Rosebud Village

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 15, 2024

  Based on interview and record review, the facility failed to ensure a fall from a mechanical lift did not occur during a transfer from the bed to the chair, resulting in cervical and thoracic fractures of the spine, for 1 of 3 residents reviewed for falls. (Resident B) The deficient practice was corrected on 1-10-24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments of the resident who had experienced a fall, conduct neurological checks, and audits related to fall events. Findings include: The clinical record of Resident B was reviewed on 2-13-24 at 5:40 p.m. […]

• No harm, potential for more than minimal, patternF558Jun 5, 2024

  Based on interview, observation, and record review, the facility failed to ensure residents had water or beverages of choice available for 4 of 4 residents reviewed for accommodation of needs. (Resident 2, Resident 89, Resident 54, and Resident C) Findings include: 1. The clinical record for Resident 2 was reviewed on 6/3/2024 at 1:55 p.m. The clinical diagnosis included dementia. A Minimum Data Set (MDS) Assessment, dated 3/28/2024, indicated Resident 2 was cognitively impaired and needed set up assistance for eating tasks. A care plan intervention, dated 5/4/2015, indicated to encourage fluids for Resident 2. An observation and interview on 6/4/2024 at 11:30 a.m., indicated Resident 2 laying in bed at this time with her television on. […]

• No harm, potential for more than minimal, patternF744Jun 5, 2024

  Based on observation, interview, and record review, the facility failed to provide their scheduled activity program on the Cottage Unit of the facility; implement and educate staff regarding a residents' individualized activity care plan; and redirect a resident with a history of wandering into other residents' rooms for 7 of 28 residents on the Cottage Unit of the facility. (Residents 6, 49, 35, 52, 60, 65, and 92) Findings include: 1. An observation of the common area of the Cottage Unit was conducted on 5/31/24 at 11:36 a.m. The common area of the unit was a very large room that consisted of a television area in the front corner with recliners around it. There was a sink and counter space in the opposite front corner of the room. […]

• No harm, potential for more than minimal, isolatedF687Jul 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure nail care and heel protectors were provided and a podiatry visit was completed for 2 of 2 residents reviewed for foot care. (Resident 37 and Resident 56)Findings include:1. a) The clinical record for Resident 37 was reviewed on 7/23/25 at 11:16 a.m. The diagnoses included, but were not limited to, dementia, hemiplegia and hemiparesis, congestive heart failure, chronic pain, and osteoporosis. The ADL (activities of daily living) care plan, last reviewed/revised 5/23/25, indicated Resident 37 required assistance and/or monitoring for ADL care. The goal was to have her ADL needs met. […]

• No harm, potential for more than minimal, isolatedF690Jul 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter drainage bag was free of the contact with the floor for 1 of 2 residents reviewed for urinary catheter usage. (Resident 86)Findings include: The clinical record for Resident 86 was reviewed on 7/28/2025 at 1:05 p.m. The medical diagnoses included cerebral palsy and neurogenic bladder.A Quarterly Minimum Data Set assessment, dated 7/3/2025, indicated Resident 86 was cognitively intact, does not refuse care, was dependent on toilet hygiene and was partially to moderately dependent on assistance from staff for personal hygiene, and utilized an indwelling catheter. […]