Rose Hill Health and Rehab

In the surveyor’s words

From the most serious findings on record at Rose Hill Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 29, 2023

  Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to prevent and/or treat pressure injuries for two of 21 residents in the survey sample, Residents #3 and #13, resulting in harm for Resident #3. The findings include: 1. For Resident #3, the facility staff failed to prevent an avoidable pressure injury from developing and being found at an advanced stage. The facility staff also failed to transcribe and implement the wound physician's treatment order dated 12/15/22. […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2023

  Based on staff interview and facility document review, it was determined the facility staff failed to maintain infection control tracking logs for two of the three months requested. The findings include: Upon entrance on 12/11/2023 at 9:15 a.m. a request was made for the infection control tracking logs for October, November, and December 2023. On 12/11/2023 at approximately 11:00 a.m. ASM (administrative staff member) #2, the director of nursing, provided a copy of the October 2023 infection control logs. She also provided a copy of a list from the pharmacy that documented what antibiotics were prescribed, but not the full documentation of a tracking log. She stated she could not find the November logs and the December logs have not been started. […]

• No harm, potential for more than minimal, patternF580Dec 13, 2023

  Based on staff interview. facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner when medications were not available or administered for three of 13 residents in the survey sample, Residents #1, #10, and #11. The findings include: 1. For Resident #1, the facility staff failed to notify the physician/nurse practitioner (NP) when Toprol XL and Meloxicam were not available administration. The physician order dated, 8/22/2023, documented, Mobic (Meloxicam) Oral tablet 15 mg (milligrams); give 1 tablet by mouth one time a day for pain. The November 2023 MAR (medication administration record) documented the above order. On the following dates at the 9:00 a.m. […]

• No harm, potential for more than minimal, patternF658Dec 13, 2023

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications for three of 13 residents in the survey sample, Residents #11, #2, and #7. The findings include: 1. For Resident #11, the facility staff failed to administer the physician ordered medications on 10/27/2023. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Hydrocortisone External gel 1%; apply to bilateral hands and leg topically two time a day for rash/itching for 7 days. […]

• No harm, potential for more than minimal, patternF622Jun 29, 2023

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent with residents upon transfer to the hospital for four of 35 residents, Residents #45, #102, #43 and #89. The findings include: 1. For Resident #45 (R45), the facility staff failed to evidence the required documents were sent with the resident upon transfer to the hospital on 3/11/2023 and 4/9/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. […]