A list of the most recent deficiencies for Rose Hill Health and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-13 | 2024-01-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-13 | 2024-01-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-13 | 2024-01-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-13 | 2024-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | 2024-01-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-13 | 2024-01-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-13 | 2024-01-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-13 | 2024-01-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-16 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-02 | 2023-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-09-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-29 | 2023-07-27 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-29 | 2023-07-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-29 | 2023-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-29 | 2023-07-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-29 | 2023-07-27 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-06-29 | 2023-07-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-29 | 2023-07-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-06-29 | 2023-07-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-29 | 2023-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-07-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-29 | 2023-07-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-29 | 2023-07-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-29 | 2023-07-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-29 | 2023-07-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-29 | 2023-07-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-29 | 2023-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-29 | 2023-05-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-05-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-29 | 2023-05-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-29 | 2023-05-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-29 | 2023-05-19 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-29 | 2023-05-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-29 | 2023-04-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-29 | 2023-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-29 | 2023-04-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-29 | 2023-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-04-26 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-29 | 2023-04-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-29 | 2023-03-03 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-29 | 2022-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-06-21 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-02 | 2022-01-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-02 | 2022-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-02 | 2022-01-04 | N |
| Respond appropriately to all alleged violations. | Health | 2021-12-02 | 2022-01-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-02 | 2022-01-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-02 | 2022-01-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-02 | 2022-01-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-02 | 2022-01-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-02 | 2022-01-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-02 | 2022-01-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-12-02 | 2022-01-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-02 | 2022-01-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-02 | 2022-01-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-12-02 | 2022-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-02 | 2022-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-02 | 2022-01-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-02 | 2022-01-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-02 | 2022-01-04 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-12-02 | 2022-01-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-02 | 2022-01-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-02 | 2022-01-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-02 | 2022-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-02 | 2022-01-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-13 | 2021-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-13 | 2021-12-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-10 | 2020-04-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-10 | 2020-04-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-10 | 2020-04-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-10 | 2020-04-08 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-03-10 | 2020-04-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-10 | 2020-04-08 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-10 | 2020-04-08 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-10 | 2020-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-10 | 2020-04-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-10 | 2020-04-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-10 | 2020-04-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-03-10 | 2020-04-08 | N |
| Post nurse staffing information every day. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-10 | 2020-04-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-03-10 | 2020-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-10 | 2020-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-10 | 2020-04-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-10 | 2020-04-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-10 | 2020-04-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-10 | 2020-04-08 | N |
