Rosewood Heights

In the surveyor’s words

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

• Immediate jeopardy, isolatedF655Apr 18, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for one (Resident #1) of five residents reviewed for baseline care plans. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. […]

• Immediate jeopardy, isolatedF689Apr 18, 2025

  Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and supervision. The facility failed to ensure staff implemented Resident #1's hospital discharge order upon admission to be placed on fall precautions. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. […]

• Immediate jeopardy, isolatedF686Jul 30, 2024

  Based on interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for treatment of pressure ulcers. The facility failed to recognize and provide treatment, and prevention measure for an open skin area on Resident #1. The area was first noted on 6/25/24 with admission, the first documentation of care being provided to the area was on 7/7/24. On 7/10/24 Resident #1 was diagnosed with a stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). The noncompliance was identified as PNC. […]

• Actual harm, isolatedF686Apr 17, 2026

  Based on observation, interview and record review the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries for 1 (Resident #1) of 5 residents reviewed for pressure injuries. The facility failed to prevent Resident #1 from receiving a shear to her right buttock, which ultimately became a stage 4 pressure ulcer that developed into sepsis (life-threatening condition caused by the body's extreme and dysregulated response to an infection, leading to organ dysfunction and potentially death) due to wound infection, infection due to polymicrobial wound flora, and osteomyelitis (infection that happens when bacteria or fungi infect the bone marrow) of sacrococcygeal wound. […]

• Actual harm, isolatedF697Jun 2, 2023

  Based on observation, interview and record review, the facility failed to ensure that pain management is provided to resident who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #24) reviewed for pain management. The facility failed to administer pain medication to Resident #24 on 06/02/23, resulting in prolonged pain for the resident. This failure could result in worsening of pain and injury to residents. […]