Alliance Health at Rosewood

In the surveyor’s words

From the most serious findings on record at Alliance Health at Rosewood, in the surveyor’s own words.

• Actual harm, isolatedF624Mar 5, 2024

  Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1's discharge was safe, and that the medications provided to him/her upon discharge were accurately reconciled by nursing, when one of the medications (Lisinopril, used to lower blood pressure) sent home with Resident #1 belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. […]

• Actual harm, isolatedF760Mar 5, 2024

  Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a planned discharge to return home, the Facility failed to ensure Resident #1 was free from a significant medication error, when the medications provided to him/her upon discharge were not accurately reconciled by nursing. One of the medications, Lisinopril (used to lower blood pressure) was sent home with Resident #1, belonged to another facility resident, (Resident #2), and was not a medication Resident #1 was prescribed by his/her physician. […]

• Actual harm, isolatedF686Jan 4, 2024

  Based on observations, records reviewed and interviews the facility failed to ensure nursing provided care consistent with professional standards of practice to prevent new pressure ulcers from developing for one Resident (#256) out of 29 sampled residents. Specifically for Resident #256, who was assessed by nursing to be at risk for skin breakdown, the facility failed to ensure nursing consistently implemented his/her physician's ordered prevalon boots (heel protectors that help reduce the risk of pressure ulcers by keeping the heels floated, relieving pressure) Subsequently, Resident #256's right heel pressure ulcer developed and was first observed by nursing, almost 29 hours after the surveyor first observed the wound. […]

• Actual harm, isolatedF686Nov 4, 2022

  Based on interview, record review and observation, the facility failed to: inform the physician of a newly identified pressure injury or conduct weekly skin assessments as ordered by the physician, resulting in the development of a Stage II wound, for one Resident (#163) of 28 sampled residents. Findings include: Review of the facility's policy Skin Management Program, dated 10/12/22, indicated: * Residents at risk for developing and/or who has a PI/PU [pressure injury/pressure ulcer} will be identified. This will be followed by implementation of appropriate individualized interventions to assist with avoiding the development/promoting healing of a PI/PU. * Resident will undergo a weekly body check by the licensed nurse. […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2022

  Based on observation, interview, and policy review the facility failed to maintain proper sanitation practices related to proper glove use and the labeling and storage of food items. Findings include: Review of the facility policy titled, Food Storage, dated 1/6/22, indicated the following: *Food shall not be stored directly on the floor. Review of the facility policy titled, Sanitary Dining Services Protocols, dated 12/15/21, indicated the following: *Gloves will be changed in between tasks. *Date and label all incoming foods *Perishable foods are stored and discarded in a timely manner to prevent spoilage and/or growth of pathogenic organisms. […]