Rosewood Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF561Dec 19, 2022

  Based on clinical record review, interview, and document review, the facility failed to ensure a resident did not have a Do Not Resuscitate (DNR) physician order without evidence the resident made the self-determination to be a DNR through an in-person assessment at the facility by the physician, the facility's physician determined the resident was cognitively able to make the self-determination for code status, and a resident signed a Physician Order for Life Sustaining Treatment (POLST) as evidence of their code status self-determination prior to the facility physician signing the POLST and determining a resident would be a DNR (Resident #4). […]

• No harm, potential for more than minimal, widespreadF761Dec 11, 2025

  Based on observation, interview, and document review, the facility failed to1) ensure medications were not stored in a resident room for one unsampled resident (Resident #91), 2) monitor and record medication refrigerator temperatures in 1 of 2 medication storage rooms, 3) remove expired medications from 1 of 2 medication rooms, 4) label and properly store an unused insulin pen, 5) store insulin pens in separate sections or individual containers for each resident in 2 of 2 inspected medication carts, 6) ensure a glucometer was not stored in the same section of the medication cart as used insulin pens, and 7) store a used insulin pen appropriately, as it was placed on top of lancets. […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2025

  Based on observation, interview, clinical record review and document review the facility failed to ensure 1) residents on Enhanced Barrier Precautions (EBP) had bins placed inside the resident's room, near the door, for the disposal of used personal protective equipment (PPE), and staff received the training and education necessary to properly dispose of PPE after use, 2) Enhanced Barrier Precautions were implemented for a resident with an indwelling medical device for one unsampled resident (Resident #118) and 3) trends in infections in the facility were investigated for potential causes contributing to the trend, and interventions to control and prevent infections were implemented based on the outcome of the investigation. […]

• No harm, potential for more than minimal, widespreadF882Dec 11, 2025

  Based on interview, clinical record review and document review, the facility failed to ensure the Infection Preventionist (IP) 1) provided education related to the Antibiotic Stewardship Program (ASP) to residents and residents' representatives/families and 2) carried out infection surveillance, investigation, prevention and control processes according to facility policies and Centers for Disease Control and Prevention (CDC) recommendations. This deficient practice had the potential to result in antibiotic-resistance and widespread transmission of infectious organisms throughout the facility.Findings include:Antibiotic Stewardship TrainingOn 12/11/2025 at 12:04 PM, the IP verbalized if an antibiotic was prescribed for a resident, the IP would visit the resident and provide education… […]

• No harm, potential for more than minimal, widespreadF812Oct 10, 2024

  Based on observation and interview, the facility failed to ensure the ice machine was free of buildup and refrigerated foods were covered, labeled and dated. The deficient practice could potentially expose residents to foodborne illnesses. Findings include: Ice Machine On 10/07/2024 at 8:18 AM, the ice machine in the kitchen had black buildup on the plastic visor above the ice. On 10/07/2024 at 8:35 AM, the Dietary Manager (DM) verbalized the ice machine was cleaned every three months. The expectation was the staff would clean any visible buildup in the machine. The DM confirmed the buildup in the ice machine and should have been cleaned. Uncovered Food On 10/09/2024 at 11:22 AM, three cups of fruit cocktail were uncovered in the trayline refrigerator. […]