Inspection Reports for Rosewood Rehabilitation Center
2045 SILVERADA BLVD, RENO, NV 89512, RENO, NV
Back to Facility ProfileDeficiencies (last 20 years)
Deficiencies (over 20 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
81 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a result of Facility Reported Incident (FRI) investigations and Complaint (CPT) investigations initiated on 2025-04-09 and concluded on 2025-04-24, related to allegations of neglect, abuse, and other care concerns at the facility.
Complaint Details
The complaint investigation included allegations of neglect, physical abuse, improper medication administration, inadequate showering and hygiene, improper nutrition, and failure to protect residents. Some allegations were not substantiated due to lack of evidence. The facility was found deficient in investigating neglect allegations and in care practices related to tube feeding and bathing.
Findings
The investigation found multiple deficiencies including failure to thoroughly investigate allegations of neglect, failure to administer medications properly, physical abuse allegations not substantiated due to lack of evidence, incomplete medical records, and failure to administer tube feeding per physician orders. The facility also failed to document showers and bed baths properly for residents. Corrective actions and monitoring plans were implemented.
Deficiencies (4)
Failure to thoroughly investigate an allegation of neglect for Resident #2.
Failure to administer tube feeding per physician order for Resident #8.
Failure to document showers and bed baths for Resident #1.
Failure to maintain complete and accurate medical records for Resident #1.
Report Facts
Census: 81
Sample size: 10
Deficiency count: 4
Shower frequency: 2
Tube feeding review frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Involved in investigation of neglect allegation and interviewed staff. | |
| Interim Director of Nursing | Oversaw investigation into neglect allegation and reviewed statements. | |
| Licensed Practical Nurse (LPN1) | Verbalized Resident #8's tube feeding orders and care. | |
| Licensed Practical Nurse (LPN2) | Administered medications and tube feeding; documented refusal incident. | |
| Certified Nursing Assistant (CNA) | Reported resident conditions and care refusals; involved in shower documentation. | |
| Administrator | Reviewed investigation and facility policies; confirmed documentation gaps. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 10, 2024
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from October 7, 2024 to October 10, 2024, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including incomplete tuberculosis testing and physical examinations for employees, missing fingerprint and background checks under the current facility license, failure to complete annual dementia training for some employees, failure to post the most recent CMS star rating conspicuously, failure to post a required discrimination statement on the facility's website, and incomplete cultural competency training for certain employees.
Deficiencies (5)
Failure to ensure annual Tuberculosis (TB) signs and symptoms screening and initial TB testing were completed timely for sampled employees, physical examinations were completed timely, and fingerprinting and Nevada Automated Background System (NABS) clearance were completed under the current facility license for sampled employees.
Failure to ensure annual dementia training was completed for sampled employees.
Failure to post the most recent CMS star rating conspicuously near the facility entrance.
Failure to post the required discrimination statement prominently on the facility's Internet website.
Failure to ensure cultural competency training was completed using a Division of Public and Behavioral Health approved training program for sampled employees.
Report Facts
Sample size: 25
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Whitney Wilding | Executive Director | Signed the inspection report |
| Employee #9 | Registered Nurse with missing TB screening, dementia training, and cultural competency training | |
| Employee #13 | Registered Nurse with late TB testing and physical examination | |
| Employee #20 | Housekeeper with missing initial TB test | |
| Employee #2 | Director of Nursing | Missing physical examination and background check |
| Employee #4 | Registered Dietician | Missing background check |
| Employee #5 | Director of Social Services | Missing annual dementia training |
| Employee #7 | Certified Nursing Assistant | Missing cultural competency training |
| Employee #22 | Speech Therapist | Missing cultural competency training |
| Employee #25 | Interim Director of Rehab | Missing cultural competency training |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
An offsite revisit was conducted on 12/21/23 to verify correction of all previous deficiencies cited on 11/02/23.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
An offsite revisit was conducted on 12/15/23 to review all previous deficiencies cited on 11/01/23.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
An offsite revisit was conducted on 12/15/23 to verify correction of all previous deficiencies cited on 11/07/23 and 11/08/23.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Life Safety
Census: 84
Capacity: 99
Deficiencies: 7
Date: Nov 8, 2023
Visit Reason
Medicare Life Safety Code recertification survey conducted at Rosewood Rehabilitation Center on 11/07/23 and 11/08/23 to assess compliance with NFPA 101 Life Safety Code, 2012 edition and NFPA 99 Health Care Facilities Code, 2012 edition.
Findings
The facility was found deficient in several life safety code areas including aisle, corridor, or ramp width obstructions; hazardous area enclosures; fire alarm system installation; sprinkler system maintenance; corridor door functionality; subdivision of building spaces smoke barriers; and electrical equipment safety. Specific issues included blocked corridors, missing self-closing devices on doors, missing fire alarm pull boxes, sprinkler escutcheon issues, non-latching corridor doors, unsealed smoke barrier penetrations, broken electrical receptacle covers, and use of extension cords in resident rooms.
Deficiencies (7)
Aisle, corridor, or ramp width obstructed by equipment and furniture.
Hazardous areas not properly enclosed with self-closing doors.
Fire alarm pull boxes missing or not installed within required distance of exits.
Sprinkler system missing escutcheons, paint on escutcheons, and gaps in escutcheons.
Corridor doors did not latch properly or were obstructed from closing.
Smoke barrier penetrations not sealed to prevent smoke passage.
Electrical receptacle cover broken and extension cords used improperly in resident rooms.
Report Facts
Licensed skilled nursing beds: 99
Resident census: 84
Manual fire alarm pull boxes missing or improperly located: 3
Sprinkler system deficiencies: 3
Corridor doors not latching or obstructed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present at discovery of sprinkler and fire alarm deficiencies | |
| Maintenance Manager | Confirmed extension cords should not be used in resident rooms | |
| Administrator or designee | Responsible for verifying corrections and inspections of fire doors, sprinkler system, and electrical safety |
Inspection Report
Routine
Census: 82
Deficiencies: 10
Date: Nov 2, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey, Facility Reported Incidents (FRI) and a complaint investigation conducted at the facility from October 30, 2023, through November 2, 2023.
Complaint Details
One complaint was investigated related to an allegation that a Certified Nursing Assistant force fed a resident. The allegation could not be substantiated due to lack of evidence.
Findings
The investigation included observations of staff assisting residents, interviews with the Director of Nursing, Employee of Concern, and Administrator, and review of resident and employee records. The facility was found to have deficiencies related to resident abuse, infection control, care planning, medication administration, and immunizations.
Deficiencies (10)
Resident #300, #309, and #311 had their names visible on an unattended open computer screen showing wounds tab in the electronic health record, violating resident privacy.
Resident #45 was involved in a resident-to-resident altercation; the care plan lacked documentation of the altercation and related interventions.
Resident #47 was found soaked in urine and the call light was unplugged; staff neglected to provide timely care.
Resident #56 and #7 had medication errors including administration prior to pain assessment and failure to scrub insulin pen rubber stopper.
Facility failed to timely transmit Minimum Data Set (MDS) assessments for residents #8, #9, #11, #41, and #46.
Facility failed to provide timely influenza and pneumococcal vaccinations to eligible residents; 45.11% of residents were not screened or vaccinated timely.
Facility failed to ensure infection prevention and control program was fully implemented including dishwasher sanitation and expired food removal.
Facility failed to ensure staff completed timely elder abuse training; 7 of 20 sampled employees lacked timely training.
Facility failed to ensure COVID-19 vaccinations were administered timely to residents and staff; documentation was incomplete.
Facility failed to ensure bed rails were used appropriately with documented assessment, alternatives, and consents for resident #31.
Report Facts
Census: 82
Sample size: 18
Complaint count: 1
FRI count: 7
Medication error rate: 33.33
Influenza vaccination non-compliance: 45.11
Expired food count: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #20 | Registered Dietician | Lacked documented elder abuse training. |
| Employee #12 | Certified Nursing Assistant | Lacked documented elder abuse training. |
| Employee #21 | Registered Nurse | Lacked documented elder abuse training. |
| Employee #22 | Licensed Practical Nurse | Lacked documented elder abuse training. |
| Employee #23 | Licensed Practical Nurse | Lacked documented elder abuse training. |
| Employee #24 | Certified Nursing Assistant | Lacked documented elder abuse training. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An offsite revisit was conducted on 09/26/23 to verify correction of all previous deficiencies cited on 08/31/23.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An offsite revisit was conducted on 07/27/23 to verify correction of all previous deficiencies cited on 06/22/23.
Findings
All deficiencies have been corrected, no new noncompliance was found, and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 3
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident (FRI) investigation regarding allegations of neglect and abuse involving multiple residents.
Complaint Details
The complaint involved allegations that a resident was neglected and mentally abused by a CNA who refused to provide care, causing the resident to fear harm. The facility reported the incident late and failed to fully investigate or substantiate the allegations. The CNA was suspended indefinitely and later terminated. The resident was discharged before the investigation was completed.
Findings
The investigation included observations, interviews with residents and staff, and clinical record reviews. Allegations of neglect and abuse were not substantiated due to lack of evidence, but concerns about staff behavior and resident safety were noted. The facility took corrective actions including staff suspension and education.
Deficiencies (3)
Failure to protect a vulnerable resident from neglect and mental abuse when a CNA refused to provide care, causing the resident to fear harm.
Failure to report alleged violations of abuse and neglect within required timeframes.
Failure to thoroughly investigate all alleged violations of abuse and neglect and to prevent further harm during investigations.
Report Facts
FRI Investigations: 12
Sample size: 14
Resident census: 74
Days late for FRI submission: 8
Days late for final FRI submission: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Named in findings related to refusal to provide care and alleged neglect and mental abuse of Resident #13. | |
| Director of Nursing (DON) | Conducted investigation and interviews related to the complaint. | |
| Licensed Practical Nurse (LPN) | Interviewed during investigation and involved in resident care. | |
| Licensed Social Worker (LSW) | Interviewed residents and documented resident statements. | |
| Administrator/Abuse Prevention Coordinator | Managed investigation and corrective actions. | |
| Physical Therapist | Interviewed during investigation. | |
| Business Office Manager | Interviewed during investigation. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 14, 2022
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at Rosewood Rehabilitation Center on December 14, 2022, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including incomplete tuberculosis testing, delayed pre-employment physicals, untimely fingerprint submissions for background checks, incomplete dementia training, failure to protect potable water due to a cross connection, and incomplete cultural competency training for multiple employees.
Deficiencies (4)
Failed to complete Tuberculosis (TB) testing for 5 of 19 sampled employees, ensure timely pre-employment physicals for 3 employees, and timely fingerprint submission for 6 employees.
Failed to ensure eight hours of initial dementia training was completed within the first 30 days of employment for 1 of 19 sampled employees.
Failed to comply with federal, state, and local regulations related to facility construction and maintenance, specifically failed to ensure potable water was protected due to a cross connection in the mop sink area.
Failed to ensure cultural competency training was completed timely using a Division of Public and Behavioral Health approved training program for 10 of 19 sampled employees.
Report Facts
Sample size: 19
Employees with incomplete TB testing: 5
Employees with delayed pre-employment physicals: 3
Employees with late fingerprint submissions: 6
Employees lacking timely dementia training: 1
Employees lacking timely cultural competency training: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Welker | Executive Director | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Employee #1 | Administrator | Lacked documented TB test, pre-employment physical, fingerprint submission was 31 days late, and cultural competency training incomplete |
| Employee #10 | Licensed Practical Nurse | Lacked documented TB test, pre-employment physical, fingerprint submission late, dementia and cultural competency training incomplete |
| Employee #11 | Licensed Practical Nurse | Lacked documented TB test, fingerprint submission late, dementia and cultural competency training incomplete |
| Employee #12 | Registered Nurse | Fingerprint submission late, cultural competency training incomplete |
| Employee #16 | Certified Nursing Assistant | Lacked documented TB test, cultural competency training incomplete |
| Employee #18 | Dietary Aide | Lacked documented TB test, pre-employment physical late, fingerprint submission late |
| Employee #19 | Housekeeper | Fingerprint submission late, cultural competency training incomplete |
| Employee #5 | Licensed Social Worker | Cultural competency training incomplete |
| Employee #13 | Licensed Practical Nurse | Cultural competency training incomplete |
| Employee #14 | Licensed Practical Nurse | Cultural competency training incomplete |
| Employee #15 | Certified Nursing Assistant | Cultural competency training incomplete |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Feb 8, 2022
Visit Reason
This report was generated as a result of a state licensure resurvey conducted at the facility to assess compliance with Nevada Administrative Code (NAC) 449 for skilled nursing facilities, focusing on physical environment and maintenance issues.
