Rosewood Rehab and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 12, 2024

  Based on interview and record review, the facility failed to ensure two sampled residents (Resident #1 and #6) out of ten sampled residents received adequate supervision and assistance. On [DATE], staff did not check on Resident #1, who had a diagnosis of dementia and a known history of pulling his/her indwelling catheter, from 12:00 A.M. until 7:00 A.M. At 7:05 A.M., the resident was found lying on his/her side in a pool of blood, urine, and feces. EMS pronounced the resident deceased . On [DATE], CNA A transferred Resident #6 with a Hoyer lift (mechanical lift) by him/herself resulting in the resident sustaining an abrasion to the resident's foot. […]

• Immediate jeopardy, isolatedF689Jun 17, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident environment was free from accident hazards, when one resident (Resident #2) was not secured appropriately with a lap belt in the facility van during transport on 5/20/24. The van abruptly stopped and the resident flew out the wheelchair onto the floor of the van and suffered a femoral fracture of the right leg that required surgical repair. There were 14 residents selected for sample. The facility census was 260. The Administrator was notified on 6/17/27 at 5:30 P.M. of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 5/20/24. Prior to any further facility transports, immediate in-servicing was completed for proper placement in the van and safety belt use with each transport. […]

• Immediate jeopardy, isolatedF600Dec 14, 2021

  Based on interview, and record review, the facility failed to follow its policies and procedures to ensure residents were free from sexual abuse. The facility failed to assess residents to determine risks, including capacity to consent to sexual contact. The failure impacted one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia. Twice the resident was found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205), who was also unclothed, and once was found on top of Resident #126. The failure also impacted one unknown resident, when Resident #290, a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Mar 25, 2026

  Based on observation, interview and record review, the facility failed to keep one sampled resident (Resident #17) out of 23 sampled residents safe from physical abuse. On 3/5/26 Resident #18 struck Resident #17 multiple times in the face, resulting in bruising and cut above Resident #17's left eye. The facility census was 251 residents.The Administrator was notified on 3/19/26 of Past Non-Compliance which occurred on 3/5/26. An all-staff in-service on Abuse and Neglect was completed by 3/6/26. The deficiency was corrected by 3/6/26. Review of the facility's Abuse Prevention and Prohibition Program revised 10/24/22 showed each resident had the right to remain free from abuse and neglect, including abuse from other residents. 1. […]

• Actual harm, isolatedF600May 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure Resident #72 and #238 were free from abuse when the residents got into a resident to resident altercation. Staff failed to separate the residents in accordance with their policy after the altercation and the residents remained roommates for 48 hours. Both residents reported being scared of the other resident. Staff failed to ensure Resident #240 was free from abuse when the resident entered Resident #215's room leading to an altercation. Resident #240 had significant facial bruising and family reported the resident to be sad and would not come out of his/her room after an altercation with Resident #215. […]