Inspection·August 22, 2024

F 554 | Resident Self-Admin Meds-Clinically Appropr SS=D CFR(s): 483.10(c)(7) | F 554 | | $483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observations, resident record review, interviews, and facility policy review, the facility failed to evaluate a resident for self-administration of medications for 1 of 1 resident sampled. (Resident #103) The findings include: On ____ at 12:49 PM, Resident #103 was observed with an inhaler at bedside. She stated she had an inhaler at bedside so she could use it when she needed it. Resident #103 stated it was "just inhaler's label read " and she had it for a long time. The this inhaler was again observed on the bedside table on ____ at 5:07 PM. (Photographic evidence was obtained) A review of Resident #103's medical record was conducted. A physician's statement stated, HFA Inhalation Aerosol 108 (90 1. Resident #103 had an inhaler on the bedside table upon observation from the surveyor and when team members found out about the inhaler it was immediately removed from Resident 103 and educated why she couldn't have it. 2. An audit was conducted on all residents that have inhalers based off their diagnosis and room sweep was completed to ensure residents don't have any unsecured inhalers. 3. All residents who go to the hospital that come ____ with new orders for medications will be inventoried for any meds the hospital may have discharged with them. We will evaluate the resident if they are a self-administration and if qualified ensure the resident has the medication secured and documentation coordinated with the nursing staff. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE /2024 Electronically Signed 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: 6WDV11 Facility ID: 11704 If continuation sheet Page 1 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES LIST OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 10/01/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105747 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 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

F 554 Continued From page 1 Base) MCG/ACT ( . . . . . . . . . ), 2 puff inhale orally every 6 hours as needed for " and was dated " and was dated Administration Record (MAR) for was scheduled as needed but was not documented. The resident's care plan did not include goals or intervention related to self-administration of medications. On at 6:09 PM, an interview was conducted with Director of Nursing (DON). The DON reviewed Resident #103's records and stated the resident had never expressed she wanted to self administer the inhaler. The DON stated the facility did not have any residents that self-administered medications. A review of facility policy "Self-administration of medication" was conducted. The policy stated, "A resident may be permitted to administer or retain any medication on his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. Should the resident's attending physician permit the resident to administer his/her medications (S) the following conditions will apply: the physician's orders must be given prior to self-administration; storage of medications in the resident's room must be such that it will prevent access by other residents."

F 644 Coordination of PASARR and Assessments SS=D CFR(s): 483.20(e)(1)(2) $483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to

F 554 4. The Director of Nursing or designee will audit weekly all residents that return from the hospital and or new admissions to the facility for capability of self-administration and that no meds are unsecured and remove them if not appropriate for self-administration. All audit results will be reviewed in the monthly QAPI committee meeting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0WDV11 Facility ID: 11704 If continuation sheet Page 2 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/01/2024 FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 105747 B. WING 08/22/2024 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 PREFIX TAG (X5) COMPLETION EACH DEFICIENCY MUST BE PRECEDED BY FULL PROVIDER'S PLAN OF CORRECTION EACH CORRECTIVE ACTION SHOULD BE PREFIX TAG DATE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 644 Continued From page 2 avoid duplicative testing and effort. Coordination includes: $483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. $483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental , intellectual , or a related condition for level II resident review upon a significant change in status assessment. This REQUIREMENT is not met as evidenced by: Based upon record review, observations, and interviews the facility failed to submit a level II screening for 1 out of 3 residents reviewed with a significant change in mental health and newly evident diagnosis of a serious mental . . . . The findings include: On , a record review of Resident #107's level I PASARR was completed. The PASARR was dated and had no indication of mental health or suspected mental health or intellectual , indicated. However, review of the resident's medical record indicated added diagnoses of Disorganized . . . . , major . . . . on . . . . , severe, with and other behavioral disturbances on . . . . . (Photographic evidence obtained) Upon interview and review of the medical health history with the Director of Nursing (DON) on

F 644 1. Resident #107 PASSR was immediately submitted for level II screening 2. An audit was done on all residents that have a diagnosis of . . . . , and other serious mental illnesses. Any resident with a serious mental illness diagnosis without a Level II PASSR screening was submitted for level II screening review. 3. The nursing department heads, and service providers were in-serviced that any serious mental diagnosis change/addition will have a Level II PASSR screening submitted. 4. A weekly audit will be conducted by the Director of Nursing or designee on all residents for serious mental diagnosis changes and Level 2 will be submitted accordingly. The Director of Nursing will review all new notes from, physicians and ARNP after visits weekly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 3 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105747 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 PRINTED: 10/01/2024 FORM APPROVED OMB NO. 0938-0391 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 (X6) (X7) (X8)

