Rosewood Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Sep 11, 2024

  Based on record review, facility reported incident review, and staff interview the facility delayed initiating Cardiopulmonary Resuscitation (CPR) to Resident #63 after staff identified he did not have a heart beat or breath sounds but was still warm to the touch. The residents record contained no documentation to indicate if he did or did not want to have CPR. The standard of care is when there is an absence of an advance directive CPR should be given. Resident #63 was found unresponsive with no pulse or respirations by facility staff at approximately 6:45 am on [DATE]. CPR was no initiated until 7:19 am which was approximately 34 minutes after he was round unresponsive with no pulse or respirations. The emergency medical squad arrived at 7:30 am and assumed care of the code. […]

• Actual harm, isolatedF697Feb 1, 2023

  Based on observation, record review, and staff interview, the facility failed to assess and treat Resident #210's pain stemming from an unstageable pressure ulcer to his left heel resulting in actual physical and psychosocial harm. The resident rated his pain as a 8 (very strong pain) on 01/30/23. The surveyor notified the resident's nurse of his pain. The resident again rated his pain as a 10 (worst pain possible) on 02/01/23 during his pressure ulcer treatment. The facility failed to provide any pain medication on 01/30/23 despite surveyor intervention. Pain medication was not provided until the surveyor again alerted staff on 02/01/23. The facility failed to monitor the effectiveness of the pain medication administered within one (1) hour after administration on 02/01/23. […]

• No harm, potential for more than minimal, widespreadF745Mar 25, 2026

  Based on record review and interviews, the facility failed to employ a qualified social worker to provide and oversee social services from 10/14/25 through the time of survey, resulting in a failure to ensure appropriate follow-up, documentation, and resident support related to an allegation of misappropriation of property, abuse, neglect, reporting, and investigation. Resident identifiers: #54, #36, #32, #30, #3. Facility census: 67. Findings Include: a) Resident #32 Record review and staff interview revealed the facility did not employ a qualified social worker from 10/14/25 through the time of survey. During an interview on 03/25/26, facility administration confirmed there had been no qualified social worker employed during this time period. […]

• No harm, potential for more than minimal, widespreadF727Oct 20, 2021

  Based on review of the staff schedules for Registered Nurse (RN) coverage and staff interview, the facility failed to ensure RN coverage eight (8) consecutive hours a day, seven (7) days a week. This had the potential to affect all residents at the facility. Facility census: 64. Review of the staffing schedules for RN coverage found three (3) occasions when RN coverage did not occur eight (8) consecutive hours a day: 10/06/21 - RN Coverage was 4.50 Hours 10/12/21 - RN Coverage was 4 Hours 10/14/21 - RN Coverage was 4 Hours On 10/19/21 at 1:45 PM, the Administrator and Director of Nursing (DON) confirmed the facility did not have RN coverage for eight (8) consecutive hours on 10/06/21, 10/12/21, and 10/14/21.

• No harm, potential for more than minimal, patternF755Mar 25, 2026

  Based on observation and interview, the facility failed to ensure that medications were disposed of in accordance with professional standards of practice for one (1) of one (1) medication storage rooms observed. The facility failed to remove and properly dispose of 11 discontinued medications that remained in the storage room in various random drawers. This failure created a potential for medication errors or unauthorized access to medications. Facility Census: 67 Findings include:The facility's policy titled Medication Storage Storage of Medications, revised 01/26, indicated that discontinued medications must be removed from the active storage area immediately and documented for disposal to prevent accidental administration.On 03/24/26 at 9:30 AM, during a review of the medication storage… […]