In an interview with Resident 112 on January 8, 2023, at 8:47 AM the resident asked the surveyor, Is there anything you can do about getting showers, I am supposed to get them twice a week. I have to wash up at the sink. I ask them, (staff), if I could get a shower and they just say it isn't your day, and I tell them I didn't get one on my day. Resident 112 could not recall the last time she had a shower, and stated she even washed her hair in the bathroom sink. Resident 112 continued to elaborate as she sat in her wheelchair, pointing to a large plastic bin sitting on top of her tall dresser that was full of toiletries, stating, I can only carry one or two bottles with me as I wheel myself into the bathroom, so that is what I use. Clinical record review for Resident 112 revealed a five-day MDS (minimum data set, an assessment…

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, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatment for one of 24 residents reviewed (Resident 83). Findings include: Clinical record review for Resident 83 revealed a physician progress note dated January 6, 2023, at 1:54 PM that Resident 83 had increased foot edema. Resident 83 reported that his feet felt slightly uncomfortable. The documentation indicated that Resident 83 spent most of his time in a wheelchair and did not elevate his lower extremities. The prescriber indicated a plan to obtain laboratory testing, give additional diuretic medication (medication used to stimulate the body to increase urination to decrease excessive fluid retention), and use tubigrips (tubular fabric used to provide compression) to Resident 83's legs. Nursing documentation dated January 6, 2023, at 4:00 PM confirmed the receipt of a physician's order to ensure that Resident 83 had tubigrips 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, clinical record review, and responsible party and staff interview, it was determined that the facility failed to provide the highest practicable care regarding pressure ulcer assessment and treatment for one of four residents reviewed for pressure ulcer/skin alterations (Resident 7). Findings include: In a telephone interview with Resident 7's responsible party (RP) on January 7, 2023, at 1:46 PM, the RP indicated she got a call on New Year's Day (Sunday, January 1, 2023) from facility staff that indicated her mother's sock was fused to her foot, and a day ago (January 6, 2023) she got a call that an area on the foot was now opened. An observation of Resident 7 on January 8, 2023, at 8:46 AM revealed the resident was lying in bed sleeping. A cushion was observed towards the bottom of the resident's bed pushed off to the side of the bed and the resident's legs and heels were resting on the bed. The resident was not wearing socks or shoes. A large tan colored bandage was observed on the resident's left heel. Electronic clinical record review did not reveal any…

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 and staff interview, it was determined that the facility failed to implement interventions for a noted decline in range of motion for one of two residents reviewed (Resident 88). Findings include: Review of Resident 88's clinical record revealed a Minimum Data Set Assessment (an assessment completed at specific intervals to determine care needs) dated May 13, 2022, and again on November 8, 2022, indicated that the facility assessed Resident 88 as having range of motion limitations to both her lower extremities. Resident 88 was previously assessed by the facility as having no limitations to her lower extremities. The facility did not assess her range of motion for the August 8, 2022, MDS assessment. There was no documented evidence in Resident 88's clinical record to indicate that the facility implemented interventions, such as therapy referrals or restorative programs to address her decline in range of motion to her lower extremities. Interview with Employee 9, physical therapist, on January 10, 2023, at 9:25 AM confirmed the above findings 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 review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure appropriate application of supplemental oxygen for two of three residents reviewed for oxygen concerns (Residents 83 and 40). Findings include: The facility policy entitled, Oxygen Administration, last reviewed without changes on January 22, 2022, revealed that staff review the resident's care plan to assess for any special needs of the resident. Steps in the procedure include to adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered. Check the tank to be sure it is in good working order. Observe the resident upon setup and periodically thereafter to be sure oxygen is tolerated. After completing the oxygen setup or adjustment, information recorded in the resident's medical record should include the date and time the procedure was performed, the name and title of the individual who performed the procedure, the rate of oxygen flow, and the signature…

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 a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 6). Findings include: Clinical record review for Resident 6 revealed the facility added a dementia diagnosis on April 7, 2022. Review of a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 6, 2022, indicated that the facility assessed Resident 6 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. Review of Resident 6's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview with the Director of Nursing on January 10, 2023, at 9:55 AM confirmed the above findings for Resident 6. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care…

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 72 and 105). Findings include: The policy entitled Antipsychotic Medication Use, last reviewed on January 22, 2022, indicates that the need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The policy provided by the facility does not specify that staff will document targeted behaviors prior to the administration of PRN psychotropics, nor does it indicate that nursing staff will attempt non-pharmacological interventions prior to the administration of a PRN psychotropic. Review of Resident 72's clinical record revealed a physician's order dated November 30, 2022, for nursing staff to administer Ativan (a medication used to treat anxiety)…

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, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 100, 6, and 65). Findings include: The facility's medication error rate was 9.68 percent based on 31 medication opportunities with three medication errors. Review of the current manufacturer's guidelines for Flonase (a nasal spray to treat allergies) nasal spray indicates that patients should blow their nose gently to clear nostrils then close one nostril and spray nozzle into the opposite nostril. Observation of a medication administration on January 7, 2023, at 8:24 AM revealed Employee 8, licensed practical nurse, administered Flonase to Resident 100. Employee 8 administered two sprays of the Flonase to both sides of Resident 100's nose. Employee 8 did not close one nostril while administering the Flonase into the other nostril nor provide instructions to Resident 100 to do so. Interview with Employee 8, on January 7, at 10:29 AM confirmed the above findings for Resident 100 and…

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 and resident and staff interview, it was determined that the facility failed to coordinate and provide dental services to meet the needs for one of three residents reviewed for dental concerns (Residents 40). Findings include: In an interview with Resident 40 on January 7, 2023, at 11:29 AM the resident was observed to have many missing teeth. Resident 40 stated her mouth is very painful and she has many teeth that have broken off at the gums, and she stated, not only does it look awful, but it also makes her talk funny. Clinical record review for Resident 40 revealed the resident received dental services on June 24, 2021, at which time the dentist noted, Patient requests remaining teeth be extracted to alleviate discomfort they cause her and so she can have dentures constructed to help her eat and speak better. Referred below to oral surgeon for extractions of remaining dentition. The next evidence of dental services for Resident 40 revealed a dental report dated September 28, 2022, (greater than 15 months since the June 2021 visit), which noted,…

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 and staff interview, it was determined that the facility failed to offer, or provide education regarding the benefits, risks, and potential side effects with the COVID-19 vaccine for three of five residents reviewed for immunizations (Residents 19, 46, and 87). Findings include: Clinical record review revealed the facility admitted Resident 19 on October 13, 2022. Further review of Resident 19's clinical record revealed no documentation that Resident 19 was offered or received the COVID-19 vaccine, or that the facility provided the resident or resident's responsible party education regarding the benefits, risks, and potential side effects of the vaccine. Clinical record review revealed the facility admitted Resident 46 on June 26, 2022. Further review of Resident 46's clinical record revealed no documentation that Resident 46 was offered or received both doses of the COVID-19 vaccine, or that the facility provided the resident or resident's responsible party education regarding the benefits, risks, and potential side effects of the vaccine. 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.