Rossmoor Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF908Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to maintain essential mechanical equipment in safe operating condition when The facility did not ensure four of four facility ice machines were cleaned, sanitized, and maintained according to manufacturer instructions. This deficient practice could expose residents to contaminated ice and increase their risk of infection, illness, hospitalization, or other adverse health outcomes for 151 of 151 residents who were residing in the facility and potentially use ice form ice machines. During a concurrent observation and interview on 7/7/26 at 10:20 a.m., with the Facilities Director (FD), FD stated he cleaned each facility ice machine every four months. […]

• No harm, potential for more than minimal, widespreadF801May 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure adequate kitchen oversight when:1. The facility did not have any Dietary Manager or equivalent, and the Registered Dietitian did not provide full time oversight of the kitchen for two weeks; and2. The facility did not have a qualified Dietary Manager, and the Registered Dietitian did not provide full time oversight of the kitchen for one week.This failure to provide adequate oversight of the kitchen resulted in staff not adhering to safe hand hygiene practices (see F tag 880) and placed all residents who received meals from the kitchen at risk of food borne illness.1. During an interview on 8/27/25, at 1:50 p.m. […]

• No harm, potential for more than minimal, patternF695Jul 9, 2026

  Based on observation, interview and record review, the facility failed to ensure respiratory therapy equipment was changed weekly for two of five sampled residents (Residents 70 and 161) who received oxygen therapy.This failure had the potential to contribute to the increased risk of infection and dry nasal passages, which could cause extreme discomfort for Resident 70 and 161. 1. During the initial tour on July 6, 2026, at 10:17 a.m., Resident 70 was receiving oxygen from an oxygen concentrator ((an oxygen concentrator is a medical device that pulls in the surrounding room air and delivers concentrated, pure oxygen) at 2 liters per minute (LPM-measures the flow rate or volume of supplemental oxygen delivered to a patient per minute ) via nasal cannula (a lightweight, flexible plastic… […]

• No harm, potential for more than minimal, patternF755May 11, 2026

  Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-7, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. […]

• No harm, potential for more than minimal, patternF880May 11, 2026

  Based on observation, interview and record review, the facility failed to ensure staff followed infection control practice when:1. [NAME] 1 did not adhere to hand hygiene practice while checking temperatures of ready to eat foods,2. non-kitchen staff entered the kitchen without performing hand hygiene to get fruit, and3. [NAME] 1 contaminated the dinner tray line with raw fish.This failure placed residents in the Medbridge unit at risk of foodborne illness which had the potential for death.1. During an observation on 8/27/25 at 4:21 p.m., [NAME] 1 was at the tray line wearing gloves while using the temperature probe to measure food temperatures. […]