Rosewood Gardens Rehabilitation and Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF641Feb 6, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 27 residents reviewed. (Resident 11).Findings include:Review of Resident 11's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 11, 2025, revealed under section N0350 - Insulin, that the resident was not marked as receiving insulin medication.Review of Resident 11's physician's orders revealed that the resident has an order for insulin.Review of Resident 11's Medication Administration Record (MAR) revealed that the resident did receive insulin on two days of the seven days look back period, December 9th and 10th 2026. […]

• No harm, potential for more than minimal, isolatedF641Nov 22, 2024

  Based upon clinical record review, it was determined the facility failed to ensure Minimum Data Set Assessments were completed accurately for two of 28 residents reviewed (Resident 46 and 106 Resident). Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. Interview with the Director of Nursing on November 24, 2024 at 8:50 a.m. […]

• No harm, potential for more than minimal, isolatedF661Nov 22, 2024

  Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of one residents reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on November 8, 2024. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the Nursing Home Administrator and Director of Nursing on November 22, 2024, at 11:30 a.m. […]

• No harm, potential for more than minimal, isolatedF842Nov 22, 2024

  Based upon clinical record review, it was determined the facility failed to ensure resident records contained accurate documentation for one of 28 residents reviewed (Resident 46). Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury that occurred on July 3, 2024. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. […]

• No harm, potential for more than minimal, isolatedF689Feb 27, 2023

  Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure adequate supervision during a transfer for one of three residents reviewed for falls (Resident 86). Findings include: Review of Resident 86's clinical record revealed diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (stroke) affecting the resident's left non-dominant side and generalized muscle weakness. Review of Resident 86's quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated September 17, 2022, revealed the resident required extensive assistance of two staff persons for transfers during the lookback period. […]