Findings
The facility was found deficient in maintaining exhaust fans and ensuring adequate ventilation in resident bathrooms. Several exhaust fans were dirty or nonfunctional, but all broken or dirty fans were replaced. The Maintenance Director was educated to perform monthly audits to prevent recurrence.
Deficiencies (2)
Failed to ensure exhaust fans were properly maintained; several exhaust fan grates were loaded with dirt.
Failed to ensure resident bathrooms had adequate outside ventilation by means of windows or mechanical ventilation; some exhaust fans were not functioning.
Report Facts
Deficiency scope: 2
Deficiency scope: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hopkins | Administrator | Signed the report |
| Maintenance Director | Named as responsible for corrective actions and audits |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 2, 2022
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at Rosewood Rehabilitation Center on February 2, 2022, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in completing annual tuberculosis (TB) screenings and pre-employment physicals for several employees, as well as failing to provide required dementia training within the first 30 days of hire for one employee. Corrective actions and monitoring plans were outlined in the submitted Plan of Correction.
Deficiencies (2)
Failure to complete annual tuberculosis screenings for 3 of 20 sampled employees and failure to ensure pre-employment physicals were completed for 5 of 20 sampled employees.
Failure to provide 8 hours of dementia training within the first 30 days of hire for 1 of 20 sampled employees.
Report Facts
Sample size: 20
Employees missing annual TB screening: 3
Employees missing pre-employment physical: 5
Employees missing dementia training: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hopkins | Administrator | Signed report and named as individual responsible for corrective actions |
| Employee #8 | Registered Nurse | Missing annual TB screening questionnaire for 2021 |
| Employee #12 | Certified Nursing Assistant | Missing annual TB screening questionnaires since date of hire and late pre-employment physical |
| Employee #14 | Licensed Practical Nurse | Missing annual TB screening questionnaire for 2022, missing pre-employment physical, and missing dementia training within first 30 days |
| Employee #5 | Social Services Director | Late pre-employment physical completed after date of hire |
| Employee #16 | Certified Nursing Assistant | Late pre-employment physical completed after date of hire |
| Employee #18 | Registered Nurse | Missing pre-employment physical |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 1
Date: Apr 29, 2021
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey from April 26, 2021 through April 29, 2021, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure all employees completed annual dementia training as required by regulation, specifically one of 23 employees lacked documented evidence of completed dementia training annually.
Deficiencies (1)
Failure to ensure all employees completed annual dementia training as required by NAC 449.74522.
Report Facts
Employees sampled: 23
Employees non-compliant: 1
Employees interviewed: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hopkins | Administrator | Named as the Administrator who completed the required dementia training and responsible for corrective action |
Inspection Report
Follow-Up
Census: 71
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
This visit was a follow-up COVID-19 Focused Infection Control survey initiated by CMS to assess compliance with infection prevention and control requirements in the facility.
Findings
The survey included a review of infection prevention and control practices, staff and resident hygiene, use of personal protective equipment, and facility screening procedures. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Census: 71
Inspection Report
Abbreviated Survey
Census: 72
Deficiencies: 0
Date: Apr 10, 2020
Visit Reason
This inspection was a Centers for Medicare and Medicaid Services (CMS) COVID-19 Focused Infection Control survey conducted to assess the facility's compliance with infection prevention and control requirements during the COVID-19 pandemic.
Findings
The survey included a review of the Infection Prevention and Control Program, policies, procedures, and practices, as well as interviews with key staff. No regulatory deficiencies were identified during this investigation.
Report Facts
Census at beginning of survey: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during the survey | |
| Director of Nursing | Interviewed during the survey | |
| Dietary Manager | Interviewed during the survey |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that an employee raised their voice toward a resident in an intimidating manner.
Complaint Details
Complaint #NV00059839 alleged an employee was raising their voice toward a resident in an intimidating manner. The complaint was substantiated. The CNA verbally abused a resident, admitted to raising their voice out of frustration, and was terminated. The facility reported the CNA to the Board of Nursing and filed a police report.
Findings
The facility was found to have failed to ensure a resident was free from verbal abuse by a Certified Nursing Assistant (CNA). The CNA admitted to raising their voice out of frustration and was terminated. The facility reported the incident to the Board of Nursing and the police.
Deficiencies (1)
Failure to ensure a resident was free from verbal abuse by a Certified Nursing Assistant (CNA).
Report Facts
Census: 81
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Named in verbal abuse finding; admitted raising voice and was terminated | |
| Director of Nursing (DON) | Confirmed CNA raised voice toward resident and reported incident |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Jul 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that a resident was not assessed for injury after a fall.
Complaint Details
Complaint #NV00057728 alleged a resident was not assessed for injury after a fall; this allegation could not be substantiated.
Findings
The complaint could not be substantiated. Observations, interviews, and record reviews were conducted, and no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Inspection Report
Deficiencies: 6
Date: May 9, 2019
Visit Reason
This document is a Statement of Deficiencies generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey at the facility on 05/09/2019.
Findings
The facility was found deficient in emergency preparedness policies and procedures, specifically regarding subsistence needs for staff and patients, emergency water supply, the facility's role under a waiver declared by the Secretary, and emergency power system inspection, testing, maintenance, and fuel supply documentation.
Deficiencies (6)
Failure to include a policy and procedure addressing how emergency water would be provided in the event of an interruption of the city water supply.
Failure to include policies and procedures for the facility's role under a waiver declared by the Secretary for provision of care and treatment at an alternate care site.
Failure to implement emergency power system inspection, testing, and maintenance requirements per NFPA standards.
Failure to provide a plan on how the facility would maintain an onsite fuel source to power emergency generators during an emergency.
The facility's essential electrical system (EES) log lacked documented evidence of service within 10 seconds on specified dates and was not exercised under load within required intervals.
The facility's fire and disaster policy/procedure lacked documented evidence on how the facility would maintain an onsite fuel source to power the EES during an emergency.
Report Facts
Deficiency completion date: Jun 14, 2019
Dates missing documented EES service within 10 seconds: 4
Dates EES not exercised under load within required interval: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to confirming deficiencies regarding emergency water supply policy and emergency power system fuel supply documentation. | |
| Maintenance Director | Named as responsible individual for corrective actions related to emergency water supply policy. | |
| Environmental Services Director | Confirmed missing documentation related to emergency power system fuel supply. |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 4
Date: May 9, 2019
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare Recertification survey conducted from May 6, 2019 through May 9, 2019, including one complaint investigation.
Complaint Details
Complaint #NV00056538 alleging staff yelled at a resident, hit a resident, and failed to provide physician care for rectal pain was investigated and not substantiated.
Findings
The facility was found deficient in multiple areas including infection control related to catheter care, respiratory care, food safety, and storage practices. One complaint alleging staff abuse was investigated and not substantiated. Deficiencies included improper catheter flushing technique risking infection, empty oxygen humidifier bottle, damaged food packaging, and improper storage of urine drainage bag.
Deficiencies (4)
Failure to provide treatment for suprapubic catheter to prevent infection and contamination.
Respiratory care deficiencies including empty oxygen humidifier bottle.
Food safety violation for storing damaged tuna fish package.
Infection control failure due to improper catheter care and contamination of catheter bag tubing.
Report Facts
Sample size: 18
Closed records reviewed: 3
Deficiencies cited: 4
Oxygen liter flow: 3
Catheter flush volume: 60
Catheter change frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to improper catheter flushing technique and contamination. |
| LPN #2 | Licensed Practical Nurse | Named in findings related to catheter bag tubing contamination. |
| Director of Nursing | Responsible for education and monitoring corrective actions related to catheter care and infection control. | |
| Dietary Manager | Named in findings related to food safety and damaged tuna fish package. |
Inspection Report
Routine
Capacity: 99
Deficiencies: 17
Date: May 9, 2019
Visit Reason
The inspection was a Medicare Life Safety Code recertification survey conducted from 05/07/19 through 05/09/19 at Rosewood Rehabilitation Center.
Findings
The facility had multiple deficiencies including means of egress obstructions, doors with self-closing devices not functioning properly, emergency lighting testing deficiencies, smoke detection sensitivity testing deficiencies, incomplete automatic fire sprinkler system, sprinkler system maintenance issues, portable fire extinguisher placement and maintenance issues, fire drills not conducted at unexpected times, smoking regulations violations, improper use of portable space heaters, electrical system labeling and maintenance issues, use of relocatable power taps as fixed wiring, and oxygen cylinder storage violations.
Deficiencies (17)
Means of egress obstructions with items protruding more than 4 inches into corridors and aisles.
Doors with self-closing devices failed to close properly.
Emergency lighting functional testing not conducted annually for 1.5 hours as required.
Smoke detection system sensitivity testing and annual functionality testing not documented or completed.
Incomplete automatic fire sprinkler system with missing sprinklers at main entrances and exits.
Fire sprinkler heads had paint overspray, dust, lint, foreign matter, physical damage, and corrosion.
Fire sprinkler escutcheons and cover plates missing or improperly installed; penetrations in fire walls not sealed.
Portable fire extinguishers exceeded installation height requirements, lacked signage, were blocked, or missing placards.
Fire drills not conducted at unexpected times on all shifts; staff unfamiliar with fire drill procedures.
Smoking area lacked proper disposal equipment with self-closing covers for cigarette butts.
Portable space heaters used in prohibited areas without required specifications.
Electrical receptacles missing GFCI protection in wet areas.
Essential electrical system testing not conducted at required intervals; documentation incomplete.
Relocatable power taps used as fixed wiring in patient care areas.
Oxygen cylinders stored with full and empty tanks mixed; storage room door missing fire rating label.
Electrical panel circuit directory not properly labeled; broken or missing receptacle covers.
Corridor doors failed to latch or resist passage of smoke; holes and kickstands present.
Report Facts
licensed_capacity: 99
fire_extinguisher_installation_height_inches: 69
fire_drill_missing_night_shift_dates: 4
emergency_electrical_system_test_interval_days: 40
oxygen_cylinders_full_and_empty_mixed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Confirmed multiple deficiencies including sprinkler issues, fire drill observations, and oxygen storage concerns. | |
| Maintenance Director | Named in multiple findings related to corrective actions, training, inspections, and monitoring of fire safety, electrical, and facility maintenance issues. | |
| Administrator | Confirmed observations related to fire extinguisher placement, fire drill announcements, and oxygen storage. | |
| Certified Nursing Assistant | Participated in fire drill scenario and was confused about manual pull station location. |
Inspection Report
Renewal
Capacity: 99
Deficiencies: 1
Date: May 8, 2019
Visit Reason
This Statement of Deficiencies was generated as a result of a state re-licensure survey conducted at the facility on 05/08/19 through 05/09/19 in accordance with Nevada Administrative Code (NAC) 449 for Facilities for Skilled Nursing.
Findings
The facility failed to ensure sufficient cooking surface coverage of the canopy-type commercial cooking hood. Specifically, the oven was placed zero inches from the perimeter of the cooking hood, not meeting the six inch overhang requirement. The Environmental Services Director confirmed unawareness of this requirement.
Deficiencies (1)
Failed to ensure sufficient cooking surface coverage of the canopy-type commercial cooking hood; oven placement did not meet six inch overhang requirement.
