Rossville Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rossville Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 23, 2025

  - R69's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle wasting and atrophy multiple sites (wasting or decrease in size of a part of the body), communication deficit, repeated falls, and muscle weakness. The Significant Change Minimum Data Set (MDS) dated 03/10/25 documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R69 was dependent on staff assistance for lower extremity dressing and bathing. She required partial to moderate staff assistance with transfers. The MDS documented R69 had two non-injury falls since the last MDS. […]

• Actual harm, isolatedF689Dec 13, 2023

  The facility identified a census of 72. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents. On 12/05/23 R1 fell forward from her wheelchair while being lowered on the facility bus lift, after staff failed to ensure the brakes were fully engaged and no staff were present on the ground monitoring the lift. This deficient practice resulted in an emergent transfer of R1 to the hospital where she was diagnosed with a subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). This deficient practice also placed R1 at further risk for injury and pain. […]

• Actual harm, isolatedF686Aug 23, 2023

  The facility had a census of 70 residents. The sample included 21 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to implement interventions to prevent the development of pressure injuries and promote healing for existing pressure injuries for Resident (R)22 and R38 who developed facility acquired pressure ulcers. […]

• Actual harm, isolatedF689Aug 23, 2023

  The facility had a census of 70 residents. The sample included 21 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24 had the appropriate fall interventions when an unwitnessed fall occurred. The facility failed to collect staff statements regarding the event, failed to investigate to rule out abuse and neglect, and failed to ensure all interventions were in place. The facility failed to identify causative factors for a fall, which resulted in a subdural hematoma (serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain) for R24. […]

• Actual harm, isolatedF692Aug 23, 2023

  The facility had a census of 70 residents. The sample included 21 residents with six reviewed for nutrition. Based on observation, record review, and interview, the facility failed to follow up and implement the nutritional interventions to prevent further weight loss and promote weight gain for Resident (R)6, who had a significant weight loss despite having enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food). […]