Health inspection·February 14, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for two of 27 sampled residents. (Residents 7, 92) Residents Affected - Few Findings include: Clinical record review revealed that Resident 7 had diagnoses that included dysarthria (neurological speech disorder), hemiplegia and hemiparesis (paralysis), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated December 1, 2024, revealed Resident 7 was dependent on staff for Activities of Daily Living (ADL's), including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 7 was at risk for falls with an intervention for staff to check that the call bell was in reach before leaving the room. On February 11, 2025, at 11:31 a.m., Resident 7 was observed in bed with the call bell tied to the light string of the adjacent bed, out of reach. Resident 7 was observed again at 1:00 p.m., in bed eating lunch, and again at 2:15 p.m., in bed with the call bell tied to the light string, out of reach. On February 12, 2025, at 8:20 a.m., 10:52 a.m., and 12:38 p.m., and on February 13, 2025, at 9:28 a.m., and 11:46 a.m., Resident 7 was observed in bed with the call bell still tied to the light string, out of reach. Clinical record review revealed that Resident 92 had diagnoses that included anxiety, bradycardia (slow heart rate), and fibromyalgia. Review of the MDS assessment, dated November 4, 2024, revealed Resident 92 required partial to moderate assistance from staff for ADL's, including dressing and personal hygiene. Review of the care plan revealed that Resident 92 was at risk for falls with an intervention for staff to be sure the call light was within reach and to encourage the resident to use it for assistance. On February 11, 2025, at 11:30 a.m., Resident 92 was observed in the bed with the call bell draped over a box on the wall behind the bed, out of reach. Resident 92 was observed again at 1:00 p.m., in bed eating lunch, and again at 2:15 p.m., in bed with the call bell draped over a box on the wall behind the bed, out of reach. On February 12, 2025, at 8:11 a.m., 10:52 a.m., and 12:38 p.m., and on February 13, 2025, at 9:28 a.m., and 11:46 a.m., Resident 92 was observed in bed with the call bell draped over a box on the wall behind the bed, out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 3 395416 395416 02/14/2025 Rosewood Rehabilitation and Nursing Center 401 University Drive Schuylkill Haven, PA 17972

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 27 sampled residents. (Resident 93) Residents Affected - Few Findings include: Clinical record review revealed that Resident 93 had diagnoses that included hypertension (high blood pressure) and atrial fibrillation (irregular heat beat). A physician's order dated January 31, 2025, directed staff to administer a medication (metoprolol) one time a day for cardiac issues. Further review of the clinical record, revealed a physician's order dated January 30, 2025, that directed staff to administer a medication (amiodarone) one time a day for atrial fibrillation. Staff were not to administer either of the medications if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mmHg). Review of Resident 93's medication administration records (MARs) revealed that staff administered each medication two times in February 2025 when the resident's SBP was less than 110 mmHg. In an interview on February 14, 2025, at 10:10 a.m., the Director of Nursing confirmed that the medications were administered outside of the established parameters for Resident 93. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395416 Page 2 of 3 395416 02/14/2025 Rosewood Rehabilitation and Nursing Center 401 University Drive Schuylkill Haven, PA 17972

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing unit pantries. (Nursing unit 3A) Findings include: Review of the facility policy entitled, Dating and Labeling Policy, dated December 9, 2024, revealed that staff were to label food items with the date the package was opened and the date was to be written legibly. Observations during the kitchen tour on February 11, 2025, at 10:00 a.m., revealed the following: At the handwashing sink, the soap dispenser lever was covered with thick dried food debris. In the cooks' utensil drawer, there was a measuring cup with a dried, flaky substance along the bottom of it and it was stored with clean utensils. In the thickened liquid cooler, there was an opened package of sliced cheese and a large opened bulk container of grape jelly that were not dated. Inside the length of the door, there was an area of dried pink substance. In the walk-in cooler, there were two areas of a dried white substance on the floor under two sets of shelves. One set of shelves had meat on it and the other set of shelves stored milk cartons. There was a large opened bulk container of grape jelly that was dated but not legible. In an interview on February 11, 2025, at 10:30 a.m., the Dietary Manager confirmed that the previously mentioned items should have been dated and the date should have been legible. Review of the facility policy entitled, Food From Home or Outside Sources-Safety, dated December 9, 2024, revealed that staff were to check the temperatures of the resident refrigerators in order to determine the proper working order of the refrigerator. The refrigerators temperatures were to be at or below 41 degrees Fahrenheit. Observation of the Nursing unit 3A pantry on February 12, 2025, at 9:15 a.m., revealed a temperature of 47 degrees Fahrenheit by two thermometers that were inside. At 11:36 a.m., the temperature was 48 degrees Fahrenheit and on February 13, 2025, at 11:15 a.m., the temperature was 46 degrees Fahrenheit. At each observation, there were eight milk and three yogurt containers in the refrigerator. In an interview on February 13, 2025, at 2:20 p.m., the Administrator confirmed the refrigerator was used for resident foods. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 395416 Page 3 of 3