Report Facts
Licensed capacity: 99
Severity level: 2
Scope: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hopkins | Administrator | Signed the Statement of Deficiencies |
| Environmental Services Director | Confirmed the oven was not recessed from the cooking hood overhang by the six inch requirement | |
| Maintenance Director | Responsible for corrective actions and trained to follow regulatory requirements related to cooking surfaces placement under the vent hood |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: Oct 17, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation at Rosewood Rehabilitation Center on 10/17/2018, triggered by one complaint with multiple allegations.
Complaint Details
Complaint #NV00054816 included six allegations regarding meal size, resident protection from strangers, facility responsiveness, medication administration, transfer prevention, and POA contact prevention; all allegations were unsubstantiated.
Findings
The investigation included observations, interviews, and clinical record reviews. None of the allegations were substantiated, and no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Oct 1, 2018
Visit Reason
The inspection was conducted as a complaint investigation initiated and completed on 10/1/18 in accordance with 42 CFR, Part 483 - Requirements for Long Term Care Facilities.
Complaint Details
Complaint #NV00054651 included allegations of Resident/Patient/Client Neglect regarding medications, failure to acquire informed consent, and admission, transfer & discharge rights; all allegations were unsubstantiated.
Findings
One complaint was investigated with three allegations related to neglect, failure to acquire informed consent, and admission, transfer & discharge rights, all of which were unsubstantiated after review of clinical records and interviews with the physician and administrator.
Report Facts
Sample size: 10
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Aug 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation initiated due to an allegation of misappropriation of property involving a missing CPAP machine from personal effects.
Complaint Details
Complaint #NV00053707 alleged misappropriation of property (missing CPAP machine). The allegation was not substantiated after investigation.
Findings
The complaint investigation included a facility tour, interviews with staff and residents, and clinical record reviews. The allegation could not be substantiated and no deficiencies were identified.
Report Facts
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley A. Rains | Named in the initial comments section as the person associated with the Statement of Deficiencies |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 10
Date: May 24, 2018
Visit Reason
The inspection was conducted as an annual Medicare Recertification Survey from May 21, 2018 through May 24, 2018, in accordance with 42 CFR Chapter IV, Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including resident rights, accuracy of assessments, comprehensive care plans, medication administration, infection control, resident call system, abuse prevention, and quality of care. Corrective actions and plans of correction were detailed for each deficiency.
Deficiencies (10)
Resident Rights/Exercise of Rights - Facility failed to ensure staff were sitting while feeding a resident.
Required Notices and Contact Information - Facility failed to inform residents of complaint filing procedures and contact information.
Safe/Clean/Comfortable/Homelike Environment - Facility failed to maintain resident room walls, door frames, baseboards, and blinds in good repair.
Accuracy of Assessments - Facility failed to identify limited range of motion and correct discharge location on MDS assessment for sampled residents.
Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive care plans for sampled residents.
Services Provided Meet Professional Standards - Facility failed to provide specialized rehabilitative services per professional standards.
Label/Store Drugs and Biologicals - Facility failed to properly label and store medications and biologicals.
Infection Prevention & Control - Facility failed to establish and maintain an infection prevention and control program.
Resident Call System - Facility failed to ensure call lights were operational in resident rooms.
Abuse, Neglect, and Exploitation Training - Facility failed to provide timely abuse training for new and existing staff.
Report Facts
Sample size: 19
Closed records reviewed: 3
Residents affected: 1
Medication doses: 9
Audit times: 4
Audit times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Observed feeding Resident #30 while standing | |
| Certified Nurse Assistant #2 | Observed feeding Resident #30 while standing | |
| Staff Development Coordinator | Responsible for in-servicing nursing staff and monitoring corrective actions | |
| Assistant Director of Nursing | Responsible for in-servicing nursing staff and monitoring corrective actions | |
| Director of Nursing | Ensures compliance with corrective actions and conducts audits | |
| Director of Maintenance | Confirmed maintenance deficiencies and conducts audits | |
| Licensed Practical Nurse (LPN) | Confirmed observations related to Resident #30 and medication administration | |
| Licensed Social Worker (LSW) | Verified documentation and orders related to Resident #26 | |
| Human Resources Director | Confirmed CNA personnel records and evaluations | |
| Executive Director | Oversaw abuse training and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 22, 2018
Visit Reason
This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey at the facility on 5/22/18.
Findings
There were no deficiencies cited during this survey.
Inspection Report
Life Safety
Capacity: 99
Deficiencies: 0
Date: May 22, 2018
Visit Reason
This survey was conducted as a Medicare Life Safety Code (LSC) recertification survey at the facility on 5/22/18.
Findings
The facility was surveyed using the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code and was found to have no deficiencies during this survey.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 3
Date: May 21, 2018
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a federal survey at Rosewood Rehabilitation Center from May 21, 2018 through May 24, 2018, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including failure to ensure annual fire and disaster training for 7 of 18 sampled personnel, lack of pre-employment physicals and timely background checks for 4 of 18 personnel, and failure to complete initial and annual dementia training for 4 of 18 sampled employees.
Deficiencies (3)
Failure to ensure annual fire and disaster training was completed for 7 of 18 sampled personnel files.
Failure to ensure pre-employment physicals and timely background checks were conducted for 4 of 18 sampled personnel files.
Failure to ensure initial and annual dementia training was completed for 4 of 18 sampled personnel files.
Report Facts
Sample size: 19
Staff lacking fire and disaster training: 7
Staff lacking pre-employment physicals and timely background checks: 4
Staff lacking dementia training: 4
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Apr 17, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated and completed on 04/17/18, involving three complaints with multiple allegations regarding resident care and facility practices.
Complaint Details
Three complaints were investigated: Complaint #NV00051124 with four allegations, Complaint #NV00051908 with one allegation, and Complaint #NV00051841 with eleven allegations. All allegations were found to be unsubstantiated after investigation.
Findings
The investigation included tours, interviews with residents and staff, and review of clinical records and policies. None of the allegations in the three complaints were substantiated, and no deficiencies were identified.
Report Facts
Sample size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed during the complaint investigation |
| Discharge Coordinator | Interviewed during the complaint investigation | |
| Case Manager | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation of an inappropriate discharge to a living environment that was not adequate to meet the resident's care needs.
Complaint Details
Complaint #NV00050101 alleged an inappropriate discharge to an inadequate living environment; the allegation was not substantiated.
Findings
The complaint was investigated through interviews with multiple staff members and review of medical records and facility checklists. The allegation could not be substantiated and no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Inspection Report
Plan of Correction
Capacity: 99
Deficiencies: 5
Date: Jul 26, 2017
Visit Reason
This Plan of Correction was prepared following a Medicare Life Safety Code recertification survey conducted on 07/26/17 and 07/27/17 at the facility to address identified fire safety deficiencies.
Findings
The facility failed to meet several Life Safety Code standards related to doors with self-closing devices, sprinkler system installation, corridor doors, utilities (gas and electric), and fire drills. Deficiencies affected smoke compartments, residents, staff, and guests, with corrective actions planned and assigned to the Maintenance Director.
Deficiencies (5)
Doors with self-closing devices were obstructed from automatically closing, affecting one of three smoke compartments.
Facility failed to maintain the automatic fire sprinkler system as required, affecting two of three smoke compartments.
Facility failed to protect corridor openings due to doors that would not close properly, affecting one of three smoke compartments.
Facility failed to maintain electrical wiring and equipment in compliance with National Electric Code.
Facility failed to conduct fire drills at expected times and ensure staff familiarity with fire response procedures, affecting three of three smoke compartments.
Report Facts
Licensed skilled nursing beds: 99
Deficiency completion date: Sep 9, 2017
Fire drill record dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Owen Smith | Administrator | Signed the Plan of Correction |
| Maintenance Director | Acknowledged deficiencies and assigned responsibility for corrective actions related to doors, sprinkler system, electrical wiring, and fire drills | |
| Occupational Therapist | OT | Participated in simulated fire drill scenario |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Date: Jul 24, 2017
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual Medicare Recertification Survey conducted from July 24, 2017 through July 27, 2017. The survey included investigation of three complaints and review of clinical records and facility policies.
Complaint Details
Three complaints were investigated. Complaint #NV00048768 was substantiated regarding neglect of a resident's wounds. Complaint #NV00049152 was substantiated regarding Certified Nurse Assistants sharing soap and lotion among residents. Complaint #NV00049527 was not substantiated.
Findings
The survey substantiated two complaints related to wound care neglect and sharing of soap and lotion among residents. The facility failed to perform accurate and timely wound assessments for one resident and had deficiencies in medication storage and infection control practices. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (5)
Failure to perform accurate and timely assessments of wounds for one resident (Resident #16).
Failure to provide care and services for highest well-being including quality of life and pain management for Resident #13.
Failure to provide ADL care including toenail care for Resident #6.
Failure to provide routine and emergency drugs and biologicals properly, including medication storage and disposal for Resident #20.
Failure to establish and implement an infection control program to prevent spread, including proper labeling and storage of linens and personal hygiene items.
Report Facts
Residents present: 81
Sample size: 17
Complaints investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as individual responsible for corrective actions and monitoring wound care and medication policies |
| Wound Care Nurse | Wound Care Nurse | Conducts wound care assessments and chart reviews; involved in wound care findings |
| Licensed Practical Nurse | Licensed Practical Nurse | Mentioned in relation to wound care treatments and documentation |
| Registered Nurse | Registered Nurse | Involved in medication room inspections and communication record reviews |
| Case Manager | Case Manager | Reported observations of resident wounds |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation involving two complaints related to admission, transfer and discharge rights, quality of care/treatment, resident safety, and call bells not operating.
Complaint Details
Two complaints were investigated: Complaint #NV00048315 regarding admission, transfer & discharge rights and quality of care/treatment; Complaint #NV00048968 regarding call bells not operating and resident safety/falls. Both complaints were not substantiated.
Findings
The investigation included review of resident assessments, physician orders, nursing progress notes, social services summaries, and interviews. Both complaints were found to be unsubstantiated and no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 2
Date: Aug 11, 2016
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a federal recertification survey from 08/08/2016 through 08/11/2016, in accordance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility failed to ensure that employees received tuberculosis testing and pre-employment physical examinations prior to employment for 5 of 22 employee files reviewed, and failed to ensure background checks for criminal history were obtained for 2 of 22 employee files reviewed. Corrective actions and process improvements were planned to address these deficiencies.
Deficiencies (2)
Facility failed to ensure employees received Tuberculosis (TB) testing and pre-employment physical examinations prior to employment for 5 of 22 employee files reviewed.
Facility failed to ensure background checks for criminal history were obtained for 2 of 22 employee files reviewed.
Report Facts
Census: 70
Employee files reviewed: 22
Employees with TB and physical exam deficiencies: 5
Employees with background check deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lowell Smith | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on report |
| Employee #2 | Director of Nursing | Named in TB testing deficiency finding |
| Employee #9 | Housekeeper | Named in TB testing and background check deficiency findings |
| Employee #11 | Cook | Named in TB testing deficiency finding |
| Employee #12 | Registered Nurse | Named in TB testing deficiency finding |
| Employee #13 | Speech Therapist | Named in TB testing deficiency finding |
| Employee #14 | Dietary Manager | Named in background check deficiency finding |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 2
Date: Aug 11, 2016
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a federal recertification survey from 08/08/2016 through 08/11/2016 to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in ensuring employees received required tuberculosis (TB) testing and pre-employment physical examinations prior to employment for 5 of 22 employee files reviewed. Additionally, background checks for criminal history were not obtained or were outdated for 2 of 22 employee files reviewed.
Deficiencies (2)
Failure to ensure employees received tuberculosis testing and pre-employment physical examinations prior to employment for 5 of 22 employee files reviewed.
Failure to ensure background checks for criminal history were obtained for 2 of 22 employee files reviewed.
