Rowan Community, INC.

Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments. The deficient practice affected 1 of 7 of the smoke compartments. The deficient practice could affect all smoke zones,10 of 63 residents, and an indeterminable number of staff and visitors.1 During the inspection, observations, and interviews with the maintenance director, it was revealed that the smoke detector in the maintenance shop is not mounted correctly.2 During the inspection, observa.. Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,63 of 63 residents, and an indeterminable number of staff and visitors.1 During the inspection, observations and interviews with the maintenance director revealed that the dining room sprinkler escutcheon is missing its second piece.2 Observations and interviews with the maintenance director during the record review revealed that the quarterly report for the fire sprinkler system was not available at.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standards 96 and 101. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones,10 of 63 residents, and an indeterminable number of staff and visitors.1. During the inspection, observations and interviews with the maintenance director indicated that the nozzles in the kitchen hood suppression system are improperly positioned.2. During the record review, observations and interviews with the maintenance director indica.. Based on observation during the course of the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 99. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones,10 of 63 residents, and an indeterminable number of staff and visitors.During the inspection, observations and interviews with the maintenance director revealed that the oxygen room should have clear signage indicating whether it is empty or full in order to eliminate any confusion.NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from f.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a one-story, Type II (III) structure with a partial basement. The basement is used for support services only. The facility is protected on the first floor and basement by a wet and dry system, protecting the concealed spaces between the ceiling and roof deck in the original building. The building is classified as fully sprinklered. The facility was constructed in 1960 and is licensed for 65 beds. This recertification survey, conducted o.. Through observation during the survey, it was determined that the facility failed to meet the rubbish chutes, incinerators, and laundry chute requirements in accordance with NFPA 101. The deficient practice affected all smoke compartments. The deficient practice affected 2 of the seven smoke compartments. The deficient practice could affect all smoke zones,20 of 63 residents, and an indeterminable number of staff and visitors.During the record review, observations and interviews with the maintenance director revealed that no inspection report was available for the laundry chute.NFPA 82 (2009) 10.2.2 Waste and linen chutes and transport systems including chute loading an..

A recertification survey with complaint #CO39957, Incident #39977, Incident #40013 and Incident #40015 was completed on 5/19/25 to 5/22/25. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 5/19/25 to 5/22/25. No deficiencies were cited. Based on interviews and record review, the facility failed to maintain a system of documenting grievances and demonstrating prompt actions for one (#6) of two residents out of 32 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility' s response to individual grievances for Resident #6. Findings include: I. Facility policy and procedureThe Grievance policy and procedure, revised 5/8/23, was provided b.. Based on interviews the facility failed to ensure one (#51) of five residents were free from abuse out of 32 sample residents. Specifically, the facility failed to protect Resident #51 from verbal and physical abuse from two staff members. Findings include:I. Facility policy and procedureThe Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 5/19/25 at 10:38 a.m. It read in pertinent part, "Residents have the right to be .. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of two units.Specifically, the facility failed to:-Ensure housekeeping staff followed the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas;-Ensure housekeeping .. Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for one (#16) of three residents reviewed for mental health out of 32 sample residents.Resident #16, was admitted on 5/1/23 and readmitted on 5/15/25, with diagnoses of bipolar disorder and dissociative disorder. The resident had a previous rep.. Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of 32 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put into place for Resident #6' s right foot. Findings include: I. Facility policy and procedureThe Restorative Nursing Services policy and procedure, revised July 2017, was provided by the n.. Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for two (#51 and #6) of four residents out of 32 sample residents. Specifically, the facility failed to:-Provide Resident #51 with privacy and dignity when receiving care, and, -Respond to Resident #51 and Resident #6' s call light timely. Findings include:I. Facility policy and procedureAnswering the Call Light policy, revised September 2022, was.. Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for two (#48 and #38) of four residents reviewed for hospice care services out of 32 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for R..

A licensure survey was completed on 5/19/25 to 5/22/25. Two deficiencies were cited. Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for one (#16) of three residents reviewed for mental health out of 32 sample residents.Resident #16, was admitted on 5/1/23 and readmitted on 5/15/25, with diagnoses of bipolar disorder and dissociative disorder. The resident had a previous reported history of suicidal ideation with self-harm. Resident #16 had documented behaviors of becoming easily agitated, verbally reactive and frequently calling emergency medical services (EMS) for all issues.Resident #16 had a behavioral care plan in place, which included monitoring mood/behavior and consulting with behavioral health services. However, the resident did not have a safety plan in place based on a past history of making suicidal ideations or triggering behaviors when her manic behaviors were escalating, including exhibiting an inability to sleep, crying and becoming easily agitated.On 2/4/25 Resident #16 self-inflicted cuts to her wrists with a pair of scissors after spending 45 minutes on the phone with the mental health crisis center. Resident #16 was sent to the hospital for her suicidal ideation and attempt to cut her wrists with scissors. Resident #16 returned from the hospital on 2/13/25 with a safet.. Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#51) of five residents reviewed out of 32 sample residents. Resident #51, who was at risk for falls and had a history of falls, experienced 21 falls between 1/13/25 to 5/15/25. The facility' s interdisciplinary team (IDT) met after the falls to determine a root cause for the resident' s falls and implement interventions.However, the facility' s review of the falls was not always timely.The root cause identified for 19 of the resident' s 21 falls was poor safety awareness, however, the facility did not identify a more specific root cause in order to determine if the fall interventions were appropriate and effective for preventing further falls. However, the facility failed to ensure multiple documented interventions were initiated and the resident was observed, during the survey, without several of the observations in place (see observations below). On 4/21/25, the resident experienced a fall which resulted in a laceration to his left eyebrow and a laceration to his chin. He was sent to the emergency department (ED) for evaluation and returned to the facility with five stitches on his left eyebrow and three stitches on his chin. The facility documented an intervention after the 4/21/25 fall for the medical directo..