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.

• Actual harm, isolatedF600Feb 15, 2023

  Based on clinical record review and facility policy review, it was determined that the facility failed to prevent resident to resident physical abuse by one resident (Resident 42) to ensure that each resident was free from abuse, resulting in harm (pelvic fractures) for one of 29 sampled residents (Resident 98). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Abuse Policy - Prevention and Management, last revised September 8, 2022, revealed the facility prohibited the abuse of residents, must provide a safe environment, and must protect residents from abuse. Resident to resident abuse was defined as the individual's action was deliberate and willful. […]

• No harm, potential for more than minimal, widespreadF812Mar 4, 2022

  Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on two of four nursing units. (Units 2A and 3B) Findings include: Observations during the initial tour of the kitchen on March 1, 2022, at 9:45 a.m., revealed a large undated container of flour with a scoop stored directly inside the container touching the flour. In the cook's refrigerator there was a container of soup with a use by date of February 26, 2022, and lunch meat with a use by date of February 28, 2022. Observation during the tour of the 2A nursing unit on March 4, 2022, at 9:50 a.m., revealed a dried yellow substance in the left crisper tray and a dried brown substance on the bottom of the refrigerator. […]

• No harm, potential for more than minimal, patternF850Jan 23, 2026

  Based on resident and staff interviews and review of facility documentation, it was determined that the facility failed to employ a full-time social worker. Findings include: During an interview on January 20, 2026, at 1:13 p.m., Resident 1 stated that the facility has not had a full-time social worker since the end of last year. During the group interview with residents on January 21, 2026, at 10:30 a.m., Resident 32 also stated that there hasn't been a full-time social worker since December 2025. At that time, Resident 113 stated that she needed social services related to a legal matter. Review of the facility employee files revealed that one of the facility's two social workers (SW 2) left the faciity on December 23, 2025, and the other (SW 3) left on December 31, 2025. […]

• No harm, potential for more than minimal, patternF550Feb 15, 2023

  Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that residents were assisted with toileting in accordance with individual need and preference on three of four nursing units. (2, 3A, 3B) Findings include: Clinical record review revealed that Resident 93 had diagnoses that included Alzheimer's dementia, anxiety, chronic kidney disease, and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the resident was frequently incontinent and required extensive assistance from two staff members for toileting. Review of the care plan revealed the resident had a self-care deficit, was incontinent and was to be provided incontinence care every two hours and as needed. […]

• No harm, potential for more than minimal, patternF688Feb 15, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent a further decrease in range of motion and/or to improve or maintain mobility for three of eight sampled residents with limited range of motion. (Residents 73, 98, 103) Findings include: Clinical record review revealed that Resident 73 had diagnoses that included moderate intellectual disabilities, difficulty in walking, and osteoarthritis of both knees. The Minimum Data Set (MDS) assessment (a periodic assessment of resident needs), dated November 21, 2022, indicated that the resident had limited range of motion in both legs and required staff assistance for dressing and transferring between surfaces. […]