Report Facts
Census: 70
Employee files reviewed: 22
Employees with deficient TB testing and physical exams: 5
Employees with deficient background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Director of Nursing | Named in finding for TB testing obtained after start date |
| Employee #9 | Housekeeper | Named in findings for lack of pre-employment physical exam and missing background check |
| Employee #11 | Cook | Named in finding for lack of pre-employment physical exam |
| Employee #12 | Registered Nurse | Named in finding for lack of pre-employment physical exam |
| Employee #13 | Speech Therapist | Named in finding for lack of pre-employment physical exam |
| Employee #14 | Contracted Dietary Manager | Named in finding for outdated background check |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 9, 2016
Visit Reason
This Plan of Correction was prepared following a Medicare Life Safety Code survey conducted at the facility on 8/9/16.
Findings
The facility failed to meet Life Safety Code standards related to doors protecting corridor openings and maintaining clear exit corridors. Specific deficiencies included hollow core doors in exit corridors and obstruction of exit corridors by a linen cart.
Deficiencies (2)
Doors protecting corridor openings were not substantial doors for 2 of 5 main exit corridors, having hollow core doors with only spring button hardware.
Exit corridors were obstructed by a linen cart reducing corridor width and blocking fire alarm pull station access.
Report Facts
Number of main exit corridors with deficient doors: 2
Number of main exit corridors with obstruction: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding door acceptability and corridor obstruction | |
| ED or designee | Responsible for in-service training of Housekeeping and Nursing staff |
Inspection Report
Life Safety
Deficiencies: 2
Date: Aug 9, 2016
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with the National Fire Protection Association's (NFPA) 101 Life Safety Code standards.
Findings
The facility was found to have deficiencies related to doors protecting corridor openings and maintaining clear exit corridors. Specifically, hollow core doors were used where solid-bonded core wood doors were required, and exit corridors were obstructed by a linen cart reducing the required clear width.
Deficiencies (2)
Doors protecting corridor openings were not substantial doors as required; hollow core doors were used in two main exit corridors.
Exit corridors were not maintained clear and unobstructed; a linen cart obstructed the fire alarm pull station access in one corridor.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 9
Date: Aug 8, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual Medicare Recertification Survey conducted from August 8, 2016 through August 11, 2016 at the facility in accordance with federal regulations for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies including failure to provide abuse training upon hire for some employees, failure to maintain housekeeping and maintenance services, failure to develop comprehensive care plans, failure to ensure proper infection control, and failure to maintain proper drug regimen and medication records. Several areas of the facility were found to be in disrepair or unsanitary conditions.
Deficiencies (9)
Failure to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Failure to provide abuse training upon hire for some employees and failure to prescreen employees for history of abuse.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failure to develop comprehensive care plans for residents.
Failure to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Failure to ensure drug regimen is free from unnecessary drugs.
Failure to provide emergency preparedness training upon hire to some employees.
Failure to maintain infection control program and prevent spread of infection.
Failure to maintain proper drug records and control of drugs.
Report Facts
Census: 70
Sample size: 15
Employee files reviewed: 22
Employees lacking abuse training: 5
Rooms inspected for housekeeping deficiencies: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #15 | Contracted Registered Dietician | Lacked documented abuse training upon hire and emergency preparedness training |
| Employee #14 | Contracted Dietary Manager | Lacked documented abuse training upon hire and emergency preparedness training |
| Employee #9 | Housekeeper | Lacked abuse training and incomplete pre-employment screening |
| Employee #16 | Social Services Staff | Incomplete pre-employment screening |
| Employee #11 | Cook | Incomplete pre-employment screening |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding failure to obtain physician orders and medication administration issues |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding medication administration and psychotropic medication use |
| Payroll Representative | Explained employee orientation and training processes |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 29, 2015
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey at the facility on 09/29/2015 to assess compliance with NFPA 101 Life Safety Code standards.
Findings
The facility was found deficient in compliance with NFPA 101 Life Safety Code, specifically regarding the use of extension cords supplying power to equipment, which is not permitted as a substitute for fixed wiring. Several extension cords were observed in various areas of the facility.
Deficiencies (1)
Use of extension cords to supply power to equipment instead of fixed wiring, violating NFPA 101 Life Safety Code standards.
Report Facts
Date of survey: Sep 29, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding extension cord use and responsible for corrective actions and education | |
| Executive Director | Responsible for ensuring compliance through monthly Quality Assurance Meetings |
Inspection Report
Deficiencies: 1
Date: Sep 29, 2015
Visit Reason
This document is a statement of deficiencies generated as a result of a Medicare recertification survey conducted at Rosewood Rehabilitation Center on 09/29/2015.
Findings
The findings include deficiencies related to electrical wiring and equipment not being in accordance with NFPA 70, National Electrical Code, specifically regarding the use of extension cords and power supply for equipment in the facility.
Deficiencies (1)
Electrical wiring and equipment is not in accordance with NFPA 70, National Electrical Code - 9.1.2.
Report Facts
Deficiency tags: 2
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 8
Date: Sep 23, 2015
Visit Reason
This inspection was conducted as an annual Medicare Recertification Survey at Rosewood Rehabilitation Center from September 21, 2015 through September 23, 2015, in accordance with federal requirements for long term care facilities.
Findings
The survey identified multiple deficiencies related to personal privacy/confidentiality of records, abuse/neglect policies, professional standards of care, drug regimen management, food sanitation, infection control, and medication administration. Corrective actions and plans to monitor compliance were outlined for each deficiency.
Deficiencies (8)
Failed to ensure computer screens were locked when not in use to protect resident information.
Failed to provide reference checks, fingerprints, and signed background statement for contracted employee.
Failed to accurately perform quality assurance monitoring for glucometers and oxygen administration for sampled residents.
Failed to ensure residents were free from unnecessary drugs and properly managed drug regimens.
Failed to follow proper hand washing technique and maintain sanitary food preparation area.
Failed to employ a licensed pharmacist to maintain drug records and ensure proper drug storage and security.
Failed to ensure medication carts were locked and medications properly stored and labeled.
Failed to establish and maintain an infection control program to prevent spread of infection.
Report Facts
Residents sampled: 18
Residents affected: 1
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Contracted Dietician | Personnel file lacked required documentation |
| Director of Nursing | Reported computer screens should be locked; involved in corrective actions and reviews | |
| Assistant Director of Nursing | Conducts in-services and reviews findings | |
| Licensed Practical Nurse | LPN | Observed unlocked medication cart and oxygen administration |
| Dietary Manager | Observed hand washing and food preparation deficiencies | |
| Registered Nurse | RN | Responsible for medication cart and acknowledged findings |
| Assistant Director of Nursing | ADON | Confirmed inability to locate documentation for gradual dose reduction |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 8
Date: Sep 23, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of an annual Medicare Recertification Survey conducted from September 21, 2015 through September 23, 2015 in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to ensure computer screens were locked to protect resident privacy, incomplete employee background checks, inadequate quality assurance monitoring of glucometers, failure to administer oxygen as ordered, failure to secure physician orders for medications, failure to attempt gradual dose reductions for certain medications, improper food handling and sanitation practices, failure to secure medication carts and properly store medications, and failure to prevent cross contamination during medication administration.
Deficiencies (8)
Failed to ensure computer screens were locked when not in use to protect resident information.
Failed to provide reference checks, fingerprints, and signed background statement for contracted employee.
Failed to accurately perform quality assurance monitoring for glucometers and failed to administer oxygen as ordered for a resident.
Failed to secure a physician's order for a medication following hospital transfer for a resident.
Failed to ensure gradual dose reduction was attempted for antipsychotic medications for three residents.
Failed to follow proper hand washing technique and maintain sanitary food preparation area.
Failed to ensure medication carts were locked when unattended, properly store internal and external medications, and avoid preparing medications in advance.
Failed to ensure medications were not touched with bare hands and barriers were used to prevent cross contamination during medication administration.
Report Facts
Census: 85
Sample size: 18
Deficiencies cited: 8
Oxygen flow rate: 2
Medication dose: 15
Medication dose: 37.5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 10, 2015
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of incorrect medication administration and delayed laboratory follow-up for a resident.
Complaint Details
Complaint #NV00042477 involved two allegations: 1) a resident received incorrect medication, and 2) a resident had a critically low potassium level with delayed laboratory follow-up. Both allegations were investigated and could not be substantiated.
Findings
The investigation reviewed multiple resident records and found no regulatory deficiencies. The allegations were not substantiated and no further action was necessary.
Report Facts
Sample size: 1
Number of complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Sep 16, 2014
Visit Reason
The inspection was conducted as a complaint investigation initiated due to allegations of failure to provide appropriate nutrition to a resident with special dietary needs, excessive noise levels, and lack of medication resulting in low blood pressure.
Complaint Details
Complaint #NV 00040382 was investigated and found unsubstantiated regarding nutrition, noise levels, and medication issues.
Findings
The complaint allegations were unsubstantiated. Observations showed noise levels were not excessive, call light chimes were audible, and interviews with staff and review of six clinical records found no deficiencies in medication administration, dietary intake, or blood pressure management.
Report Facts
Sample size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during complaint investigation | |
| Director of Nursing | Interviewed during complaint investigation | |
| Speech Therapy Manager | Interviewed to determine recognition, assessment and interventions for residents with swallowing difficulties | |
| Dietary Manager | Interviewed to determine recognition, assessment and interventions for residents with swallowing difficulties |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 4
Date: Jul 24, 2014
Visit Reason
The inspection was conducted as an annual Medicare re-certification survey from July 21, 2014 through July 24, 2014, including investigation of one complaint (NV00039647) which was found to be unsubstantiated.
Complaint Details
One complaint (NV00039647) was investigated during the survey and was determined to be unsubstantiated. The allegations regarding an unsafe and inappropriate discharge were not substantiated through document review, clinical record review, and interview with facility staff.
Findings
The facility was found deficient in multiple areas including failure to meet professional standards in medication administration, inaccurate tube feeding documentation, improper medication labeling, improper medication disposal, and inadequate infection control practices including hand hygiene and linen handling.
Deficiencies (4)
Failure to ensure licensed nurses performed the five rights of medication administration, specifically the right dose for Resident #17, and failure to clarify physician orders for tube feedings for Resident #8.
Failure to ensure accuracy of tube feedings total volume administered per physician orders for Resident #8.
Failure to ensure medications were labeled appropriately for one bottle of liquid Vancomycin following a dosage change for Resident #17; and medications were appropriately discarded to prevent unauthorized access for Resident #18.
Failure to ensure proper hand cleaning between glove use during wound care and inadequate dry paper towel storage in an isolation room.
Report Facts
Census: 72
Sample size: 18
Vancomycin dosage: 125
Vancomycin dosage: 240
Tube feeding rate: 90
Tube feeding duration: 10
Tube feeding volume: 900
Tube feeding documented volume: 0
Tube feeding documented volume: 720
Tube feeding documented volume: 900
Tube feeding documented volume: 207
Tube feeding documented volume: 970
Tube feeding documented volume: 1440
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Employee #4 involved in medication pass and confirmed label discrepancy for Vancomycin for Resident #17 | |
| Licensed Practical Nurse | Explained tube feeding administration and confusion regarding orders for Resident #8 | |
| Director of Staff Development | Assessed Resident #8's medical record and requested order clarification for tube feeding | |
| Dietary Manager | Informed by Director of Staff Development to get clarification on tube feeding orders | |
| Unit Manager | Explained tube feeding administration and planned to change orders for Resident #8 | |
| Registered Dietitian | Acknowledged discrepancy in tube feeding documentation for Resident #8 | |
| Registered Nurse | Observed discarding medications in trash for Resident #18 | |
| Wound Care Nurse | Observed not performing hand hygiene between glove changes during wound care |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 24, 2014
Visit Reason
This visit was conducted as a Medicare Life Safety Code survey using Chapter 19, Existing Health Care Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code.
