Rosebud Health Care Center

In the surveyor’s words

From the most serious findings on record at Rosebud Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 1, 2022

  Based on observation, interview, and record review, the facility neglected to act in a timely manner for the assessment and implementation of interventions to address a resident's prolonged coughing and choking episodes, which resulted in the resident's health decline and hospital admission for pneumonia, for 1 (#9) of 1 sampled resident; and, a staff member left a hot pack on a resident (#7) and left without communicating the use and placement of the hot pack to oncoming staff, and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an observation on 8/30/22 at 7:52 a.m., resident #9 was coughing during her meal. […]

• Actual harm, isolatedF689Sep 1, 2022

  Based on observation, interview, and record review, a facility staff member left a hot pack on a resident for an extended period of time, and the resident (#7) sustained 1st and 2nd degree burns and increase in pain from the injuries, of 1 sampled resident; and, a resident (#9) was having coughing/choking episodes, for an extended period, which the facility did not address timely or sufficiently, and the resident was hospitalized , of 1 sampled resident. Findings include: 1. Review of resident #7's nursing progress notes, dated 8/6/22, showed, Resident c/o pain to skin on back .8 in x 7 in area of pink to red skin .2 cm x 2 cm fluid filled blister to center of area .CNA did place hot pack at lunch for c/o back pain .area appears to be possible burn from hot pack. […]

• Actual harm, isolatedF692May 27, 2021

  Based on interview and record review, the facility failed to identify a severe weight loss and implement measurements timely to prevent the continued weight loss for 1 (#22) of 21 sampled residents. Findings include: Review of resident #22's weight change history showed: 2/25/21 - 150 lbs 3/4/21 - 146 lbs 3/15/21 - 139 lbs 4/9/21 - 137 lbs 4/13/21 - 134 lbs 4/23/21 - 128 lbs The resident experienced a severe weight loss from 2/25/21 to 3/15/21 of 7.33 percent in less than one month, and between 4/9/21 and 4/23/21 the resident had an additional severe weight loss of 6.57 percent in less than a month. The total percentage of weight loss between 2/25/21 and 4/23/21 was 13.9 percent. […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated after the package was opened, failed to ensure food items in the freezer were stored off the floor, and failed to label and date items in the refrigerator in the resident's dining room. This deficient practice increased the risk of food borne illness for all residents who were served food from the kitchen. Findings include:During the initial tour of the kitchen on 12/15/25 at 2:24 p.m., the following were observed:- A plastic bag contained what appeared to be chow mein noodles, located in the dry storage area. […]

• No harm, potential for more than minimal, widespreadF868Dec 18, 2025

  Based on interview and record review, the facility failed to ensure the Medical Director or designee attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. This deficient practice limited the Medical Director's ability to fully participate and add value to the QAPI meetings. Findings include:During an interview on 12/17/25 at 3:31 p.m., staff member B stated the Medical Director participated in the QAPI program by notification of the meeting date and time, and was also provided the QAPI meeting documentation. Staff member B further stated that the information was shared with the Medical Director at monthly board meetings and medical staff meetings. […]