Rose City Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Rose City Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 8, 2024

  Based on interview and record review it was determined the facility failed to ensure bowel status was assessed and a bowel care medication regimen was administered as ordered for 1 of 3 sampled residents (#1) reviewed for bowel care. Resident 1 developed abdominal pain, was admitted to the hospital and required surgery to remove part of the large intestine due to impaction (hardened stool stuck in the rectum or lower colon due to chronic constipation-occurs when constipated for a long time) and a colostomy (surgical procedure used to bring the healthy end of the large intestine through the abdominal wall for feces to leave the body) was placed. […]

• Actual harm, isolatedF689May 6, 2021

  Based on observation, interview and record review it was determined the facility failed to provide supervision for safety for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 sustained a second degree burn to her/his inner thigh. Findings include: The facility's Accidents and Incidents Policy revised 7/2017 revealed all accidents or incidents involving residents occurring on the premises were to be investigated and reported to the Adminsitrator. Documentation was to include when the accident or incident occuured, the nature of the injury, the circumstances surrounding the injury and the condition of the injured resident. Resident 1 was admitted to the facility in 2019 with diagnoses including dementia. […]

• No harm, potential for more than minimal, widespreadF727Feb 26, 2025

  Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day, seven days per week for 33 of 61 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: The facility's Staffing, Sufficient and Competent Nursing Policy, last revised 8/2022, indicated the following: -A registered nurse provided services at least eight consecutive hours every 24 hours, seven days a week. A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following: In 7/2024, nine days were reviewed and revealed four days without appropriate RN coverage on 7/16/24, 7/20/24, 7/22/24 and 7/23/24. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 4 of 4 kitchen refrigerators and 1 of 1 unit refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: Review of the US FDA 2022 Food Code indicated the following: -Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. -Food must be labeled with a use-by-date if stored for at least 24 hours. -Food could be stored up to seven days. […]

• No harm, potential for more than minimal, widespreadF727Oct 20, 2023

  Based on interview and record review it was determined the facility failed to ensure an RN worked eight consecutive hours per day seven days per week for 46 of 97 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: Review of the Direct Care Staff Daily Reports from 1/1/23 through 1/25/23, 2/19/23 through 2/28/23, 3/1/23 through 3/31/23 and 9/16/23 through 10/16/23 revealed the following days in 2023 with no RN coverage for eight consecutive hours: -January: 1, 2, 9, 10, 12, 13, 16, 17, 22, 23 and 24. -February: 19, 20, 21, 22, 24, 25, 26, 27 and 28. -March: 3, 4, 5, 6, 7, 12, 13, 14, 16, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31. -September: 17. -October: 1, 8 and 15. […]