Findings
There were no deficiencies cited during this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of complaint investigations conducted at Rosewood Rehabilitation Center on 10/2/13, related to multiple complaints alleging unsafe discharge, deficient quality of care, improper medication administration, untimely call light response, staff eating during patient care, dirty dietary department, and improper infection control practices.
Complaint Details
Complaint #NV00036556 alleged unsafe discharge; unsubstantiated based on interviews with two social workers and medical record review. Complaint #NV00036900 alleged deficient quality of care and improper medication administration; unsubstantiated based on interviews with the director of nursing and personnel file reviews. Complaint #NV00036499 alleged deficient quality of care and untimely call light response; unsubstantiated based on direct observations, resident interviews, personnel file review, and interview with the director of nursing. Complaint #NV00036634 alleged staff eating during patient care, dirty dietary department, and improper infection control practices; unsubstantiated based on observations of kitchen, resident rooms, bathrooms, resident care, infection control policy review, and interviews with residents and staff.
Findings
All complaints investigated (#NV00036556, #NV00036900, #NV00036499, #NV00036634) were found to be unsubstantiated based on interviews, medical record reviews, observations, and policy reviews. No regulatory deficiencies were identified.
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 16
Date: Jun 27, 2013
Visit Reason
Annual Medicare Recertification survey conducted from June 24-27, 2013 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found deficient in multiple areas including failure to notify physician of significant weight loss, privacy violations, grievance procedures, medication self-administration screening, abuse investigation procedures, resident grooming, resident choice in meal times, maintenance and housekeeping issues, medication administration errors, wound care pain management, water temperature control, dietary sanitation, infection control, and accident hazard prevention.
Deficiencies (16)
Failed to promptly notify the physician of a significant weight loss for 1 of 24 residents (#1).
Failed to ensure residents' right to privacy were respected regarding photographs and clinical needs.
Failed to ensure residents knew the procedure for filing grievances and did not act on resolving a grievance.
Failed to ensure residents were screened appropriately to self-administer medications for 2 of 24 residents (#20 and #24).
Failed to ensure allegations of resident abuse and/or neglect were thoroughly investigated and potential mistreatment prevented.
Failed to ensure residents were properly groomed (Residents #22, #21).
Failed to allow residents to choose meal times and dining companions.
Failed to ensure maintenance and repair of overhead light cords, walls, laminate in vanity areas, and wheelchair handle and brakes for 1 resident (#24).
Failed to ensure torn bed linens were changed for one resident (#10).
Failed to ensure loud noises were kept to a minimum.
Failed to ensure professional standards regarding medication administration, physician notification, maintenance of equipment and storage of medication were followed.
Failed to ensure water temperatures were above 110 degrees Fahrenheit in resident rooms and showers.
Failed to ensure dietary equipment was properly cleaned and nourishment refrigerators were sanitary.
Failed to establish and maintain an infection control program that monitors antibiotic use and ensures cleanliness of bathrooms and urinals.
Failed to accurately record weights for 1 resident (#3) and failed to administer pain medication prior to wound care for 1 resident (#1).
Failed to ensure water temperatures were safe and within required range to prevent accidents.
Report Facts
Sample size: 24
Weight loss: 13.2
Weight loss percentage: 7.84
Wound measurement length: 11.3
Wound measurement width: 4.7
Wound measurement depth: 3.8
Hot water temperature: 118
Hot water temperature: 110
Hot water temperature: 104
Torn bed linen size: 1
Medication dose error: 122
Insulin units: 7
Fingerstick blood glucose: 94
Fingerstick blood glucose: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Nurse | Observed preparing insulin dose and instructing Resident #20 |
| Employee #5 | Certified Nursing Assistant | Observed using personal smart phone to take resident photographs |
| Employee #2 | Assistant Director of Nursing | Accompanied surveyor on tour and interviewed regarding medication self-administration |
| Employee #10 | Infection Control Nurse / Facility Educator | Interviewed regarding abuse policies and infection control practices |
| Employee #1 | Administrator | Interviewed regarding abuse investigation and facility policies |
| Employee #7 | Registered Nurse | Observed medication pass and interviewed regarding medication errors |
| Employee #11 | Treatment Nurse | Interviewed regarding use of Zinc Oxide ointment |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Jun 20, 2013
Visit Reason
The inspection was conducted as a complaint investigation following allegations of sexual abuse of Resident #1, failure to report the incident timely, and failure to suspend the accused staff during the investigation.
Complaint Details
Complaint #NV000 35049 involved allegations of sexual abuse of Resident #1, failure to report the incident timely, and failure to suspend accused staff. The sexual abuse and reporting allegations were unsubstantiated, but the failure to suspend accused staff was substantiated.
Findings
The allegations of sexual abuse and failure to report timely were unsubstantiated based on observation, record review, and interviews. However, the facility failed to follow its policy requiring suspension of accused staff during the investigation, as the accused CNA continued to care for residents including Resident #1 during the investigation period.
Deficiencies (1)
Facility failed to follow written procedures regarding protection of residents by allowing accused staff to continue working during abuse investigation.
Report Facts
Facility census: 77
Dates of internal investigation: From 2013-06-07 to 2013-06-11
Completion date for plan of correction: Jul 9, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Accused staff member who continued to care for Resident #1 during the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 16, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility on 5/16/13 regarding an allegation that Resident #1 was being held against his will in violation of regulations.
Complaint Details
Complaint #NV000 35568 was investigated and found unsubstantiated.
Findings
Based on observation, record review, and interviews with staff, the allegation was found to be unsubstantiated. Resident #1 has dementia due to head trauma, requires assistance with most activities of daily living, and discharge home would be unsafe. No regulatory deficiencies were identified and no further action is necessary.
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: May 1, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on allegations including failure to provide bed baths, failure to pad side rails, improper medication administration through J-tube, seizures requiring hospital transfer, resident falls, lack of water for resident, and baths not given.
Complaint Details
Complaint #35022 included allegations of no bed baths, failure to pad side rails, improper medication administration, and seizures requiring hospital transfer. Complaint #35238 included allegations of multiple falls, no water left for resident, and baths not given. Both complaints were found unsubstantiated with no violations.
Findings
Based on observation, record review, and interviews with facility staff including the Administrator and Director of Nurses, no violations of regulations were found. Residents were clean and well-groomed, medication administration was safe and per responsible party requests, falls were reduced by preventative measures, and hydration and bathing needs were met according to resident preferences and safety considerations.
Report Facts
Facility census: 69
Resident files reviewed: 7
Inspection Report
Complaint Investigation
Census: 68
Capacity: 99
Deficiencies: 1
Date: Feb 11, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding Resident #1, including lost clothing, dirty room, treatments not done as ordered, no ice water provided, insufficient showering, lack of assistance with meals, and colostomy bag not emptied.
Complaint Details
Complaint #NV000 34548 involved allegations about Resident #1's care including lost clothing, dirty room, treatments not done as ordered, no ice water, insufficient showering, lack of meal assistance, and colostomy bag not emptied. Several allegations were unsubstantiated, but documentation deficiencies were confirmed.
Findings
The investigation found several allegations unsubstantiated, including dirty room, no ice water, assistance with meals, colostomy bag care, call bell accessibility, phone use instruction, and physician visits. However, documentation was incomplete for lost clothing, treatments not done as ordered, insufficient showering, and pain medication administration. The facility failed to maintain accurate and complete clinical records for Resident #1, including incomplete personal effects inventory, inconsistent wound dressing application, lack of shower documentation, and incomplete pain assessment documentation.
Deficiencies (1)
Failed to maintain complete and accurate clinical records for Resident #1, including incomplete documentation of personal effects, wound care, showering, and pain assessments.
Report Facts
Licensed capacity: 99
Census: 68
Medication administration exceptions: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed during investigation | |
| Director of Nurses | Interviewed during investigation and provided information on shower documentation | |
| Housekeeper | Interviewed during investigation | |
| Wound care Nurse | Interviewed regarding wound care and dressing orders | |
| Certified Nurses Aide | Interviewed and noted failure to document showers | |
| Restorative Aide | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 99
Deficiencies: 1
Date: Jan 11, 2013
Visit Reason
The inspection was conducted as a result of complaint investigations regarding allegations of inappropriate discharge of a resident and failure to notify a responsible party timely, and unnecessary drug use in the facility.
Complaint Details
Complaint #34047 alleging inappropriate discharge and failure to notify was unsubstantiated. Complaint #34246 regarding unnecessary drugs was substantiated.
Findings
The complaint about inappropriate discharge and failure to notify was unsubstantiated. However, the complaint regarding unnecessary drugs was substantiated, with findings that the facility failed to allow one resident to be free from chemical restraints, administering psychotropic medication without timely consent and resulting in the resident's lethargy and uncommunicativeness after discharge.
Deficiencies (1)
Facility failed to allow one of seven residents to be free from chemical restraints by administering Ativan without timely consent.
Report Facts
Licensed capacity: 99
Census: 71
Residents reviewed: 7
Medication doses given: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding complaint and findings | |
| Director of Nurses | Interviewed regarding complaint and findings | |
| Assistant Director of Nurses | Interviewed regarding complaint and findings | |
| Social Worker/Discharge Planner | Interviewed regarding complaint and findings |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 99
Deficiencies: 0
Date: Oct 2, 2012
Visit Reason
The inspection was conducted as a result of a complaint investigation (Complaint NV00033050) at Rosewood Rehabilitation Center on 10/2/12, focusing on allegations related to resident care and discharge procedures.
Complaint Details
Complaint NV00033050 involved allegations that Resident #1 was bullied by staff to comply with an NPO order and get a PEG tube, and that Resident #2 was discharged prematurely without home safety checks or medication discharge instructions. Both allegations were found unsubstantiated.
Findings
The investigation reviewed seven resident files, interviewed staff and residents, and observed care. Allegations regarding bullying of Resident #1 over swallowing evaluation and improper discharge of Resident #2 were unsubstantiated based on evidence and interviews.
Report Facts
Licensed beds: 99
Resident census: 71
Resident files reviewed: 7
Resident #2 discharge date: Aug 31, 2012
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 6
Date: Jun 29, 2012
Visit Reason
The inspection was conducted as an annual Medicare Recertification survey in accordance with 42 CFR Chapter IV Part 483, Requirements for States and Long Term Care Facilities, from June 25, 2012 to June 28, 2012.
Complaint Details
One complaint (#NV00031583) alleging inappropriate transfer or discharge was investigated during the survey and was found to be unsubstantiated.
Findings
The facility was found deficient in several areas including dignity and respect of individuality, professional standards of services provided, treatment and services for mental/psychosocial difficulties, food procurement and sanitary conditions, drug records and infection control. Corrective actions and staff training plans were outlined to address these deficiencies.
Deficiencies (6)
Failure to maintain resident dignity and respect, including improper handling of urinary drainage bags.
Services provided did not meet professional standards, including improper training and oversight of nursing staff.
Failure to provide treatment and services for mental/psychosocial difficulties.
Food procurement, storage, preparation, and serving were not sanitary.
Failure to properly label, store, and secure drugs and biologicals.
Infection control program deficiencies including hand hygiene and prevention of infection spread.
Report Facts
Census: 80
Sample size: 19
Complaint number: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Registered Nurse | Named in findings related to dignity and respect, professional standards, and medication administration. |
| Employee #8 | Certified Nursing Assistant (CNA) | Mentioned in relation to confirming privacy bag placement and behavior monitoring. |
| Employee #11 | Certified Nursing Assistant (CNA) | Mentioned in relation to inappropriate comments and behavior monitoring. |
| Employee #12 | Mentioned in relation to medication cart security and counseling. | |
| Employee #9 | Resident involved in behavior monitoring. | |
| Employee #6 | Mentioned in relation to behavior monitoring and interviews. | |
| Employee #3 | RN preceptor mentioned in staff development. | |
| Employee #17 | Resident involved in blood glucose testing deficiency. | |
| Employee #18 | Resident involved in blood glucose testing deficiency. | |
| Employee #19 | Resident involved in dignity and respect deficiency. | |
| Employee #15 | Resident involved in behavior monitoring. | |
| Employee #2 | Resident involved in wound care deficiency. | |
| Employee #8 | Mentioned in wound care and infection control. |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 6
Date: Jun 29, 2012
Visit Reason
The inspection was conducted as an annual Medicare Recertification survey from June 25, 2012 to June 28, 2012. One complaint alleging inappropriate transfer or discharge was also investigated and found unsubstantiated.
