Rosewood Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jul 19, 2023

  Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including CPR, to a resident requiring emergency care according to the resident's advanced directive and physician's order for 1 (Resident #1) out of 4 (Resident #1, Resident #2, Resident #3, Resident #6) residents reviewed for advanced directives. On [DATE] at 9:20 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code status, did not receive CPR (Cardio-pulmonary Resuscitation) upon being found unresponsive by S2LPN. At approximately 9:31 p.m. on [DATE], S2LPN notified S4MD and the hospice nurse that the resident was found with her eyes open, mouth open, and lips purple. […]

• Actual harm, patternF686Mar 1, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents received the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing by failing to conduct weekly skin assessments for 2 (#R2, and #R12) of 4 (#1, #R2, #R11 and #R12) residents reviewed for facility acquired pressure ulcers. This deficient practice resulted in an actual harm for: 1. Resident #R2, who was a risk for developing pressure ulcers, was discovered to have a Stage 3 pressure ulcer on her left elbow on 2/15/23 at 3:24 p.m. Staff failed to conduct a weekly skin assessment from 02/01/23 to 02/14/23, which delayed the identification and treatment of the wound. 2. […]

• Actual harm, patternF689Mar 1, 2023

  Based on record review, and interview, the facility failed to ensure residents were free of accident hazards by failing to: 1. properly restrain a resident in her wheelchair during transport in the facility's van for 1 (Resident #1) out of 4 (#1, #R3, #R4, #R5) residents who were transported in the facility's van. 2. provide adequate supervision for 1 (#3) out of 7 (#3, #R6, #R7, #R8, #R9, #R10, #R11) residents who were assessed to be at risk for wandering. The deficient practice resulted in an actual harm for: 1. Resident #1 when S12CNADriver (Certified Nursing Assistant) failed to use the seat/lap belt to properly secure the resident in her wheelchair during transport. On 10/01/22 at 5:29 a.m., S12CNA Driver and Resident #1 were involved in a motor vehicle accident. […]

• Actual harm, isolatedF689Mar 31, 2026

  Based on observation, interviews, and record reviews, the facility failed to ensure residents were free from hazards for 1 (Resident #1) out of 8 sampled residents.This deficient practice resulted in actual harm on 03/12/2026 during the 10:00 a.m. group activity when Resident #1 spilled hot coffee on her lap. The dietary staff failed to follow the facility's hot beverage policy when S8DA distributed coffee for residents at an unsafe temperature. As a result, Resident #1 sustained a 2nd degree and a 3rd degree burn to her left thigh and received treatment at the facility.The facility implemented a corrective action plan on 03/15/2026 and was in substantial compliance at the time of the state agency's investigation on 03/31/2026; thus it was determined to be a Past Noncompliance… […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a mechanical lift transfer for 1 (#1) of 7 (#1, #2, #3, R1, R2, R3, and R4) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1 on 08/08/2024 at 2:15 p.m., when S3CNA (Certified Nursing Assistant) attempted to transfer the resident from a shower bed to bed while utilizing the mechanical lift without assistance of another qualified staff person. Resident #1 fell from the lift sling during the transfer and landed on the floor resulting in a fractured right leg. Resident #1 was transferred to the hospital on 08/08/2024. X-ray report dated 08/08/2024 at 4:53 p.m. […]