Rotary Senior Living

In the surveyor’s words

From the most serious findings on record at Rotary Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF757Mar 17, 2026

  Based on observation, interviews, and document review, the facility's administrative staff failed to ensure the nursing staff adequately monitored the INR level (international normalized ratio, a test measured how quickly blood clots) for 1 of 1 resident on warfarin (Resident #2), including after Resident #2's physician prescribed medications which could increase Resident #2's INR. Resident #2's physician started Resident #2 on an antibiotic (which can increase the INR) on 1/21/26, and added another antibiotic on 1/22/26. The nursing staff discovered a large bruise on Resident #2's mons pubis (the fatty area surrounding the penis) on 1/24/26. The nursing staff did not begin increased monitoring of Resident #2's bruising or check Resident #2's INR upon discovery of the bruise. […]

• Immediate jeopardy, isolatedF678May 10, 2023

  Based on clinical record review, policy review and staff interviews, the facility failed to initiate cardiopulmonary resuscitation (CPR) as ordered by the physician after he was found expired in his room [DATE] at approximately 3:00 AM for 1 of 1 residents reviewed (Resident #1). The Licensed Practical Nurse (LPN) working during the incident stated she would have initiated CPR had she known Resident #1 was a full code. The facility also failed to communicate physician's orders accurately related to CPR and Do Not Resuscitate (DNR) orders for 3 of 6 residents sampled (Residents #9, #10 and #11). Those situations constituted Immediate Jeopardy to resident health and safety. The facility reported a census of 38 residents. […]

• Actual harm, isolatedF684Feb 19, 2025

  Based on observation, clinical record review, policy review, resident, family, and staff interviews, the facility failed to provide needed services in accordance with professional standards by not assessing, intervening and documenting for a resident with a wound for 1 of 3 resident reviewed (Resident #1). In addition, the facility failed to assess his lower legs when applying or removing his ankle, foot brace (AFO) as ordered by the physician. Resident #1 had a wound on their right shin, that went unidentified until dermatology observed while at his appointment for a different situation. The clinic took a sample of the wound while at the dermatology appointment and ordered an antibiotic along with a culture of the drainage of the wound. […]

• No harm, potential for more than minimal, widespreadF885Jan 6, 2022

  Based on staff interviews, resident records, and CDC recommendations the facility failed to notify residents and families of new positive cases of Novel Coronavirus 2019 (COVID) in the facility. Since 10/1/21 the facility reported 9 cases of COVID for staff members and one positive case for a resident (Resident #10). The facility reported a census of 29 residents. Findings include: 1. The COVID Tracker - Staff dated 1/4/22 showed the nine positive cases since 10/1/21 related to facility staff. The COVID Tracker - SNF dated 1/4/22 showed one positive case since 10/1/21. 2. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF880Aug 3, 2023

  Based on observations, record review, policy review, and staff interview the facility failed to complete proper hand hygiene during cares for two of three residents reviewed (Resident #23 and Resident #33) and failed to cover residents' personal laundry and linen during delivery rooms and halls to maintain standard precaution for infection control. The facility reported a census of 37 residents. Findingd include: 1. The Minimum Data Set (MDS) assessment for Resident #28 dated 5/11/2023, included diagnoses of Non-Traumatic Brain Dysfunction, Non-Alzheimer's Dementia, Anxiety Disorder, and depression. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, personal hygiene and was always incontinent of bladder and bowel. […]