Complaint Details
Complaint #NV00031583 alleged inappropriate transfer or discharge. The complaint was investigated and found unsubstantiated after review of clinical records, interviews with staff, and documentation showing the responsible party was aware of the transfer.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to meet professional standards in nursing care, inadequate monitoring and treatment of residents with mental or psychosocial difficulties, unsanitary food handling practices, failure to secure medications, and inadequate infection control practices including improper hand hygiene and unsafe handling of needles and medical equipment.
Deficiencies (6)
Failure to maintain resident dignity, including administering insulin in a dining room with other residents present and failure to cover urinary drainage bags.
Failure to meet professional nursing standards, including improper use and cleaning of glucometers, failure to wash hands, and inadequate training and oversight of a new Registered Nurse.
Failure to ensure residents with mental or psychosocial difficulties were properly monitored and treated, including lack of specific behavior monitoring and care plans for residents with behavioral issues.
Failure to serve food under sanitary conditions, including a cook not washing hands between glove changes.
Failure to secure medications, including medication carts left unlocked and unattended during medication administration.
Failure to maintain infection control, including improper hand hygiene after glove removal, failure to clean glucometers between uses, unsafe handling of used needles, and failure to instruct residents on infection prevention.
Report Facts
Sample size: 19
Deficiency completion dates: Jul 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Registered Nurse | Named in multiple findings including failure to maintain resident dignity, improper infection control, and failure to secure medications. |
| Employee #8 | Wound Care Nurse | Observed failing to maintain infection control during wound care. |
| Employee #12 | Registered Nurse | Observed leaving medication cart unlocked and failing to perform hand hygiene. |
| Employee #3 | Registered Nurse, Preceptor | Reported supervising Employee #10 and signing off on skills. |
| Employee #6 | Involved in behavior care planning and interviews regarding resident monitoring. | |
| Employee #11 | Certified Nursing Assistant | Reported inappropriate resident comments and staff interventions. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 26, 2012
Visit Reason
This Statement of Deficiencies was generated as a result of a Medicare Life Safety Code (LSC) survey conducted at the facility on 6/26/12.
Findings
The facility was surveyed using Chapter 19, EXISTING Health Care Occupancies, of the 2000 Edition of the National Fire Protection Association's (NFPA) 101, Life Safety Code. There were no deficiencies cited during this survey.
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 3
Date: Sep 1, 2011
Visit Reason
This document is the Statement of Deficiencies generated as a result of the annual Medicare recertification survey conducted at the facility from August 29, 2011 through September 1, 2011.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for a resident's gastrostomy tube protection, failure to ensure gastrostomy tube placement was checked prior to medication administration for two residents, and failure to maintain an effective infection control program including appropriate disinfection for Clostridium difficile and prevention of cross contamination during ice distribution.
Deficiencies (3)
Failed to provide a soft abdominal wrap to protect a resident's gastric tube for 1 of 16 residents (Resident #9).
Failed to ensure gastrostomy tube placement was checked prior to medication administration and medications administered by gastrostomy tube were administered per facility policy for 2 of 17 residents (Resident #2 and #17).
Failed to establish and maintain an infection control program to prevent spread of infection, including failure to use appropriate disinfectants for Clostridium difficile and failure to prevent cross contamination while passing ice in resident rooms and dining room.
Report Facts
Sample size: 16
Unsampled residents: 1
Deficiencies cited: 3
Water flush volume: 30
Sodium hypochlorite concentration: 5.25
Sodium hypochlorite concentration: 6.15
Dilution ratio: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN-Employee #6) | Interviewed regarding missing soft abdominal wrap for Resident #9 | |
| Registered Nurse (RN-Employee #7) | Observed administering medications via gastrostomy tube to Residents #2 and #17 and interviewed about medication administration practices | |
| Director of Housekeeping (Employee #4) | Interviewed regarding disinfectant agent used for cleaning isolation rooms for residents with Clostridium difficile | |
| Certified Nursing Assistant (CNA-Employee #8) | Observed passing ice to resident rooms and interviewed about infection control practices |
Inspection Report
Life Safety
Deficiencies: 3
Date: Aug 30, 2011
Visit Reason
This document is a Medicare Life Safety Code survey conducted to assess compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code standards at the facility.
Findings
The facility failed to maintain clear and unobstructed corridors, with several blood pressure machines and medication carts reducing corridor widths below required standards. Additionally, the facility failed to maintain accurate records of generator testing and had electrical safety violations including improper use of extension cords.
Deficiencies (3)
Width of aisles or corridors (clear and unobstructed) serving as exit access is less than 4 feet due to equipment and med carts obstructing corridors.
Facility failed to maintain accurate records of generator testing.
Electrical wiring and equipment not in accordance with NFPA 70 National Electrical Code; use of extension cords as permanent wiring.
Report Facts
Date of survey: Aug 30, 2011
Generator inspection duration: 30
Corridor width reduction: 1
Corridor width reduction: 2
Inspection Report
Life Safety
Deficiencies: 3
Date: Aug 30, 2011
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) survey to assess compliance with the 2000 edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code for existing health care occupancies.
Findings
The facility failed to maintain clear and unobstructed corridors, did not properly test and document generator load testing, and used an extension cord as permanent wiring, violating NFPA 101 and NFPA 70 standards.
Deficiencies (3)
Width of aisles or corridors serving as exit access was obstructed by blood pressure machines and med carts, reducing corridor width below required 4 feet.
Generators were not inspected and exercised under load as required; records did not reflect load testing.
Electrical wiring did not comply with NFPA 70; extension cord used as permanent wiring to power a bedside fan.
Report Facts
Dates of generator testing: Records dated 11/27/10, 4/30/11, and 7/2/11 did not reflect load testing.
Corridor width reduction: 6
Corridor width reduction: 7
Generator exercise duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding generator testing and documentation. |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 3
Date: Aug 29, 2011
Visit Reason
The inspection was conducted as part of the annual Medicare recertification survey at the facility from August 29, 2011 through September 1, 2011.
Findings
The facility was found deficient in providing reasonable accommodations for residents' needs, specifically failing to provide a soft abdominal wrap to protect a resident's gastric tube. Additional deficiencies included failure to ensure gastrostomy tube placement was checked prior to medication administration for some residents and inadequate infection control practices related to Clostridium difficile.
Deficiencies (3)
Failed to provide a soft abdominal wrap to protect a resident's gastric tube for 1 of 16 residents.
Failed to ensure gastrostomy tube placement was checked prior to medication administration for 2 of 17 residents.
Failed to establish and maintain an effective Infection Control Program to prevent spread of infection, including use of ineffective disinfectant against C-diff spores.
Report Facts
Census: 77
Sample size: 16
Unsampled residents: 1
Closed records reviewed: 3
Residents with gastrostomy tube medication errors: 2
Residents with C-diff infection: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Counseled by Director of Nursing for failure to properly check placement of PEG tube and medication administration errors | |
| Employee #6 | Licensed Practical Nurse | Interviewed regarding lost abdominal wrap for Resident #9 |
| Employee #4 | Director of Housekeeping | Interviewed regarding disinfectant agent used for cleaning isolation rooms |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 8
Date: Aug 6, 2010
Visit Reason
This document is the Statement of Deficiencies generated as a result of the annual Medicare recertification survey conducted at Rosewood Rehabilitation Center from August 2, 2010 through August 6, 2010.
Findings
The facility was found deficient in multiple areas including failure to update employee fingerprinting and background screening, lack of staff training on abuse and neglect, failure to maintain resident dignity, inaccurate documentation of glucometer quality control, failure to provide preventive care to a resident, unsanitary food handling practices, inadequate infection control in the medication room, and lack of ongoing disaster training for staff.
Deficiencies (8)
Failed to ensure fingerprinting and background screening was completed or updated for 2 of 11 employees.
Failed to provide and ensure staff received training on abuse and neglect for 3 of 11 staff.
Failed to maintain an environment that enhanced resident dignity for 1 of 15 residents.
Failed to accurately document control ranges in glucometer quality control log and failed to date control solutions.
Failed to ensure preventive care was provided to 1 of 15 residents (failure to provide pre-medication antibiotics prior to dental appointments).
Failed to ensure glove and food handling practices were followed in dietary services.
Failed to maintain sanitary conditions in the medication room, including storing and spinning down laboratory specimens in a clean medication room.
Failed to provide evidence of ongoing disaster training and staff were unable to consistently identify emergency procedures.
Report Facts
Census: 66
Sample size: 15
Employees reviewed: 11
Residents reviewed: 15
Out of range glucometer tests: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Named in deficiency for failure to update fingerprinting/background screening and glucometer quality control interview | |
| Employee #10 | Named in deficiency for failure to update fingerprinting/background screening and abuse training | |
| Employee #5 | Named in deficiency for failure to provide abuse training and interviewed regarding food handling and trayline policies | |
| Employee #11 | Named in deficiency for failure to provide abuse training | |
| Employee #12 | Interviewed regarding use of centrifuge in medication room | |
| Employee #13 | Interviewed confirming fingerprinting/background screening not updated for Employees #6 and #10 |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 5, 2010
Visit Reason
This document reports the results of a Medicare Life Safety Code survey conducted at the facility on 8/5/10 to assess compliance with the National Fire Protection Association's Life Safety Code.
Findings
No deficiencies were noted at the time of the survey, indicating full compliance with the Life Safety Code requirements.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 8
Date: Aug 2, 2010
Visit Reason
The inspection was conducted as the annual Medicare recertification survey at the facility from August 2, 2010 through August 6, 2010, in accordance with federal regulations for long term care facilities.
Findings
The facility was found deficient in multiple areas including failure to complete fingerprinting and background screening for some employees, failure to provide abuse and neglect training to staff, failure to maintain dignity and respect for residents, failure to meet professional standards in services provided, failure to maintain sanitary food handling practices, and failure to properly conduct emergency procedure training. Corrective actions and plans of correction were submitted for these deficiencies.
Deficiencies (8)
Failure to ensure fingerprinting and background screening was completed upon hire or updated for 2 of 11 employees.
Failure to provide and ensure staff received training on abuse and neglect for 3 of 11 staff.
Failure to maintain an environment that enhanced resident dignity for 1 of 15 residents.
Failure to meet professional standards of quality in services provided, including inaccurate documentation of glucometer control ranges.
Failure to ensure preventive care was provided to 1 of 15 residents.
Failure to maintain sanitary food handling practices, including failure to wash hands and glove use by dietary staff.
Failure to maintain sanitary conditions in the medication room.
Failure to train all employees in emergency procedures and conduct unannounced staff drills.
Report Facts
Census: 66
Sample size: 15
Employees reviewed: 11
Residents reviewed: 15
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 12, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #NV00024365, which was partially substantiated with a cited deficiency regarding transfer or discharge of a patient.
Complaint Details
Complaint #NV00024365 was partially substantiated with a deficiency cited under Tag Z61 related to transfer or discharge of a patient.
Findings
The facility failed to follow its policy for notification of the resident's power of attorney during an emergent transfer to an acute care facility, preventing the acute care facility from obtaining a comprehensive medical history for one resident. The deficiency was cited under NAC 449.74429.
Deficiencies (1)
Failure to notify the resident's power of attorney of an emergent transfer to an acute care facility and failure to provide a comprehensive medical history for the resident.
Report Facts
Complaint number: 24365
Severity level: 2
Scope: 1
Plan of Correction submission timeframe: 10
In-Service Training date: Apr 27, 2010
Correction completion date: Apr 27, 2010
Monitoring period: 30
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 12, 2010
Visit Reason
This inspection was conducted as a result of a complaint investigation (Complaint #NV00024365) at Rosewood Rehabilitation Center on 02/12/2010, finalized on 02/18/2010.