F 644 Continued From page 3 . . . . . . at approximately 05:04 PM, the DON stated "myself and the Assistant Director of Nursing review and complete the PASARRs on all new residents and submit new ones as needed or as indicated." When asked about a level II PASARR for Resident #107, she stated she would have to review the health history and review medical records from the hospital and the records from the facility where Resident #107 resided prior to the current admission. During a follow up interview with the DON on at approximately 10:00 am, the DON stated, "There was no documentation of any mental health issues prior to her being admitted for our facility that I could find. We did not apply for a level II screening when the new diagnosis was added in . However, we did submit a Level II screen today."

F 656 Develop/Implement Comprehensive Care Plan SS=D CFR(s): 483.21(b)(1)(3) $483.21(b) Comprehensive Care Plans $483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and . . . needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and . . . well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required

F 644 and a Level II will be submitted if a new serious mental health issues. All findings from audits will be reviewed by the monthly QAPI committee meeting.

F 656 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 4 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 10/01/2024 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 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 (X5) COMPLETION DATE PREFIX TAG (X6) SUMMARY STATEMENT OF DEFICIENCIES (X7) PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 656 Continued From page 4 F 656 under $483.24, $483.25 or $483.40 but are not provided due to the resident's exercise of rights under $483.10, including the right to refuse treatment under $483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. ( ) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. $483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and -informed. This REQUIREMENT is not met as evidenced by: Based on staff interviews and electronic medical record (EMR) review, the facility failed to develop a comprehensive person-centered care plan for use for 1 of 2 residents sampled for care planning. (Resident #111) The findings include: A review of the physician's orders reveals an 1. Resident #111 care plan updated to reflect the use of , . based on MDs order. 2. An audit of all residents on completed and ensured all were care planned according to MDs order 3. All nurses were educated on care plan updating with new orders for use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11794 If continuation sheet Page 5 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 105747 B. WING PRINTED: 10/01/2024 FORM APPROVED 08/22/2024 NAME OF PROVIDER OR SUPPLIER 3107 NORTH H STREET STREET ADDRESS, CITY, STATE, ZIP CODE ROSEWOOD HEALTHCARE AND REHABILITATION CENTER 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

F 656 Continued From page 5 order placed on . . . . . for Minocycline . Oral Capsule 100 Mg - Give 1 capsule by one time a day for . . . . . (a broad-spectrum used to treat . . . . . ). A review of the comprehensive care plan initiated on . . . . . and last updated on . . . . . does not include evidence obtained) use. (photographic A review of the annual minimum data set (MDS) (a standardized assessment tool that measures health status in nursing home residents), dated indicate "yes" for . . . . . but did use. On . . . . . at approximately 11:21 AM during an interview with Staff G, Registered Nurse (RN) and MDS coordinator, she reviewed the EMR and confirms there is no care plan in place for Resident #111 for . . . . . use. She indicated that there should be a care plan for . . . . . use.

F 677 ADL Care Provided for Dependent Residents SS=D CFR§: 483.24(a)(2) $483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record review, the facility failed to ensure activities of daily living (ADL) for bathing and grooming were provided to 1 of 6 residents sampled for ADL care. (Resident #42) The findings include:

F 656 4. A weekly audit with be completed by the Director of Nursing or designee on . . . . . use with care plan in place. All findings from audits will be brought to the monthly QAPI committee meeting.

