Rosewood Heights

Penalty

Inspection fine: $16,350

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide pressure injury prevention and care consistent with professional standards for one highly dependent resident, resulting in the development and deterioration of a severe sacral/right buttock wound. The resident was an older female with extensive comorbidities including stroke with quadriplegia, neurogenic bladder, diabetes, respiratory failure, dysphagia with PEG tube, morbid obesity, and chronic kidney disease. On admission, she was totally dependent for all ADLs, bedfast, completely immobile, and at high risk for pressure injuries per the Braden Scale, with constant moisture, friction, and shear problems identified. The admission nursing assessment, completed by an LVN, documented her skin as dry and intact with no pressure injuries, despite the LVN later stating she realized the next day that the resident had a sore on the sacral/right buttock area that should have been documented but was not. The comprehensive MDS and care plan identified her as at risk for skin breakdown and called for turning and repositioning every 2–3 hours, pressure-relieving devices, and skin monitoring, but the initial skin assessment failed to capture an existing wound or accurately reflect her skin status. A new skin issue on the right gluteus was formally documented on 1/20 by the wound care nurse as an in-house acquired trauma wound, with measurements recorded and a wound care NP noting that the wound appeared to result from trauma likely occurring during a mechanical lift transfer. The DON, however, later asserted that the wound did not result from a mechanical lift but from shear during repositioning of a large, immobile resident when staff could not fully lift her. CNAs reported the resident required two-person assistance and used a mechanical lift for transfers, and one CNA recalled first noticing a skin tear during a brief change and reporting it to the nurse. The facility’s TARs and progress notes show evolving documentation of skin issues, including MASD to the sacrum and incontinence-associated dermatitis to the buttocks, with weekly skin checks repeatedly coded as having no skin issues or no new skin issues even after the wound had been identified. The wound care NP later described the same area as sacral, noting significant deterioration of the wound over time despite the resident being on an air mattress and staff being advised to continue pressure-relieving interventions. Subsequent wound care notes documented continued deterioration, strong odor suggestive of infection, and the need for surgical debridement and advanced topical treatments. A wound panel led to initiation and extension of IV antibiotics for a polymicrobial wound infection. The wound progressed to an unstageable lesion and then to a full-thickness sacral decubitus ulcer with increased depth as devitalized tissue was removed. Despite serial debridements and ongoing dressing changes, the resident ultimately developed an infected stage 4 sacrococcygeal pressure ulcer with osteomyelitis and sepsis, as confirmed by infectious disease consultation and hospital records. Interviews with the DON, wound care providers, nursing staff, the resident, and her representative revealed inconsistent accounts regarding whether the wound was present on admission, whether it was trauma- or pressure-related, and the adequacy of repositioning and moisture management. The facility’s own skin and wound prevention policy required identification of risks, early detection of skin breakdown, and implementation of appropriate interventions, but the inaccurate admission assessment, delayed and conflicting characterization of the wound, and progression of the lesion to a stage 4 infected pressure ulcer with osteomyelitis and sepsis formed the basis of the cited deficiency. The resident and her representative also reported concerns about the visibility and progression of the wound. The resident stated she could not move her legs and relied on staff for repositioning, did not recall a wound care specialist regularly seeing her, and only recognized the term “debridement” from staff discussions. Her representative reported being told weekly by a wound care doctor that the wound was healing, while personally observing what she believed to be pus and mucus on the wound and doubting that it was improving. Facility leadership acknowledged that the resident was immobile, obese, and required staff to reposition her, and that comorbidities such as CVA, diabetes, and kidney disease were barriers to healing. The DON and ADM both described expectations for accurate skin assessments, weekly skin checks, and maintenance of skin integrity, and acknowledged that if a resident admitted with no skin issues and then acquired a wound, the resident could develop infection or sepsis. These documented actions, inactions, and inconsistent assessments and monitoring practices, in the context of a high-risk, fully dependent resident, led to the development and worsening of a sacral/right buttock wound into a stage 4 infected pressure ulcer with osteomyelitis and sepsis, constituting the cited failure to provide appropriate pressure ulcer care and prevention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update its menus periodically and failed to follow the menu for 3 of 3 meals served. The report states the facility had not updated the menu since Fall/Winter 2024, and that Week 5 of the Fall/Winter 2024 menu was not followed. The facility’s undated Menu Planning policy states menus are to be updated twice each year, reviewed and approved by the Consultant Dietitian, and signed and dated by the Consultant Dietician, with intermittent changes also reviewed and approved. Record review of the Fall/Winter 2024 menu showed Week 5 lunch menus for Tuesday through Thursday included beef stew, lemon pepper chicken, and Swedish meatballs with specified sides and desserts. However, observations of test trays on 8/12/2025, 8/13/2025, and 8/14/2025 showed different meals being served, including Swedish meatballs with mashed potatoes and white beans, baked chicken with mashed potatoes and broccoli, and Swedish meatballs with noodles, broccoli, roll, and peaches. During interview, the DM stated the facility received menus from corporate, they were slow getting the menus out, and there had been multiple changes. The DM said menus should have been followed because it was a resident right and their diet, and that it was not acceptable to serve the same entree within the same week. The DT stated she was not okay that the same entree was served twice that week.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store food in accordance with professional standards in 1 of 1 kitchen reviewed for Food and Nutrition Services. During observation of the walk-in refrigerator, surveyors found lemons in a black container with no date and mold on them, raspberries dated 8/4/2025 in their original container with mold, bell peppers in a black container with no date and mold on them, grapes in a box dated 7/11 in their original bag with mold on them, and a half squash wrapped in plastic that was undated. In the pantry, hot dog buns had an expiration date of 5/11/2025, tortillas had an expiration date of 7/31/2025, and a storage container with sugar was undated. Surveyors also observed clean serving utensils stored in a clear container that contained food debris. Interviews with the DA, CKs, DM, DT, and ADM reflected that staff were expected to check daily for expired or moldy food, label and date items, and follow first-in-first-out rotation, and they acknowledged that expired or moldy food could cause resident illness. The facility’s food handling policy stated that all containers must be labeled and dated, scoops must be stored in a protected area near food containers, and leftovers over 72 hours old must be discarded.

