Inspection·June 27, 2023

Agency for Health Care Administration PRINTED: 08/01/2023 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ________ B. WING ________ (X3) DATE SURVEY COMPLETED 11704 R 06/27/2023 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) On June 27, 2023, a revisit to a relicensure and complaint survey was conducted at Rosewood Healthcare and Rehabilitation Center in Pensacola, Florida. An additional complaint investigation was completed at the same time. Deficiencies were not identified at the time of survey. All previous deficiencies were found corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 07/05/23 STATE FORM 6809 C8MY12 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 08/01/2023 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING (X3) DATE SURVEY COMPLETED 105747 B. WING R 06/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 3107 NORTH H STREET PENSACOLA, FL 32501 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE [F 000] INITIAL COMMENTS [F 000] On June 27, 2023, a revisit for a federal recertification and complaint survey was conducted at Rosewood Healthcare and Rehabilitation Center in Pensacola, Florida. An additional complaint investigation was completed at the same time. The facility was in compliance with Code of Federal Regulations (CFR) 42, Part 483.73. Requirements for Long-Term Care Facilities. All deficiencies from the original survey were found corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 07/05/2023 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 of survey 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:C8MY12 Facility ID: 11704 If continuation sheet Page 1 of 1