F 677 1. Resident #42 was given a shower that day and had nails cleaned and trimmed. 2. An audit of all residents that refuse showers and grooming to ensure that it is care planned and documented in the EMR. 3. An inservice was conducted with all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0W0V11 Facility ID: 11704 If continuation sheet Page 6 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 10/01/2024 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 ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 105747 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 SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETION DATE

F 677 Continued From page 6 F 677 During an observation and interview on nursing staff for documentation of resident at 11:50AM, Resident #42 said his refusal of care to be documented in the is really dry because he doesn't get his hair EMR and care planned for each resident. washed and would like to receive a shower in 4. The Director of Nursing or designee the shower room. Resident #42 said he has only had will conduct weekly audits for compliance one shower where he was taken to the shower with charting in EMR and care planning room since he's been admitted to the facility, and refusal of care. All findings from audits he needs someone to take him because he can't will be brought to the monthly QAPI use his . He added, most of the time they committee meeting. only provide a bed bath, and his hair doesn't get washed. Resident #42 has of left and nails on right are noted to be dirty and long, extending past the tip of the with the middle noted to be very thick and discolored, long, and curved in toward the tip of the . The resident was noted to have an odor of A review of Resident #42's medical record showed he was admitted to the facility on and had diagnoses of anoxic damage, adult major and parasthesia of skin (lack of sensation), type 2, and acquired absence of left upper . The record showed Resident #42 and had a ( ) score of 12 (a score of indicates moderately cognition). On a review of bathing documentation revealed Resident #42 was scheduled to receive a shower on Mondays, Wednesdays, and Fridays, but there was no documentation of any bed bath or shower occurring between and documented shower for the resident was dated and the most recent bed bath documented was dated . There was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 7 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 10/01/2024 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 LIST OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 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 (X5) COMPLETION PREFIX TAG TAG DATE (SUMMARY STATEMENT OF DEFICIENCIES (PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION)) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F 677 F 677 Continued From page 7 no documentation of refusal of care, no care plan related to behaviors of refusing care, and no documentation of attempts to bathe resident or offer showers on days when there was no shower documented. During an observation on ____ at 2:10pm, Resident #42 was in his wheelchair in the hallway, wearing a red ballcap with his hair sticking out on the sides beneath the cap and appeared unwashed, there was a faint odor of detected. On ____ at 9:23 am, in an interview, Certified Nursing Assistant (CNA) A, who was standing in Resident #42's room, said she has only had this assignment for two days and hasn't bathed Resident #42, but believes he is on the 3:00 pm - 11:00 pm shower schedule. She said Resident #42 mentioned to her that he would like a shower, and she usually provides care "like wiping the resident down in between when they ask" and she motioned to her underarm area. Resident #42 was observed at 10:05am on ____ returning from the smoking area wearing a blue ball cap and still had an odor of ____ Later in the day, at 12:29PM, Resident #42 was observed sitting in his wheelchair in his room and said he was waiting for lunch. The observation revealed Resident #42 had a substance that appeared to be dried, flaked off skin in his ____ and a flaky particle that also appeared to be dried skin in the hair sticking out under his ball cap. There was an odor of and cigarette smoke. During an observation of Resident #42 at 4:04 PM on ____, he was in his bed with his shirt off, and appeared not to have had a shower. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 8 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 10/01/2024 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _____ B. WING _____ (X3) DATE SURVEY COMPLETED 08/22/2024 105747 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 SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

F 677 F 677 Continued From page 8 In an interview immediately following this observation, CNA D described and demonstrated the method for documenting a shower or bed bath using the electronic documentation system. During the interview, she said she had showered Resident #42 before and takes him to the shower room. On . . . . . . at 8:34AM, Resident #42 was observed in bed, alert and oriented, with shirt off, hair appeared freshly washed and combed, no odors noted. The resident was noted to have dirt and/or debris under his . . . . . . on his right . . . . . . , which remained long and untrimmed, with the middle . . . . . . was still thick and discolored, extending past the tip of his . . . . . . and curling . . . . . . toward the tip of his middle . . . . . . . Resident #42 was asked if he was offered nail care during his bath, and he replied "no" and added he would like them trimmed, especially the middle . . . . . . which is very long. Resident #42 said he had a shower last night and it is only the second time he has received a shower since being in the facility. On . . . . . . at 8:39AM, Registered Nurse (RN) B explained in an interview the expectation for ADL care is that CNA reports to the nurse when done and the nurse assigned to the hall would note if anything needed to be followed up on such as not completing the care. RN B observed Resident #42's nails and agreed the nails needed to be cleaned and trimmed. She also agreed that the middle . . . . . . which was very thick and discolored should be assessed by a nurse prior to trimming. In a follow up interview with RN B, she said she confirmed that a registered nurse can trim that nail, and she will have the nurse assigned trim the nail today. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 9 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 10/01/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105747 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 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