Complaint Details
Complaint #NV00024365 was partially substantiated with a deficiency cited related to failure to notify the resident's power of attorney of an emergent transfer.
Findings
The facility was found to have failed to follow their policy for notification of the resident's power of attorney regarding an emergent transfer to an acute care facility, which prevented the acute care facility from obtaining a comprehensive medical history for one resident.
Deficiencies (1)
Failure to notify the resident's power of attorney of an emergent transfer to an acute care facility, preventing the acute care facility from obtaining a comprehensive medical history for one resident.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 2, 2010
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility on 2/2/2010, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Complaint Details
Complaint #NV00024217 was unsubstantiated.
Findings
Complaint #NV00024217 was unsubstantiated. No regulatory deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 9, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at Rosewood Rehabilitation Center on 12/9/09, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Complaint Details
Complaint #NV00023731 was investigated and determined to be unsubstantiated.
Findings
The complaint #NV00023731 was found to be unsubstantiated. No deficiencies or violations were explicitly cited in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 28, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation at Rosewood Rehabilitation Center on 10/28/09, finalized on 11/3/09, in accordance with Nevada Administrative Code, Chapter 449, Facilities for Skilled Nursing.
Complaint Details
Complaint #NV00023460 was substantiated with no regulatory deficiencies cited.
Findings
Complaint #NV00023460 was substantiated with no regulatory deficiencies cited. The findings do not prohibit any criminal or civil investigations or other claims under applicable laws.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 1
Date: Jul 24, 2009
Visit Reason
The inspection was conducted as the annual Medicare recertification survey at the facility from 7/20/09 through 7/24/09 in accordance with 42 CFR Chapter IV Part 483 Requirements for Long Term Care Facilities.
Findings
The facility failed to ensure that the plan of care for an indwelling urinary catheter was followed for 1 of 17 sampled residents (#5). Specifically, the catheter change scheduled for 7/18/09 was not completed as prescribed, though it was later completed on 7/21/09.
Deficiencies (1)
Failure to ensure that the plan of care for an indwelling urinary catheter was followed for 1 of 17 residents (#5).
Report Facts
Sample size: 17
Resident census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 (unit nurse) interviewed regarding catheter change responsibility and confirmation | ||
| Employee #5 (nurse) confirmed catheter change on 7/21/09 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 19, 2009
Visit Reason
The inspection was conducted as a complaint investigation based on substantiated and unsubstantiated complaints regarding the facility's compliance with Nevada Administrative Code for skilled nursing facilities.
Complaint Details
Complaint #NV00022124 was substantiated with deficiencies cited. Complaint #NV00022222 and Complaint #NV00022296 were unsubstantiated.
Findings
The facility was found deficient for failing to ensure that an 'Ice Man' was obtained in accordance with the physician's order and preadmission documentation for Resident #1. The deficiency was cited with a severity level of 2 and scope 1.
Deficiencies (1)
Facility failed to ensure that an 'Ice Man' was obtained in accordance with the physician's order and preadmission documentation and ready for implementation when Resident #1 was admitted.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 19, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by three complaints, of which one (#NV00022124) was substantiated with deficiencies cited.
Complaint Details
Complaint #NV00022124 was substantiated with deficiencies cited. Complaints #NV00022222 and #NV00022296 were unsubstantiated.
Findings
The facility failed to ensure that an 'Ice Man' was obtained in accordance with the physician's order and preadmission documentation and ready for implementation when Resident #1 was admitted to the facility.
Deficiencies (1)
Failed to ensure that an 'Ice Man' was obtained in accordance with the physician's order and preadmission documentation and ready for implementation when Resident #1 was admitted.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 27, 2009
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a survey conducted on 03/27/2009 at Rosewood Rehabilitation Center.
Findings
The document does not provide specific findings or deficiency details; it serves as a formal statement of deficiencies and plan of correction form without detailed content.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 12, 2008
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #NV00019534, which was substantiated.
Complaint Details
Complaint #NV00019534 was substantiated. The facility failed to notify the resident's sister of the fall and hospital transfer despite policy requirements.
Findings
The facility failed to notify a family member of a resident's fall that required transfer to the hospital. Resident #1 was found on the floor, transferred to the hospital, but the resident's sister was not notified of the fall or transfer. The Director of Nurses confirmed the policy to notify family members was not followed in this case.
Deficiencies (1)
Facility failed to notify a family member of a fall requiring hospital transfer for Resident #1.
Report Facts
Residents involved: 1
Date of fall: Sep 23, 2008
Date of hospital transfer: Sep 24, 2008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed on 11/12/08 confirming notification policy and Resident #1's alert status | |
| Director of Social Services | Met with Resident #1's sister to explain oversight in notification |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 9
Date: Jun 23, 2008
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual Medicare recertification survey conducted at the facility from 6/23/08 through 6/30/08.
Findings
The survey found multiple deficiencies including failure to post survey results and contact information, improper use and documentation of physical restraints for residents, failure to provide medically-related social services for some residents, inadequate food storage and preparation practices, failure to follow physician orders regarding restraints and medications, and deficiencies in infection control and pharmacy services.
Deficiencies (9)
Facility failed to post a notice of the availability of the most recent survey results and failed to post the results in a place readily accessible to residents.
Facility failed to post information on how residents could contact the Bureau of Licensure and Certification.
Facility failed to ensure the use of waist restraints was assessed, less restrictive measures attempted, consented to by responsible party and medically necessary for 7 of 23 residents.
Facility failed to provide medically-related social services for 2 of 23 residents.
Facility failed to clarify and/or implement physicians orders and notify the physician when orders had not been carried out for 1 of 23 residents.
Facility failed to ensure that Foley catheters were changed every 30 days per policy for 2 of 23 residents and failed to ensure catheter collection bags were not placed on the floor for 1 of 23 residents.
Facility failed to ensure residents were free from unnecessary drugs.
Facility failed to ensure food was stored and prepared under sanitary conditions.
Facility failed to establish and maintain an infection control program to prevent disease and infection and maintain records of corrective actions.
Report Facts
Census: 89
Sample size: 23
Residents affected by restraint deficiency: 7
Residents affected by social services deficiency: 2
Residents affected by physician order deficiency: 1
Residents affected by Foley catheter deficiency: 2
Residents affected by Foley catheter collection bag deficiency: 1
Residents affected by unnecessary drugs deficiency: 1
Residents affected by social services dental appointment deficiency: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2006
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging failures in resident meal assistance, staffing, food temperature, refrigerator cleanliness, medication room drug disposal, and dining room cleanliness.
Complaint Details
Complaint #NV00013525 alleged failure to assist residents during meals, insufficient staff for meal assistance, and cold food; complaint #NV00013540 alleged failure to keep refrigerators clean, dispose of outdated drugs in the medication room, and keep the dining room clean. Both complaints were unsubstantiated.
Findings
The complaints were investigated and found to be unsubstantiated; no deficiencies were cited related to the allegations.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 8, 2006
Visit Reason
The inspection was conducted as a complaint investigation following Complaint #NV00013372 alleging physical abuse of a resident by an employee. The complaint was substantiated with federal deficiencies cited.
Complaint Details
Complaint #NV00013372 alleged physical abuse of a resident by an employee. The complaint was substantiated with federal deficiencies cited (Tags F224, F226, F492).
Findings
The facility failed to follow its abuse and neglect policies, resulting in physical abuse of a resident by a certified nursing assistant. The investigation revealed bruising consistent with abuse, lack of proper documentation, failure to take photographs of injuries, and inadequate background checks and training for staff.
Deficiencies (3)
Facility failed to develop and implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Facility failed to develop an abuse and neglect policy addressing screening and training of contracted nursing agency employees.
Facility failed to fingerprint and screen new employees for criminal background and failed to provide dementia training within 30 days of hire.
Report Facts
Complaint number: 13372
Dates of investigation: Investigation conducted on 11/8/06 and finalized on 11/9/06
Resident age: 85
Incident date: Incident occurred approximately at midnight on 10/26/06
File review dates: CNA #1 employment from 7/1/05 to 8/31/05; fingerprint files dated 7/1/05 and 9/5/06 to 11/3/06
Dementia training timeframe: 30
Suspension and termination dates: CNA #1 suspended on 10/26/06 and terminated on 11/3/06
X-ray date: Resident received x-ray on November 1, 2006
Physician evaluation date: Resident received physician evaluation on November 6, 2006
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in physical abuse incident and deficiencies related to abuse policy and background checks |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident and facility policies; confirmed no photographs were taken of bruises |
| LPN #1 | Licensed Practical Nurse | From contracted nursing agency; involved in incident and background checks |
| LPN #2 | Licensed Practical Nurse | Interviewed about resident bruising and incident |
| Director of Social Services | Director of Social Services | Conducted investigation of the incident |
| Administrator | Facility Administrator | Interviewed regarding policies and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 5, 2006
Visit Reason
The inspection was conducted as a result of a confidential complaint alleging staff to resident abuse, medication administration issues, meals being late and cold, and poor staffing at the facility.
Complaint Details
Complaint # NV00012815 was investigated. The staff to resident abuse allegation was unsubstantiated. Medication administration and staffing concerns were substantiated but no deficiencies were cited.
Findings
The alleged staff to resident abuse was found to be unsubstantiated. Concerns regarding medication administration and staffing were substantiated but no deficiencies were cited as these issues had been addressed in the recertification survey or were unavoidable.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
Date: Aug 28, 2006
Visit Reason
The inspection was conducted as part of the annual Medicare re-certification survey from August 28 to September 1, 2006, including investigation of 4 complaints during the survey.
Complaint Details
Four complaints were investigated during the survey. Two complaints regarding resident rights, quality of care, physical environment, and dietary services were substantiated with deficiencies cited. One complaint of an injury incident was not substantiated with deficiencies. One complaint regarding misappropriation of property was substantiated with deficiencies cited.
Findings
The survey identified multiple deficiencies related to resident rights, quality of care, physical environment, dietary services, medication administration, and staffing concerns. Specific issues included failure to maintain proper food temperatures, failure to knock before entering resident rooms, and inadequate assistance with call lights and incontinence care.
Deficiencies (4)
Failure to maintain proper food temperatures for room trays.
Failure to knock on doors before entering resident rooms.
Failure to provide adequate assistance with call lights and incontinence care for residents.
Failure to assist residents in obtaining routine and emergency dental care.
Report Facts
Census: 70
Sample size: 15
Complaints investigated: 4
Food temperature measurements: 90
Food temperature measurements: 120
Food temperature measurements: 42
Food temperature measurements: 50
Food temperature measurements: 45
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 15, 2006
Visit Reason
The inspection was conducted as a complaint investigation triggered by a self-reported incident of an injury of unknown origin at the facility.
Complaint Details
Complaint #NV00012015 was a self-reported incident of an injury of unknown origin. The event was substantiated but no deficiencies were cited.
Findings
The event was substantiated, but no deficiencies were cited based on the facility's corrective actions.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 18, 2006
Visit Reason
This inspection was conducted as a complaint investigation based on Complaint #NV00011430 alleging failure to transfer a resident to the hospital in a timely manner and inadequate staffing. The complaint was found to be unsubstantiated, but other deficiencies were identified and cited.
Complaint Details
Complaint #NV00011430 alleged failure to transfer a resident to the hospital timely and inadequate staffing. The complaint was unsubstantiated, but other deficiencies were cited.
Findings
The facility failed to conduct timely and comprehensive assessments and reassessments of a resident's change in condition, failed to provide necessary care and services to maintain the resident's highest practicable physical, mental, and psychosocial well-being, and failed to administer antibiotics and send sputum samples as ordered. Documentation and follow-up assessments were lacking, and the resident was ultimately transferred to an acute hospital due to worsening condition.
