Rosedale Green

In the surveyor’s words

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

• Actual harm, isolatedF656Sep 23, 2021

  Based on interview, record review and review of the facility's policy and procedure, it was determined the facility failed to implement the comprehensive care plan for one (1) of eight (8) sampled residents (Resident #2). The facility's care plan for Resident #2 documented the requirement for extensive assistance of two (2) staff, and the use of a Hoyer lift, for transferring. However, on 08/30/2021, two staff performed a Stand Pivot transfer with a gait belt, during which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Sep 23, 2021

  Based on interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of eight (8) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #2). The facility assessed that Resident #2 was totally dependent for chair-to-bed transfers and was no longer able to rise from sitting to standing as of Minimum Data Set (MDS) assessment dated [DATE]. Resident #2's care plan reflected that a Hoyer lift was required for chair-to-bed transfer as of 04/05/2021. On 08/30/2021, Certified Nursing Assistant (CNA) #2 and CNA #3 transferred Resident #1 from his/her wheelchair to bed with Stand Pivot technique and a gait belt. During this process, Resident #2 sustained a full thickness laceration. […]

• No harm, potential for more than minimal, patternF880Apr 17, 2025

  Based on observation, interview, record review, review of the Centers for Medicare and Medicaid (CMS) memorandum, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations revealed the facility failed to clean the mechanical lift after use for two of three sampled residents, Resident (R) 1 and R117. […]