F 677 Continued From page 9 F 677 On at 9:04 AM, during an interview, CNA E showed where the ADL care supplies are kept, and the implements used for nail care. CNA E said that he offers nail care during the bath and that should be completed. On at 11:22 AM, the staff development coordinator, RN C, was asked during an interview to describe what she teaches as far as bathing and nail care. RN C said that the expectation is residents are provided a shower in the shower room unless specifically refusing or stating a preference for a bed bath and the expectation taught for bathing includes ensuring nails are clean. On at 11:40 AM, during an interview, the Director of Nursing (DON) said Resident #42 is care planned for fabricating stories and will say that he did not get showers but then he refuses. The DON was told that Resident #42 was consistent about his desire for a shower throughout the week since Monday, and specifically that his hair doesn't get washed, which was consistent with observations of the resident having flakes of skin in his hair, appearing un-showered, and having an odor of about him. The DON said he only gets showers on Monday, Wednesday and Fridays and he often refuses. She said that she was the one who went in today to trim his middle which was very thick. She agreed the nail was long and had not been trimmed. The DON was shown that no documentation in the record was found which demonstrated a nurse had been notified and the resident refused the care to his nail or other refusals of care or bathing. She left and said she would look for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 If continuation sheet Page 10 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 10/01/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 105747 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 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 (X5) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X6) ID PREFIX TAG (X7) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X8) COMPLETION DATE

F 677 Continued From page 10 documentation in the record of these behaviors to provide. At 12:07 PM, the DON came and provided one page of documentation with a late entry written by RN B that Resident #42 was "offered a shower earlier in the shift, stated that he would prefer it after dinner and his smoke break. Resident refused x 2 when asked at the requested time. Will reattempt tomorrow." The note was entered on ______ at 15:39PM as a late entry for ______. No other documentation of refusals of care or behavior of fabricating stories were provided for Resident #42. On ______ at 12:27 PM, in a follow up interview with Resident #42 about whether he refused care of a shower, he said he thinks he did ask to have the shower after he smokes, but wouldn't refuse a shower unless it was time to go smoke. Review of policies provided for bathing and nail care included under the heading "Key Procedural Points" for Shower/Tub Bath - Dependent Resident: 2. Insofar as practical, encourage the resident to participate in the bath care. 6. Trim the resident's toenails or ______ unless otherwise instructed by the staff/Charge Nurse. Key Procedural Points of the section titled "______/Toenails, Care of" included: 1. Nails can be cleaned during bath care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0WDV11 Facility ID: 11704 if continuation sheet Page 11 of 11 Agency for Health Care Administration PRINTED: 10/01/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: ________ B. WING ________ (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) (X6) COMPLETE DATE

N 000 INITIAL COMMENTS

N 000 An unannounced re-licensure survey was conducted at Rosewood Healthcare and Rehabilitation Center in Pensacola, FL on to . . . . . . . . The provider had deficiencies at the time of the visit.

N 072 59A-4.109(2), FAC; Comprehensive Care Plans SS=D

N 072 59A-4.109 FAC (2) The nursing home licensee develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and . . . . . needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. This Statute or Rule is not met as evidenced by: Based on staff interviews and electronic medical record (EMR) review, the facility failed to develop a comprehensive person-centered care plan for use for 1 of 2 residents sampled for care planning. (Resident #111) The findings include: A review of the physician's orders reveals an order placed on Oral Capsule 100 MG - Give 1 Minocycline by one time a day for (a broad-spectrum used to treat . . . . . . ). A review of the comprehensive care plan initiated and last updated on 1. Resident #111 care plan updated to reflect the use of , , , based on MDs order. 2. An audit of all residents on completed and ensured all were care planned according to MDs order 3. All nurses were educated on care plan updating with new orders for use. 4. A weekly audit with be completed by the Director of Nursing or designee on use with care plan in place. All findings from audits will be brought to the monthly QAPI committee meeting. AHCA Form 3020-0001 LABORATORY DIRECTOR OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE /24 STATE FORM 6809 OWDV11 If continuation sheet 1 of 7 Agency for Health Care Administration PRINTED: 10/01/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) (X6) COMPLETE DATE

