Rosewalk Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 13, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia who was at risk of elopement did not exit the facility unsupervised for 1 of 3 residents reviewed for accidents. (Resident B) Resident B was found in the community, had fallen, and was transported to the hospital for treatment.The immediate jeopardy began, on 10/28/25, when Resident B exited the facility unsupervised and without the staff's knowledge while wearing a wanderguard device (a wearable device used to alert staff when a resident approached restrictive areas/doors). The resident was located approximately 0.6 miles away from the facility. The resident was found lying face down on the ground by a concerned citizen. […]

• Actual harm, isolatedF689Nov 16, 2022

  Based on interview and record review, the facility failed to ensure a resident (Resident B), who was deemed dependent on staff for bed mobility and transfers, did not experience increased pain and swelling after being transferred by a staff member and later identified with a fracture, and not ensuring the use of a gait belt during a transfer for 1 of 1 resident reviewed for injury of unknown origin. Findings include: The clinical record for Resident B was reviewed on 11/16/22 at 11:10 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, [CONDITION(S)], [CONDITION(S)], age-related [CONDITION(S)], cognitive communication deficit, and spinal stenosis. […]

• Actual harm, isolatedF686Dec 2, 2021

  Based on interview and record review, the facility failed to adequately assess, monitor, and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The clinical record for Resident F was reviewed on 12/1/21 at 1:44 p.m. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly skin and vital signs assessment, dated 9/17/21, indicated he had a reddened area on his coccyx. On 9/23/21, he was discharged to an acute care hospital for an unrelated condition. A wound consult note from the acute care hospital, dated 9/27/21, indicated he had shearing (friction) to his bilateral buttocks which measured 10cm x 8 cm and was red in appearance. […]

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure expired food was disposed of timely with the potential to affect 98 of 98 residents that receive food from the kitchen. (Facility) Findings include: The facility kitchen was observed with Culinary Aide 2 (CA) on [DATE] at 9:45 a.m. The inspection of the dry storage was conducted with CA 2. During an interview with CA 2, he indicated the top dates on the boxes were delivery dates and bottom dates were expiration dates. […]

• No harm, potential for more than minimal, patternF880Mar 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by not ensuring hand hygiene was performed prior to donning gloves, failed to utilize hand hygiene during a medication administration, popping pill medication in bare hands for 3 of 6 residents randomly observed for medication administration, and not donning personal protective equipment (PPE) during bathing and dressing for 1 of 1 resident reviewed for dialysis. (Resident 2, Resident 12, Resident 20, and Resident 24) Findings include: 1. The clinical record for Resident 20 was reviewed on 3/9/25 at 11:31 a.m. […]