Inspection·June 19, 2023

Agency for Health Care Administration PRINTED: 07/18/2023 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING: 05 - MAIN LIC B. WING ______ 11704 R 06/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CI 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (K 000) INITIAL COMMENTS (K 000) An unannounced Fire & Life Safety revisit survey was conducted on 06/19/2023 at Rosewood Healthcare & Rehabilitation Center, a Nursing Home in Pensacola, Florida. This was a follow-up to the Annual Fire & Life Safety survey completed on 05/08/2023. All previously cited Fire & Life Safety deficiencies were corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 07/03/23 STATE FORM 6809 C8MY22 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/18/2023 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED R 06/19/2023 NAME OF PROVIDER OR SUPPLIER 105747 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE [K 000] INITIAL COMMENTS [K 000] An unannounced Fire & Life Safety revisit survey was conducted on 06/19/2023 at Rosewood Healthcare & Rehabilitation Center, a Nursing Home in Pensacola, Florida. This was a follow-up to the recertification survey completed on 05/08/2023. The facility is in compliance with 42 CFR 483.90 (a), and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012) requirements for nursing homes. Previously cited deficiencies were found to be corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 07/03/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:C8MY22 Facility ID: 11704 If continuation sheet Page 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/18/2023 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105747 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED R 06/19/2023 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE [E 000] Initial Comments [E 000] During a revisit survey conducted on 6/19/2023 to the recertification survey conducted on 05/08/2023 at Rosewood Healthcare & Rehabilitation Center, a nursing home, in Pensacola, Florida, the Emergency Preparedness Program was reviewed. Rosewood Healthcare & Rehabilitation Center is in compliance with the Emergency Preparedness rule per Code of Federal Regulations (CFR) 42, Part 483.73, and Requirements for Long-Term Care Facilities. Previously cited deficiencies were found corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 07/03/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:C8MY22 Facility ID: 11704 If continuation sheet Page 1 of 1