N 072 Continued From page 1 N 072 does not include . . . use. (photographic evidence obtained) A review of the annual minimum data set (MDS) (a standardized assessment tool that measures health status in nursing home residents), dated . . . indicated no . . . but did indicate "yes" for . . . use. On . . . at approximately 11:21 AM during an interview with Staff G, Registered Nurse (RN) and MDS coordinator, she reviewed the EMR and confirms there is no care plan in place for Resident #111 for . . . use. She indicated that there should be a care plan for . . . use. Class III

N 201 SS=D 400.022(1)(I), FS Right to Adequate and Appropriate Health Care N 201 (I) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. This Statute or Rule is not met as evidenced by: Based on observations, interviews, and record review, the facility failed to ensure activities of daily living (ADL) for bathing and grooming were provided to 1 of 6 residents sampled for ADL care. (Resident #42) The findings include: 1. Resident #42 was given a shower that day and had nails cleaned and trimmed. 2. An audit of all residents that refuse showers and grooming to ensure that it is care planned and documented in the EMR. 3. An inservice was conducted with all AHCA Form 3020-0001 STATE FORM notes 0WDV11 If continuation sheet, 2 of 7 Agency for Health Care Administration PRINTED: 10/01/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) (X6) COMPLETE DATE

N 201 Continued From page 2

N 201 nursing staff for documentation of resident refusal of care to be documented in the EMR and care planned for each resident. 4. The Director of Nursing or designee will conduct weekly audits for compliance with charting in EMR and care planning refusal of care. All findings from audits will be brought to the monthly QAPI committee meeting. During an observation and interview on ... at 11:50AM, Resident #42 said his is really dry because he doesn't get his hair washed and would like to receive a shower in the shower room. Resident #42 said he has only had one shower where he was taken to the shower room since he's been admitted to the facility, and he needs someone to take him because he can't use his . He added, most of the time they only provide a bed bath, and his hair doesn't get washed. Resident #42 has of left and nails on right are noted to be dirty and long, extending past the tip of the with the middle noted to be very thick and discolored, long, and curved in toward the tip of . The resident was noted to have an odor of A review of Resident #42's medical record showed he was admitted to the facility on and had diagnoses of anoxic damage, adult , major and parasthesia of skin (lack of sensation), type 2, and acquired absence of left upper . The record showed Resident #42 and had a ( ) score of 12 (a score of indicates moderately cognition). On a review of bathing documentation revealed Resident #42 was scheduled to receive a shower on Mondays, Wednesdays, and Fridays, but there was no documentation of any bed bath or shower occurring between and . The most recent documented shower for the resident was dated and the most recent bed bath documented was dated . There was no documentation of refusal of care, no care plan AHCA Form 3020-0001 STATE FORM notes 0WDV11 If continuation sheet, 3 of 7 Agency for Health Care Administration PRINTED: 10/01/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______ B. WING ______ (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) (X6) COMPLETE DATE

N 201 Continued From page 3

N 201 related to behaviors of refusing care, and no documentation of attempts to bathe resident or offer showers on days when there was no shower documented. During an observation on at 2:10pm, Resident #42 was in his wheelchair in the hallway, wearing a red baliccap with his hair sticking out on the sides beneath the cap and appeared unwashed, there was a faint odor of detected. On at 9:23 am, in an interview, Certified Nursing Assistant (CNA) A, who was standing in Resident #42's room, said she has only had this assignment for two days and hasn't bathed Resident #42, but believes he is on the 3:00 pm - 11:00 pm shower schedule. She said Resident #42 mentioned to her that he would like a shower, and she usually provides care "like wiping the resident down in between when they ask" and she motioned to her underarm area. Resident #42 was observed at 10:05am on returning from the smoking area wearing a blue ball cap and still had an odor of . Later in the day, at 12:29PM, Resident #42 was observed sitting in his wheelchair in his room and said he was waiting for lunch. The observation revealed Resident #42 had a substance that appeared to be dried, flaked off skin in his and a flaky particle that also appeared to be dried skin in the hair sticking out under his ball cap. There was an odor of and cigarette smoke. During an observation of Resident #42 at 4:04 PM on , he was in his bed with his shirt off, and appeared not to have had a shower. In an interview immediately following this observation, CNA D described and demonstrated AHCA Form 3020-0001 STATE FORM notes OWDV11 If continuation sheet 4 of 7 Agency for Health Care Administration PRINTED: 10/01/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: __________ B. WING ________ (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) COMPLETE DATE

