Rawlins House Health & Living Community

In the surveyor’s words

From the most serious findings on record at Rawlins House Health & Living Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents with a diagnosis of dementia were free from antipsychotic medications being used as a chemical restraint due to lack of gradual does reductions (GDR), statements of contraindication, and failed GDR without documented psychotic behaviors for 3 of 4 residents reviewed for antipsychotic use. (Residents 42, 46, and 10) Findings include:1.Resident 42's clinical record was reviewed on 12/18/25 at 1:47 p.m. Current diagnoses included dementia with psychotic disturbance, dementia without behaviors, depression, and anxiety. The resident resided on a secured dementia/memory care unit. Current orders included olanzapine/Zyprexa 5 mg (antipsychotic medication) administer 1 tablet daily (5/13/25). […]

• No harm, potential for more than minimal, patternF628Dec 22, 2025

  Based on record review and interview, the facility failed to provide notice of transfer/discharge and bed hold policy to the resident or resident representative for 4 of 5 residents reviewed for hospitalizations. (Resident 112, 25, 3, and 64, )Findings include:1. Resident 112's clinical record was reviewed on 12/19/25 at 9:15a.m. Diagnoses included congestion heart failure, Parkinson's disease, and Alzheimer's disease. An admission Minimum Data Set (MDS) indicated the resident was moderately cognitively impaired. A 11/7/25, nursing note indicated the resident was sent to the emergency room (ER) after a physician's visit to the facility for impending respiratory failure. Family was contacted by phone. […]

• No harm, potential for more than minimal, patternF803Sep 11, 2024

  Based on observation, interview and record review, the facility failed to ensure menus were followed for 4 of 4 residents reviewed for receiving diets/menus as ordered (Residents 45, 10, 42 and 60). Findings include: A current facility document titled Week at a Glance, provided by Administrator following the entrance conference on 9/3/24, indicated the following: Lunch Menu 9/6/24 Lunch: Tomato Basil Soup- 6 oz Saltine crackers- I pack Ultimate grilled cheese sandwich -1 sandwich Breaded green beans- 4 oz Ranch dressing -2 oz Pineapple tidbits 1/2 cup. […]

• No harm, potential for more than minimal, patternF806Sep 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure resident food preferences were reviewed and honored for 4 of 4 residents reviewed for food preferences (Residents 45, 10, 42 and 60). Findings include: 1. During an observation on 9/6/24 at 12:20 p.m., Resident 45 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an interview on 9/9/24 at 2:32 p.m., Resident 45's responsible party indicated they had never been asked to complete a select menu for their resident. They had never been asked anything about Resident 45's food preferences. It would be a good idea to get their input about food likes. […]

• No harm, potential for more than minimal, isolatedF883Dec 22, 2025

  Based on record review and interview, the facility failed to administer the appropriate Pneumococcal vaccinations per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 12/19/25 at 11:29 a.m. Diagnoses included unspecified dementia, repeated falls, and neuromuscular dysfunction of the bladder. A 12/9/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment. […]