Health inspection·November 22, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based upon clinical record review, it was determined the facility failed to ensure Minimum Data Set Assessments were completed accurately for two of 28 residents reviewed (Resident 46 and 106 Resident). Residents Affected - Few Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. Interview with the Director of Nursing on November 24, 2024 at 8:50 a.m. confirmed the MDS was inaccurately completed and further confirmed Resident 46 did not have a right foot pressure ulcer. A review of Resident 106's Annual Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated September 15, 2024, revealed resident was taking an Antipsychotic medication (Are prescription medications that treat certain disorders by changing how the brain works). A review of Resident 106's September 2024, Medication Administration Records revealed resident were on Lexapro and Remeron (A medication used for depression) and Lorazepam (A medication for anxiety). Clinical records failed to reveal that Resident was on Antipsychotic medication. An interview with licensed nurse Employee E3 was conducted on November 21, 2024, at 11:57 a.m. Employee E3 confirmed Resident 106 was not taking Antipsychotic mediation and that MDS was coded in error. The facility failed to ensure residents' assessments were completed accurately. 28 PA Code 211.5(a)(b)(f) Clinical Records Page 1 of 3 395052 395052 11/22/2024 Rosewood Gardens Rehabilitation and Nursing Center 146 Marple Road Broomall, PA 19008

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of one residents reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on [DATE]. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the Nursing Home Administrator and Director of Nursing on November 22, 2024, at 11:30 a.m. confirmed that the recapitulation was not completed prior to discharge. 28 Pa Code 211.5 (f) Clinical records 395052 Page 2 of 3 395052 11/22/2024 Rosewood Gardens Rehabilitation and Nursing Center 146 Marple Road Broomall, PA 19008

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based upon clinical record review, it was determined the facility failed to ensure resident records contained accurate documentation for one of 28 residents reviewed (Resident 46). Residents Affected - Few Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury that occurred on July 3, 2024. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. Review of wound tracking documentation completed by the wound nurse from July 2024 through September 2024, revealed Resident 46 had a right foot pressure ulcer. Review of progress notes completed by the Nurse Practitioner from July 2024, through September 2024, further revealed Resident 46 had a right foot pressure ulcer. Interview with the Director of Nursing on November 24, 2024, at 8:50 a.m. confirmed Resident 46 did not have a right foot pressure ulcer and further confirmed that documentation in Resident 46's clinical record was inaccurate as Resident 46 did not have a right foot pressure ulcer. 28 PA Code 211.5(a)(b)(f) Clinical Records 395052 Page 3 of 3