Rosewood Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725Nov 24, 2021

  Based on observation, record review and interview during an abbreviated survey (Case #NY 730) conducted on 11/20/21, the facility failed to provide adequate staffing to meet the needs of the residents on 2 of 2 units. Specifically, on 11/20/2021, the facility failed to provide nursing staff to pass resident medications and attend to residents' medical needs from 7:58 AM until 10:30 AM, after the night shift nurses left the facility, leaving the facility with no licensed nursing staff. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 75 residents in the facility. The Immediate Jeopardy was lifted on 11/23/2021. […]

• Immediate jeopardy, patternF578Feb 25, 2026

  Based on record review and interviews during a survey, the facility failed to ensure residents were afforded the right to formulate advanced directives including having a physician's order related to their code status (the level of medical interventions a person wishes to have started if their breathing stopped such as cardiopulmonary resuscitation or do not resuscitate), and establishing mechanisms for documentation and communicating the residents' choices to the staff responsible for their care, which had the likelihood to result in serious harm or death for nine (9) (Residents #6, 7, 8, 9, 10, 11, 12, 13, and 14) of 53 residents reviewed for advanced directives. […]

• Immediate jeopardy, isolatedF689Feb 25, 2026

  Based on observation, record review, and interviews during a survey ), the facility failed to ensure the resident environment remained as free of accident hazards as is possible for two (2) (Resident #s 2 and 3) of three (3) residents reviewed. Specifically, on 01/29/2026 at 12:13 PM, Resident #2, who had severe cognitive impairment, had three (3) prescription medications (Sertraline HCl 50 milligram (antidepressant), Eliquis five (5) milligram (blood thinner), and Levetiracetam 500 milligram (antiseizure) in prescription medication bottles inside a plastic bag on their nightstand. Additionally, on 01/29/2026 at 12:01 PM, the front cover of Resident #3's electric baseboard heater in their bathroom was removed and laying on the floor in front of the running heater. […]

• Actual harm, isolatedF684Feb 25, 2026

  Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for five (5) (Resident #'s 1, 23, 24, 85, and 87) of 22 residents reviewed. Specifically,(a.) Resident #1 was hospitalized three (3) times between 11/11/2025 and 02/17/2026 related to bowel constipation. Provider instructions for bowel regimen and assessment were not followed by the facility. As a result, Resident #1 required fecal disimpaction under general anesthesia.(b.) Resident #85 had symptoms of urinary tract infection identified on 09/19/2025. The provider ordered a urinalysis (urine test) six (6) days later on 09/25/2025. […]

• No harm, potential for more than minimal, widespreadF550Feb 25, 2026

  Based on observation, record reviews and interviews conducted during a surveys, the facility did not ensure that residents were treated with dignity respect throughout the facility for two (2) (Residents #1 and #4) of two (2) residents reviewed for dignity. Specifically, (a.) staff members used derogatory language in the resident hallways of the facility; (b.) Resident #1 was called pet names by the staff, and their personal belongings had been moved by staff without their knowledge; and (c.) Administrator #1preformed a search of Resident #4's personal belongings without their permission. […]