Rosewood Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 9, 2022

  Based on observation, interview and record review, the facility failed to adequately supervise one of three totally dependent (the resident needs the staff to completely and totally perform the task) on staff residents (Resident 1) after transferring her back to bed. Certified Nursing Assistants (CNA 2 and CNA 3) left her in bed, unattended, and unsupervised resulting in an avoidable fall out of bed. This failure resulted in Resident 1 sustaining a right leg fracture (broken bone), pain, and a transfer to Acute Care Hospital (ACH 1) for follow up care. Findings: During a record review of Resident 1 ' s Admission Record dated 11/14/22, the record showed Resident 1was admitted to the facility in 08/15/2015. […]

• No harm, potential for more than minimal, widespreadF838May 15, 2026

  Based on interview and record review, the facility failed to ensure the facility assessment (an assessment of the resources and staffing that the facility needs to competently care for the specific patient population) was complete when the following required components were not included. 1. Staffing plan 2. Staff training/education and competencies This failure had the potential to negatively affect a vulnerable population.Findings: 1. During a record review of the facility assessment dated 3/23/26, there was no documented evidence that the facility assessment included the following required component: a. […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2023

  Based on observation, interview and record review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions for 89 of 97 residents whose food were prepared in the kitchen. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an initial tour of the kitchen with the Dietary Supervisor (DS) on [DATE] at 9:40 A.M., the following were observed: - A jar of Kikkoman soy sauce had a use by date of [DATE]. - A 4.5lb container of sweet and sour sauce did not have an open date and a use by date. - A one-gallon jar of mayonnaise had no open date and use by date. […]

• No harm, potential for more than minimal, patternF880Aug 4, 2026

  Based observation, interviews, and record review, the facility failed to ensure infection prevention and control practices were followed for five of six sampled residents (Residents 1, 2, 3, 4, and 5) when:1. Two soiled dressings were observed on Resident 1 and Resident 2's nightstands during two separate occasions.2. One licensed nursing staff member failed to clean and disinfect the glucometer (a handheld device used to measure a person's blood sugar level) after using it for Resident 3 and subsequently used the same contaminated device for Residents 4 and 5 without sanitizing it.These failures had the potential to increase the risk of bacterial transmission, expose residents to cross-contamination (germs are accidentally transferred from one person, object, or surface to another person… […]

• No harm, potential for more than minimal, patternF812May 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure cold drinks were held at 41 degrees Fahrenheit or below during lunch tray line.This failure had the potential to result in the growth of bacteria, placing the residents at risk for contracting a food borne illness.Findings:During a concurrent observation and interview on 5/13/26 at 11:53 a.m. with the Registered Dietitian (RD), RD stated that the temperature checks were going to be performed and logged. The cold drinks were taken out of the refrigerator, placed on a cart in a plastic tub of ice, and placed next to the tray line to be placed on the meal trays. The juice temperature was registered at 45 degrees Fahrenheit (F) (unit of temperature), and the milk temperature was registered at 43 degrees F. […]