Penalty

Inspection fine: $9,193

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with significant medical needs, including weakness, cerebral edema, intracerebral hemorrhage, acute respiratory failure with hypoxia, and abnormal gait and mobility. The resident was identified as a high fall risk due to balance problems, chronic health issues, debility, cognitive impairment, and difficulty moving or propelling herself in a wheelchair. Despite these risk factors, the admission assessment and baseline care planning were incomplete, and no fall risk interventions were documented or communicated effectively to staff. Observations and interviews revealed that the admitting nurse did not complete the necessary sections of the admission assessment related to fall risk, and the baseline care plan lacked focus, goals, and interventions for fall prevention. The Kardex system, which should have served as a reference tool for staff, did not reflect fall precautions or interventions, and staff were not adequately trained in its use or in updating and referencing it. Communication breakdowns were evident, as CNAs relied on verbal reports rather than documented care plans or Kardex information, and several staff members were unaware of how to access or update care plans. As a result of these systemic failures, the resident was left alone in her room while up in her wheelchair, leading to a fall in which she hit her head and required hospitalization. The lack of a timely and comprehensive baseline care plan, incomplete documentation, and insufficient staff training and communication placed the resident at risk for serious harm. The facility's policies required prompt assessment and care planning, but these were not followed in this case.

Removal Plan

• Review charts of all admissions/readmissions for completion of the admission/readmission assessment and baseline care plans.
• Audit all residents' care plans to validate accuracy of each resident's ADL care needs.
• Educate Director of Nursing Services, Assistant Director of Nursing, and Reimbursement Nurses on the process for validating the completion of all admission/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
• Educate Director of Nursing Services, Assistant Director of Nursing, and Reimbursement Nurses on Abuse/Neglect and Residents Rights.
• Provide education to all licensed nurses on the process of completion of admissions/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
• Ensure all licensed nurses on leave, agency, or PRN staff are in-serviced prior to working their shift.
• Ensure administrative nursing staff provide in-service/education prior to team members working their assigned shift.
• Ensure all residents who require respiratory care are provided such care.
• Audit all residents' care plans to validate accuracy of each resident's ADL care needs.
• Provide education to all licensed nurses on the process of completion of admissions/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
• Conduct skills validations of accuracy and completion of admissions/readmission/baseline care plans of nurses.
• Review all admission/re-admission orders in the clinical meeting to validate accuracy and completion of admission/readmission/baseline care plans.
• Place this plan and all education and auditing tools in a binder and keep with the Administrator or Director of Nursing Services.
• Report findings of observations to the QAPI committee during monthly meetings.

