Roselawn Gardens Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Roselawn Gardens Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802Jun 2, 2022

  Based on observation, record review and interview the facility failed to ensure sufficient staff to effectively carry out the functions of the food and nutrition services. This affected one sampled resident (#24) and had the potential to affect all 41 residents residing in the facility. Findings include: Record review for Resident #24 revealed an admitted [DATE] with diagnoses including muscle wasting, atrophy and adult failure to thrive. Review of the physician's orders for Resident #24 for the months of May 2022 and June 2022 revealed orders for a regular texture diet with regular consistency, whole milk with each meal, cream soup with lunch and supper, large portions each meal and a magic cup (supplement) before meals and at bedtime four times a day. On 05/31/22 at 9:25 A.M. […]

• No harm, potential for more than minimal, widespreadF804Jun 2, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure food items were served at an appetizing and palatable temperature for all residents. This affected four residents (#14, #3, #17 and #24) and had the potential to affect all 41 residents residing in the facility. Findings include: Review of the Resident Council Meeting Minutes, dated 01/06/22 revealed resident concerns with dietary which included concerns of cold food. On 05/31/22 at 9:52 A.M. interview with Resident #17 revealed breakfast was cold every morning and lunch was not good either. On 05/31/22 at 10:49 A.M. interview with Resident #3 revealed dietary concerns including the food was always cold, never warm when served. On 05/31/22 at 11:25 A.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2022

  Based on observation, facility policy and procedure review and interview the facility failed to ensure food items were prepared and distributed under sanitary conditions to prevent contamination and/or food borne illness. This had the potential to affect all 41 residents residing in the facility. Findings include: On 06/01/22 at 11:42 A.M. observation of the tray line service for the lunch meal revealed Dietary Manager #23 had tested the temperatures of the of the food items on the steam table. Dietary Manager #23 had disposable gloves on both hands. After completing the food temperatures, Dietary Manager #23 dropped the alcohol wipe including the wrap the wipe came in on the floor. […]

• No harm, potential for more than minimal, patternF883Feb 13, 2025

  Based on medical record review, interview, and review of the facility policy, the facility failed to ensure Resident #31 received the pneumococcal vaccine after signing consent, failed to ensure that Residents #34, #36, and #39 or their resident representative were given the opportunity to consent to or refuse the pneumococcal vaccine, and failed to ensure the medical record contained evidence Residents #31, #34, #36, #38, and #39 received education regarding the benefits and risks of immunization against the pneumococcal virus and each of these residents either received or did not receive the pneumococcal vaccine. This affected five residents (#31, #34, #36, #38, and #39) of 13 residents who were reviewed for immunizations. The facility census was 40. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF600Jun 18, 2025

  Based on record review and interview, the facility failed to ensure Resident #10 and Resident #15 was free from resident to resident sexual abuse. This finding affected two residents (Resident #10 and Resident #15) of three residents reviewed for abuse. Findings include: Review of the Self-Reported Incident Investigation (SRI) tracking number #261364 dated 06/08/25 at 1:38 P.M. revealed the nurse was advised by the Certified Nursing Assistant (CNA) that Resident #10 was in his wheelchair with his pants down while Resident #15 had his head in Resident #10's lap performing oral sex. […]