Accordius Health at Rose Manor LLC

In the surveyor’s words

From the most serious findings on record at Accordius Health at Rose Manor LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 29, 2024

  Based on observations, record review, Emergency Medical Service (EMS) personnel interview, and staff interview the facility failed to provide supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without staff's knowledge. On 1/22/24 Resident #83 was found by EMS personnel approximately 1.9 miles from the facility seated on the ground on a sidewalk outside at 3:05 AM with icicles hanging from his nose and beard. He was treated for hypothermia by EMS and was taken to the hospital. This was for 1 of 3 residents reviewed for accidents. Immediate Jeopardy began on 1/22/24 when Resident #83 exited the facility unsupervised and without staff's knowledge. […]

• Actual harm, isolatedF689Aug 27, 2026

  Based on observation, record review, staff, resident and Nurse Practitioner interviews, the facility failed to safely transfer a resident from his wheelchair to his bed with the use of a mechanical lift. The unsafe transfer resulted in a residents fall with injuries that included headache, arm pain, neck pain and a cut to his cheek. The resident was transported to the emergency department (ED) on 8/14/26 where he had a laceration repair to his left cheek that required 4 sutures/stitches. This was reviewed for 1 of 3 residents (Resident #48) reviewed for supervision to prevent accidents. […]

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  Based on observation and staff interviews, the facility failed to implement a system to air dry all cleaned dishes. The facility also failed to follow the manufacturer's instructions for a minimum temperature of 120 degrees Fahrenheit (F) and the sanitization up to the required level of at least 50 parts per million (ppm) for three of three observations. These practices had the potential to affect food served to residents. The findings included: An observation and interview with the Certified Dietary Manager (CDM) were conducted on 5/05/25 at 10:43 AM in the kitchen. The CDM stated that all dishes near the dish room were ready for service. […]

• No harm, potential for more than minimal, widespreadF925May 8, 2025

  Based on observations, record review, staff and a pest control service technician interviews, the facility failed to maintain an effective pest program that was free of roaches for 3 of 4 observations for pest control. The findings included: Review of the pest control invoices provided by the Administrator from February - April 2025 revealed the following information related to cockroach activity and pest control identification of problem areas: 2/21/25: Cockroach activity was not observed during service. Sanitation issues: kitchen area interior - spilled food material found on the floor. This has been like that for months and remained untouched. Structural concerns: kitchen area interior - floor tiles or baseboards loose/missing. […]

• No harm, potential for more than minimal, widespreadF812Sep 16, 2022

  Based on record review, observations and staff interviews, the facility failed to discard expired foods stored for use in 1 of 1 walk-in refrigerator; label, date food items, monitor freezer and refrigerator temperatures, and provide a resident nourishment refrigerator solely for resident's food items brought into the facility; prevent potential cross contamination of food when a staff member (Certified Occupational Therapy Aide #1) placed a leftover food tray into the enclosed meal cart that had meal trays waiting to be served to residents for 1 of 2 meal observations; monitor temperatures on the wash cycle and the temperature during a chemical solution rinse cycle for the dish machine to ensure sanitation of dishes; and ensure 3 of 4 dietary staff (Dietary Aide (DA) #1 and Regional… […]