Rosedale Health & Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF684Sep 21, 2023

  Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the plan of care for transporting a resident which resulted in an injury for one of 40 residents in the survey sample, Resident #33. The resident sustained a fracture of the right femur (1) which constituted harm, cited at past non-compliance. The findings include: For Resident #33 (R33), the facility staff failed to provide support to the resident's feet while transporting them in the wheelchair in the facility hallway, which resulted in the resident's feet dropping to the floor which caused R33 to fall from the wheelchair and subsequently sustained a fractured femur. […]

• Actual harm, isolatedF686Sep 21, 2023

  Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure injuries for three of 40 residents in the survey sample, Residents #106, #108 and #96. For Resident #106, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries, failed to obtain physician's orders for the treatment of the pressure injuries, and failed to implement interventions to prevent further pressure injuries, which constituted harm. The findings include: 1. […]

• Actual harm, isolatedF658Apr 23, 2021

  Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards for medication administration for one of 25 residents in the survey sample, (Resident #47). The facility staff failed to provide the care and services in accordance with professional standards of practice for documenting the administration of medications on 7/2/2020 for Resident #47. On the evening of 7/2/2020, Resident #47 was inadvertently assigned to both LPN [licensed practical nurse] #4 and RN [registered nurse] #2. […]

• Actual harm, isolatedF760Apr 23, 2021

  Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure one of 25 residents in the survey sample, (Resident #47), was free of a significant medication error. On the evening of 7/2/2020, Resident #47 was administered all of her multiple physician prescribed evening medications twice, by two nurses, LPN [licensed practical nurse] #4 and RN [registered nurse] #4, resulting in a significant medication error. Resident #47 was subsequently was transferred to a local hospital for evaluation/treatment. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2025

  Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for the facility. The findings include: The facility staff failed to follow infection control practices for linen storage. On 4/1/25 at approximately 5:50 AM, ASM (administrative staff member) #1, the administrator and this surveyor were making round of the unit linen closets to review levels. ASM #1 stated, we have more linen than this. They start bringing out the linen cart at 6:45 AM. ASM #1 took me to linen/EVS area and stated, there is more linen on those shelves. Packs of blankets, wrapped in plastic were on shelves next to one blanket and one sheet on open shelf next to environmental services cart and mops. […]