Deficiencies (2)
Failure to conduct comprehensive assessments and reassessments of resident's change in condition.
Failure to provide necessary care and services to attain or maintain highest practicable physical, mental, and psychosocial well-being.
Report Facts
Dates of resident condition change review: 6
Dates for corrective action completion: Lab Log by 4-24-06, 24-hour Report Forms by 4-22-06, Alert Charting by 4-22-06, Chart Audits by 4-28-06
Resident oxygen saturation levels: 86
Resident temperature: 103.7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2006
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint NV00010786 alleging poor quality of care due to inadequate infection control practices.
Complaint Details
Complaint NV00010786 was substantiated regarding poor quality of care due to inadequate infection control practices.
Findings
The facility failed to establish and maintain an infection control program, as general staff were not periodically educated on infection control procedures and precautions. Documentation showed gaps in staff education and incomplete attendance records.
Deficiencies (1)
Facility did not establish and maintain an infection control program; staff were not periodically educated on infection control procedures and precautions.
Report Facts
Dates of staff inservice sign-in sheets: 3
Time period without staff education: 7
Time period without nurse aide education: 8
Scheduled staff education dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johnson | Director of Operations | Signed the report as Director of Operations |
| Director of Nurses | Asked to provide evidence of staff education but no full name provided |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 24, 2006
Visit Reason
The inspection was initiated as a complaint investigation starting January 24, 2006, continuing until May 3, 2006, to consider additional evidence related to allegations of poor quality of care, inadequate staffing, and resident-to-resident abuse.
Complaint Details
Complaint NV00010661 alleged poor quality of care due to failure to assure resident safety (substantiated), inadequate facility staffing (unsubstantiated), and resident-to-resident abuse (substantiated).
Findings
The facility was found to have substantiated deficiencies related to failure to assure resident safety and resident-to-resident abuse, specifically failing to appropriately investigate and report resident-to-resident abuse for one resident. The facility did not adequately investigate or report incidents involving an Alzheimer's patient wandering into another resident's room, causing fear and safety concerns.
Deficiencies (1)
Failure to appropriately investigate and report resident-to-resident abuse for one resident.
Report Facts
Complaint investigation period: 100
Corrective action date: 2006
Incident reporting timeframe: 5
Incident notification timeframe: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Johnson | Director of Operations | Author of memorandum reinforcing policy on reporting resident abuse |
| Unnamed Director of Nursing Services | Director of Nursing Services | Employed at time of incident, no longer employed at facility |
| Unnamed Registered Nurse | Director of Nursing Services | Appointed to Director of Nursing Services after previous director left |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 9, 2005
Visit Reason
The inspection was conducted as a result of four complaint investigations regarding incidents involving resident altercations and a resident sliding from a wheelchair.
Complaint Details
Four complaints were investigated: NV00009928, NV00009937, NV00009938, and NV00009977. Each involved resident altercations or falls with no injuries. All incidents were substantiated, but no deficiencies were cited.
Findings
All four complaints were substantiated, but no injuries occurred and no deficiencies were cited based on the facility's actions.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 26, 2005
Visit Reason
The inspection was conducted as a result of complaint investigations related to multiple entity-reported incidents involving resident injuries and abuse at Rosewood Rehabilitation Center.
Complaint Details
Complaint #NV00009417 involved a resident with a skin tear injury of unknown origin. Complaint #NV00009395 involved an employee causing a resident's skin tear while protecting herself. Complaint #NV00009398 involved a witnessed fall resulting in minor injury. Complaint #NV00009402 involved resident-to-resident abuse without injury. All complaints were substantiated with no regulatory deficiencies cited due to appropriate facility responses.
Findings
All complaints investigated were substantiated; however, due to the immediate, appropriate, and timely actions of the facility staff, no regulatory deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2005
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by multiple complaints alleging injury of unknown origin, resident to resident abuse, and lack of protective supervision.
Complaint Details
Complaints NV00009393, NV00009394, NV00009396, and NV00009397 were substantiated since the events did occur, but no regulatory deficiencies were cited due to implemented Plans of Correction.
Findings
The complaints were substantiated as the events did occur; however, no regulatory deficiencies were cited because the facility had implemented Plans of Correction. No further action was necessary.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 26, 2005
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00009271 alleging neglect of a resident who was transported to an emergency room dehydrated, dirty, and neglected, and who subsequently died.
Complaint Details
Complaint #NV00009271 alleged neglect of a resident who was transported to an emergency room dehydrated, dirty, and neglected. The complaint was substantiated.
Findings
The facility failed to provide necessary care and treatment to maintain the resident's highest practicable well-being, including failure to properly care for pressure sores, maintain nutritional health and hydration, and prevent neglect. The resident was found severely dehydrated, with multiple pressure ulcers, poor nutrition, and was unbathed. The resident was sent to the hospital in unacceptable condition and died shortly thereafter.
Deficiencies (5)
Failure to provide services and treatment necessary to maintain the patient's highest practicable physical, mental and psychosocial well-being.
Failure to provide care, services and treatment to promote healing and prevent new pressure sores.
Failure to maintain nutritional health including weight maintenance and adequate protein intake.
Failure to provide sufficient fluids to maintain proper hydration and health.
Failure to carry out procedures prohibiting mistreatment and neglect of patients.
Report Facts
Weight loss: 32
Weight loss percentage: 8.4
Fluid intake adequacy days: 11
Pressure ulcer measurements: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2005
Visit Reason
The inspection was conducted as a result of two complaint investigations at the facility on 05/10/2005.
Complaint Details
Complaint #NV00008058 included allegations about a lost hearing aide (unsubstantiated), missing dentures (substantiated with no deficiencies), and poor grooming (unsubstantiated). Complaint #NV00008072 alleged a resident eloped, which was substantiated with no deficiencies cited.
Findings
The investigation found that a hearing aide was lost twice but the delay in replacement was unsubstantiated; the facility could not locate a resident's dentures which was substantiated but no regulatory deficiencies were cited; a claim of poor grooming was unsubstantiated; and a resident elopement was substantiated with no regulatory deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 22, 2005
Visit Reason
The inspection was conducted as a complaint investigation following allegations that a resident was burned and made fun of by a CNA during a shower, and that the resident did not receive a shower.
Complaint Details
Complaint #NV00007906 alleged that the resident was burned and made fun of by a CNA during a shower and that the resident did not receive a shower. The abuse allegations were not substantiated, but deficiencies related to care accommodations and care planning were found.
Findings
The allegations of abuse and neglect by the CNA were not substantiated; however, the facility failed to provide reasonable accommodations for the resident's individual needs in communication, bathing, and sense of well-being, and failed to develop a comprehensive care plan addressing communication needs.
Deficiencies (2)
Facility failed to provide reasonable accommodations for the resident's individual needs and preferences in communication, bathing, and sense of well-being.
Facility failed to develop a comprehensive care plan that addresses the resident's specific need in the area of communication.
Report Facts
Dates of corrective actions: Corrective actions include changes and evaluations dated between 4/22/05 and 6/08/05.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Investigated the complaint and determined no staff fault; responsible for corrective actions and monitoring. | |
| LPN #1 | Licensed Practical Nurse | Involved in shower incident and resident care; provided statements regarding the incident. |
| CNA #1 | Certified Nursing Assistant | Involved in shower incident; reported problems and interactions with resident. |
| CNA #2 | Certified Nursing Assistant | Involved in shower incident; assisted resident during shower. |
| CNA #3 | Certified Nursing Assistant | Observed shower incident and resident behavior. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2005
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident falls, injuries, and a decubitus ulcer at Rosewood Rehabilitation Center.
Complaint Details
Complaint #NV00007619 involved a resident fall with injury and was substantiated with no deficiencies cited. Complaint #NV00007559 involved a resident found sitting on the floor with six falls since admission and a stage IV decubitus ulcer; substantiated with no deficiencies cited. Complaint #NV00007562 involved falls of a newly admitted resident resulting in minor injuries; substantiated with no deficiencies cited. Complaint #NV00007560 involved a resident found with a 3-inch laceration; substantiated with no deficiencies cited.
Findings
The complaints were substantiated, including incidents of resident falls with injuries and a stage IV decubitus ulcer, but no regulatory deficiencies were cited due to appropriate actions and interventions taken by the facility.
Report Facts
Number of falls: 6
Laceration size: 3
Complaint dates: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 11, 2005
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident fell at the facility, became unresponsive, and died after a failed code in the emergency room, and that high lab values from the facility had not been acted upon.
Complaint Details
Complaint NV00007319 alleged a resident fall resulting in death and unaddressed high lab values; the allegations were found to be unsubstantiated.
Findings
The investigation found that some information in the allegation was erroneous; there was no documentation of a recent fall, the resident had not coded or expired in the ER, and the allegation that high labs had not been acted on was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 25, 2005
Visit Reason
The inspection was conducted as a result of five complaint investigations at the facility beginning on February 25, 2005, and finalized on March 9, 2005. Complaints included allegations of neglect, loss of resident belongings, altercations between residents, and resident falls.
Complaint Details
Five complaints were investigated: neglect, loss of belongings, altercation between residents, and resident falls. Neglect was not substantiated; loss of belongings was substantiated but no deficiency was cited; altercation was substantiated with no deficiency cited; falls were substantiated with deficiencies cited related to notification, investigation, documentation, and safety measures.
Findings
The investigations substantiated loss of resident belongings and several resident falls, but no deficiencies were cited based on the facility's actions for those issues. However, deficiencies were cited related to failure to notify the resident's physician or responsible party of a fall, failure to investigate and report results of an unwitnessed fall, failure to document and assess a resident found on the floor, and failure to implement safety devices to prevent accidents.
Deficiencies (4)
Failure to notify the resident's physician or responsible party of a fall (Resident #6).
Failure to investigate and report results of an unwitnessed fall (Resident #6).
Failure to document, assess, and report that a resident was found on the floor (Resident #6).
Failure to implement safety devices as ordered for a resident with a history of numerous falls (Resident #6).
Report Facts
Number of complaint investigations: 5
Date inspection began: Feb 25, 2005
Date investigations finalized: Mar 9, 2005
Employees mentioned
| Name | Title | Context |
|---|---|---|
| June C. Maduzia | Associate Administrator | Signed the Statement of Deficiencies |
| Director of Nursing | Director of Nursing | Involved in interviews and corrective actions related to failure to notify and investigate falls |
| Nurse on Duty | Nurse on Duty | Involved in interviews and corrective actions related to failure to notify and investigate falls |
| Associate Administrator | Associate Administrator | Involved in monitoring corrective actions and education |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 3, 2005
Visit Reason
The inspection was initiated as a complaint investigation starting on 2005-02-03 regarding alleged failure of the facility to render needed care and services related to a pressure sore. The complaint was substantiated.
Complaint Details
Complaint #NV00007106 alleged failure of the facility to render needed care and services related to a pressure sore. The complaint was substantiated.
Findings
The facility failed to provide adequate documentation and care related to a resident's pressure sores, including failure to document wound size and appearance, conduct comprehensive assessments, and implement appropriate interventions. The resident had multiple pressure ulcers and related complications, and the facility did not provide sufficient fluid intake to maintain proper hydration.
Deficiencies (4)
Failure to provide evidence that wound size and appearance was being documented in accordance with facility policy and standards of practice.
Failure to provide evidence that a comprehensive assessment of all precipitating factors contributing to worsening of Resident #1's wound status was conducted.
Failure to provide evidence of a change in Resident #1's plan of care related to pressure sore prevention and treatment.
Failure to provide Resident #1 with sufficient fluid intake to maintain proper hydration.
Report Facts
Date of complaint investigation start: Feb 3, 2005
Date of complaint investigation end: Feb 23, 2005
Stage III decubitus ulcer size: 10
Stage IV pressure sore size: 8
Resident weight: 139.9
Fluid intake required: 1920
Fluid intake provided: 2600
Urine output range: 500
Urine average output: 1200
Report
Report
Viewing
Loading inspection reports...