Penalty

Inspection fine: $9,193

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure a newly admitted resident received adequate supervision and accident prevention measures. The resident, who had a history of cerebral edema, nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, and significant mobility and cognitive impairments, was admitted with hospital discharge orders to be placed on fall precautions. However, these orders were not implemented upon admission, and no fall precautions were entered into the resident's order summary. The baseline care plan was not developed or implemented within 48 hours of admission to address the resident's high fall risk status, and the admission assessment and baseline care planning were incomplete. Staff did not have adequate knowledge or access to the resident's care plan, and the Kardex system, which should have provided key safety and care information to direct care staff, was not updated to reflect the resident's fall risk or necessary interventions. Interviews with nursing and CNA staff revealed that fall risk information was not consistently documented or communicated through the Kardex, and staff relied on verbal reports rather than written care plans or Kardex entries. The admitting nurse believed that checking a high fall risk box would automatically update the care plan and Kardex, but was unaware of how to verify or access these documents. As a result of these systemic failures, the resident was left unsupervised in her room and experienced a fall from her wheelchair, hitting her head and exhibiting pain and nystagmus, which required transfer to an acute care hospital. The facility's failure to implement fall precautions, develop and communicate a baseline care plan, and ensure staff competency in using the Kardex system directly contributed to the incident. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious adverse outcomes.

Removal Plan

• Physician notification by licensed nurse of the fall.
• Responsible party notified by licensed nurse of the fall.
• Resident sent to the hospital.
• Director of Nursing Services/Assistant Director of Nursing Services/Registered Nurse Assessment Coordinator conducted an audit of all residents to review Fall Risk Assessments and care plans for person-centered interventions.
• Director of Nursing Services and administrative nurses provided education by way of in-service to nurses on Abuse Neglect, Residents Rights, initiating interventions to prevent a fall, and Fall Prevention Guidelines.
• All admissions will be reviewed during clinical connect meeting to ensure interventions are initiated to prevent a fall for those residents identified as a fall risk.
• Director of Nursing Services/Administrative Nursing is responsible for ensuring compliance and oversight of monitoring and education.
• Direct care team educated on review of the Kardex before providing care to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care.
• Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided.
• Licensed nurses will initiate interventions to prevent falls for those identified as a fall risk upon admission and/or as indicated.
• All nursing staff will receive the in-service prior to working next shift.
• All newly hired nursing staff will receive in-service training prior to assuming shift responsibility during orientation process.
• All agency nursing staff will receive in-service training prior to assuming shift responsibility.
• Director of Nursing Services/Administrative nurses conducted skills validation of all nurse aides in training and certified nurse assistants of accessing the Kardex.
• No licensed nurse, nurse aides in training, or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex.
• Community will ensure administrative nursing staff provide in-service/education prior to team members working their assigned shift; these trainings will also be conducted with new hires.
• Director of Nursing Services/administrative nurses provided education to direct care team on Fall Prevention Guidelines/Abuse Neglect/Residents Rights, Kardex Use prior to providing care.
• Director of Nursing Services/Administrative Nurses is responsible for ensuring compliance and oversight of monitoring and education.
• Licensed nurse will initiate interventions to prevent falls upon admission and as indicated for those at risk for falls.
• Director of Nursing Services/Administrative nurses conducted skills validation to direct care staff on accessing the Kardex.
• Community will ensure all staff on leave/agency/PRN staff/new hires are in-serviced prior to working their shift.
• No licensed nurse, certified medication aide, or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex.
• Director of Nursing Services/Administrative nurses will review Admission/Readmission Assessments in the Daily Clinical Connect meeting to ensure residents at risk for falls have interventions in place and documented using a monitoring tool.
• Administrator/Director of Nursing Services will conduct random audits of care plans to validate fall intervention care plans are in place.
• Director of Nursing Services/Administrative Nurses/Designee will conduct random skills validations regarding Kardex use to ensure direct staff is compliant with the use of the Kardex.
• All findings will be reported to the QAPI committee during monthly meeting until there is compliance observed during observations.
• Additional education will take place based on needs observed during this process.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate and complete medical records for a resident, leading to several documentation errors. The resident's September 2024 Medication Administration Record (MAR) inaccurately documented that the resident received two enteral feedings simultaneously, which was not possible according to staff interviews. The Director of Nursing (DON) and other staff confirmed that incorrect documentation was the issue, as the resident often paused feedings due to nausea and vomiting, and did not receive two feedings at the same time. Additionally, the resident's weight records were incomplete and inaccurate. The facility failed to document an admission weight and did not record a weight on the specified day as ordered by the physician. A significant discrepancy in the resident's weight was noted, with a recorded weight loss of 26.1 pounds over two days, which was not re-verified. The DON acknowledged the error in the weight documentation but did not reweigh the resident to confirm the accuracy, citing the resident's illness as a