Rosewood Health Facility

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 11, 2025

  Based on interview and record review, the facility failed to ensure the Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) met to discuss if one of three sampled residents (Resident 1) who was high risk for falls (move downward, typically rapidly and freely without control from a higher to a lower level), had a history of falls, and had a diagnosis of Dementia (a progressive state of decline in mental abilities), was safe to have one-on-one monitoring (1:1- a type of care where a healthcare professional provides constant supervision to a resident) discontinued. […]

• No harm, potential for more than minimal, widespreadF882Feb 12, 2026

  Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This failure resulted in ineffective infection surveillance (continuous method to collect, analyze, monitor and reduce infections) and antibiotic stewardship program (a program to monitor the use of antibiotics - medications used to treat infections in healthcare settings) and had the potential to increase the spread of infectious diseases to residents, staff, and visitors.Findings:During a concurrent interview and record review on 2/11/26 at 9:13 a.m. with IP, IP's training record was reviewed. IP stated she had not completed the specialized training in infection prevention and control. […]

• No harm, potential for more than minimal, widespreadF880Nov 7, 2024

  Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Water Management Program for 71 of 71 sampled resident's when the facility cooling tower (device that removes heat from water and used to cool a building) tested positive for Legionella (bacteria causing lung infection). This failure had the potential to spread a highly contagious, infectious bacteria to residents, visitors, and staff. Findings: During an interview on 11/6/24 at 9:30 a.m. with Safety Officer (SO), SO stated the cooler connected to the water tower tested positive for Legionella and the water treatment company treated the water. […]

• No harm, potential for more than minimal, widespreadF756Feb 9, 2023

  Based on interview and record review, the facility failed to ensure medication irregularities noted by the consultant pharmacist in the Medication Regimen Review (MRR-a comprehensive pharmacy evaluation of the residents' medications) for 11 of 29 sampled residents (Resident 6, Resident 9, Resident 10, Resident 15, Resident 16, Resident 24, Resident 39, Resident 42, Resident 46, Resident 61, and Resident 165) were reviewed and acted upon by the attending physician and the Director of Nursing (DON) promptly. This failure had the potential to place residents at risk for adverse consequences and other medication-related problems. […]

• No harm, potential for more than minimal, widespreadF812Feb 9, 2023

  Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices when one of one sampled staff member (Activities Staff- AS) did not wear hair net properly upon entering kitchen. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 2/7/23, at 11:14 AM, with Certified Dietary Manager (CDM) 2, in the Resident dining room, AS was observed going into and coming out of the kitchen with approximately one half of the back of his head uncovered by a hair net. […]