Rosary Care Center

In the surveyor’s words

From the most serious findings on record at Rosary Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 13, 2022

  Based on review of medical records, staff interview, observations, and policy review, the facility failed to ensure the mechanical lift sling was properly used. This resulted in Actual Harm when Resident (#3) was transferred utilizing a mechanic lift, with the tabs of the lift sling coming off the lift causing Resident #3 to suffer a fall with a fracture ot the thoracic vertebrae. This affected one (#3) of three residents reviewed for falls. The facility identified 51 residents to require two person assistance for transfers. The facility census was 67. Findings include: Review of Resident #3's medical records revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2025

  Based on observation, staff interview, and review of policy, the facility failed to ensure staff practiced appropriate hand hygiene during meal service and ensured food was free from contamination. This had the potential to affect all residents in the facility except Resident #1 who was identified to not eat food by mouth. The facility census was 71. Findings include: Observations on 01/07/25, beginning at 3:56 P.M., revealed [NAME] #182 taking temperatures of food items before meal service. [NAME] #182 wore disposable gloves while touching the thermometer, serving utensils, a pen and paperwork, lids covering food items, and then picked up a pork chop with his left hand and inserted the thermometer into the pork chop. […]

• No harm, potential for more than minimal, patternF760Jan 9, 2025

  Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in delay in administration of anticonvulsant medication, anti-diabetic medication, anti-dementia medication and anti-psychotic medication. This affected four (#12, #36 #40, #66 ) of eight residents reviewed for medication administration. The facility census was 71. Findings include: 1. Observation on 01/07/25 at 7:27 A.M., noted Licensed Practical Nurse (LPN) #130 to obtain Resident #12 medications from the medication cart. LPN #130 stated Lamotrigine 200 milligrams (mg) was not available in the facility or in the contingency box supply. […]

• No harm, potential for more than minimal, patternF880Jan 9, 2025

  Based on observation, staff interview, and review of policy, the facility failed to doff and appropriately store soiled personal protective equipment (PPE). This had the potential to affect all 23 residents on the second floor (#2, #3, #5, #10, #14, #15, #19, #22, #23, #24, #27, #29, #35, #36, #44, #51, #56, #62, #64, #66, #67, #70, and #71). The facility census was 71. Findings include: Observation on 01/06/25 at approximately 10:45 A.M., revealed Certified Nursing Aide (CNA) #116 removing PPE in the doorway of Resident #10's room and placing it in a trash can located in the hallway outside Resident #10's room. Concurrent interview with CNA #116 confirmed Resident #10 was on Enhanced Barrier Precautions (EBP) and required staff to wear PPE while providing personal care. […]

• No harm, potential for more than minimal, patternF569Oct 6, 2022

  Based on medical record review, resident account list review and business office file review and staff interviews, the facility failed to notify a resident when their personal funds account balance was within two hundred dollars of the state allowed limit. This affected five (#15, #23, #26, #39 and #47) of five residents reviewed for personal funds. The facility census was 66. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident account list revealed a balance of $2,348.08. Review of the business office file revealed no evidence a spend down letter was issued to Resident #15, or their representative as required. 2. […]