reason. Furthermore, the resident's Treatment Administration Record (TAR) was incomplete, with missing documentation for the cleaning of the j-tube, monitoring of the surgical site for infection, and treatment of a skin tear. Staff interviews revealed that if treatments were not documented, it was unclear whether they were performed, potentially leading to complications. The facility's policies on nutrition, weight measurement, and enteral nutrition were not adhered to, contributing to the deficiencies in documentation and care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper pharmaceutical services for a resident by not removing a discontinued medication order from the medication cart. The resident, a male with diabetes and essential primary hypertension, had a discontinued order for Labetalol HCL 300 MG, which was not removed from the cart. This oversight led to a situation where a Med Tech almost administered an incorrect dosage of Labetalol, combining the discontinued 300 MG tablets with the current 200 MG tablets, resulting in a potential overdose. The incident was discovered when the resident's family member questioned the medication being administered. The family member noticed that the Med Tech was about to give a total of 1000 MG of Labetalol instead of the correct 400 MG dosage. The family member's intervention prompted an LVN to check the resident's blood pressure and remove the incorrect tablets from the medication cup. The Med Tech admitted to not paying full attention to the Medication Administration Record (MAR) and being confused by the presence of different dosages of the same medication on the cart. Interviews with facility staff revealed a lack of communication and protocol adherence. The Administrator and Director of Nursing were not informed of the medication error until days later, preventing timely staff education and corrective measures. The facility's policy required discontinued medications to be removed from the cart, a responsibility of the charge nurses, which was not fulfilled in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was at risk due to a medication administration error. The error involved the discontinued medication Labetalol HCL 300 mg, which was not removed from the medication cart. This oversight led to a situation where Med Tech A prepared to administer an incorrect dosage of Labetalol, totaling 1000 mg, instead of the prescribed 400 mg. The error was identified and stopped by the resident's family member, who requested LVN B to check the resident's blood pressure, preventing the administration of the incorrect dosage. The resident involved was a male with a history of diabetes and essential primary hypertension. His care plan indicated a risk for complications associated with diabetes. The resident's medication orders had been updated to reflect a change from Labetalol 300 mg to 200 mg, but the discontinued medication was not removed from the cart, leading to the potential for a significant medication error. The resident's family member played a crucial role in identifying the error before it could affect the resident's health. Interviews with facility staff revealed a lack of communication and oversight in handling the medication error. The Administrator and Director of Nursing were not informed of the incident until days later, and the charge nurses were responsible for removing discontinued medications from the cart. Med Tech A admitted to not verifying the medication administration record (MAR) properly, which contributed to the error. The facility's policy on medication administration emphasized the importance of accurate and safe medication practices, which were not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident was admitted with an open wound on the coccyx, which was not documented or treated until several days later. The initial assessment failed to recognize the wound, and subsequent documentation did not accurately reflect the resident's condition, leading to a delay in treatment. The resident's condition worsened over time, with the wound progressing to a stage III pressure injury. Despite the resident's complaints of pain during dressing changes, there was a lack of consistent documentation and communication regarding the wound's status. The wound care nurse and other staff were not adequately informed or involved in the resident's care until the wound had significantly deteriorated. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's wound care. Agency nurses and facility staff were not consistently informed of the resident's condition, and there was a failure to notify the nurse practitioner or physician of the wound's progression. The facility's policies and procedures for skin and wound management were not followed, resulting in inadequate care for the resident.

Penalty

Inspection fine: $16,755

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive care plan for a resident, identified as Resident #17, which compromised his highest practicable physical, mental, and psychosocial well-being. Resident #17, a male with severe cognitive impairment and multiple health issues, required substantial assistance with activities of daily living and was dependent on others for transfers. Despite this, his care plan inaccurately reflected that he required assistance from one staff member with a gait belt, rather than the mechanical lift and assistance from two staff members that he actually needed. Observations and interviews revealed that Resident #17 was consistently transferred using a mechanical lift by two staff members, contrary to what was documented in his care plan. The resident himself confirmed that he was unable to use his legs due to pain and weakness, necessitating the use of a mechanical lift for transfers. Staff members, including an LVN and a CNA, acknowledged the discrepancy between the care plan and the actual transfer method used, highlighting a lack of communication and documentation regarding the resident's transfer needs. The MDS LVN responsible for care plans admitted that the transfer status was never updated in the care plan or Kardex, as there were no progress notes or change in condition notifications to prompt such updates. The DON confirmed that staff were educated to report changes in residents' conditions, but it was unclear why Resident #17's transfer status was not updated. The facility's policies on safe resident handling and care plans emphasize the importance of accurate documentation and communication to ensure resident safety, which was not adhered to in this case.