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Deficiency Records for Rosewood Rehabilitation Center
A list of the most recent deficiencies for Rosewood Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Rosewood Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-01 | 2024-08-19 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Develop a communication plan. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Establish methods for sharing information. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-08 | 2023-12-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-02 | 2023-12-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-02 | 2023-12-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-02 | 2023-12-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-02 | 2023-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-02 | 2023-12-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-02 | 2023-12-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-02 | 2023-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-12-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-02 | 2023-12-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-11-02 | 2023-12-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-02 | 2023-12-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-02 | 2023-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-12-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-02 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-02 | 2023-12-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-02 | 2023-12-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-02 | 2023-12-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-31 | 2023-09-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-31 | 2023-09-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-31 | 2023-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-09-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-22 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-22 | 2023-07-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-22 | 2023-07-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-19 | 2023-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-19 | 2023-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-19 | 2023-01-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-19 | 2023-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-19 | 2023-01-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-19 | 2023-01-23 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-12-19 | 2023-01-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-19 | 2023-01-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-19 | 2023-01-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-12-19 | 2023-01-23 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-12-19 | 2023-01-23 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2022-12-19 | 2023-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-19 | 2023-01-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-19 | 2023-01-23 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-19 | 2023-01-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-19 | 2023-01-23 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2022-12-19 | 2023-01-23 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-19 | 2023-01-23 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2022-12-19 | 2023-01-23 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2022-12-19 | 2023-01-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-20 | 2023-01-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-04 | 2022-03-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-04 | 2022-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-04 | 2022-03-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-03-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-08 | 2022-03-01 | N |
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