N 201 Continued From page 4

N 201 the method for documenting a shower or bed bath using the electronic documentation system. During the interview, she said she had showered Resident #42 before and takes him to the shower room. On ______ at 8:34AM, Resident #42 was observed in bed, alert and oriented, with shirt off, hair appeared freshly washed and combed, no odors noted. The resident was noted to have dirt and/or debris under his ____ on his right ___, which remained long and untrimmed, with the middle ___ was still thick and discolored, extending past the tip of ___ and curving ___ toward the tip of his middle ___. Resident #42 was asked if he was offered nail care during his bath, and he replied "no" and added he would like them trimmed, especially the middle ___, which is very long. Resident #42 said he had a shower last night and it is only the second time he has received a shower since being in the facility. On ______ at 8:39AM, Registered Nurse (RN) B explained in an interview the expectation for ADL care is that CNA reports to the nurse when done and the nurse assigned to the hall would note if anything needed to be followed up on such as not completing the care. RN B observed Resident #42's nails and agreed the nails needed to be cleaned and trimmed. She also agreed that the middle ___ which was very thick and discolored should be assessed by a nurse prior to trimming. In a follow up interview with RN B, she said she confirmed that a registered nurse can trim that nail, and she will have the nurse assigned trim the nail today. On ______ at 9:04 AM, during an interview, CNA E showed where the ADL care supplies are AHCA Form 3020-0001 STATE FORM notes GWDV11 if continuation sheet, 5 of 7 Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 10/01/2024 FORM APPROVED (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 11704 (X2) MULTIPLE CONSTRUCTION A. BUILDING: ____________ B. WING ____________ (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER ROSEWOOD HEALTHCARE AND REHABILITATION CI 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) COMPLETE DATE

N 201 Continued From page 5 kept, and the implements used for nail care. CNA E said that he offers nail care during the bath and that should be completed. On ______ at 11:22 AM, the staff development coordinator, RN C, was asked during an interview to describe what she teaches as far as bathing and nail care. RN C said that the expectation is residents are provided a shower in the shower room unless specifically refusing or stating a preference for a bed bath and the expectation taught for bathing includes ensuring nails are clean. On ______ 11:40 AM, during an interview, the Director of Nursing (DON) said Resident #42 is care planned for fabricating stories and will say that he did not get showers but then he refuses. The DON was told that Resident #42 was consistent about his desire for a shower throughout the week since Monday, and specifically that his hair doesn't get washed, which was consistent with observations of the resident having flakes of skin in his hair, appearing un-showered, and having an odor of about him. The DON said he only gets showers on Monday, Wednesday and Fridays and he often refuses. She said that she was the one who went in today to trim his middle ____, which was very thick. She agreed the nail was long and had not been trimmed. The record was shown that no documentation a nurse had been notified and the resident refused the care to his nail or other refusals of care or bathing. She left and said she would look for documentation in the record of these behaviors to provide. At 12:07 PM, the DON came and provided one page of documentation with a late entry written by RN B that Resident #42 was

N 201 AHCA Form 3020-0001 STATE FORM notes GWDV11 If continuation sheet 6 of 7 Agency for Health Care Administration PRINTED: 10/01/2024 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 08/22/2024 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 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) (X6) COMPLETE DATE

N 201 Continued From page 6 N 201 "offered a shower earlier in the shift, stated that he would prefer it after dinner and his smoke break. Resident refused x 2 when asked at the requested time. Will reattempt tomorrow." The note was entered on ... at 15:39PM as a late entry for ... No other documentation of refusals of care or behavior of fabricating stories were provided for Resident #42. On ... with Resident #42, in a follow up interview at 12:27 PM about whether he refused care of a shower, he said he thinks he did ask to have the shower after he smokes, but he wouldn't refuse a shower unless it was time to go smoke. Review of policies provided for bathing and nail care included under the heading "Key Procedural Points" for Shower/Tub Bath - Dependent Resident: 2. Insofar as practical, encourage the resident to participate in the bath care. 6. Trim the resident's toenails or ... unless otherwise instructed by the staff/Charge Nurse. Key Procedural Points of the section titled ... /Toenails, Care" included: 1. Nails can be cleaned during bath care. Class III AHCA Form 3020-0001 STATE FORM notes GWDV11 If continuation sheet, 7 of 7