The Rosewood Health Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Feb 10, 2023

  Based on record review and staff interviews the facility failed to develop a documented water management plan that included an assessment to identify were Legionella and other waterborne pathogens could grow and spread and what control measures were in place. This had the potential to affect all residents in the facility. Findings included: A review of the infection prevention and control program policy dated October 2018 revealed no documented water management plan. During an interview with the Maintenance Director on 2/10/23 at 11:44 am it was revealed the facility did not have a plan in place to assess and or monitor for Legionella and other opportunistic waterborne pathogens. […]

• No harm, potential for more than minimal, patternF760Jun 6, 2025

  Based on record review, and staff and physician interviews, the facility failed to administer medications as prescribed by the physician for resulting in significant medication error for 1 of 5 residents reviewed for unnecessary medications (Resident #25). The findings included: 1. Resident #25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included hypertension (HTN), history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, paroxysmal atrial fibrillation and nonrheumatic aortic (valve) stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and peripheral vascular disease. […]

• No harm, potential for more than minimal, isolatedF550Jul 16, 2026

  Based on observations, record review, and staff interviews, the facility failed to provide a dignified dining experience when 1.) Nurse #3 stood up while providing assistance with eating to a resident (Resident #27), and 2.) staff did not ensure all residents seated at that table were served their meals at the same time when Resident #25 was served her meal more than 10 minutes after the remaining residents seated at the same table for 2 of 3 residents reviewed for dignity. A reasonable person expects to be treated with dignity while dining. Findings included:1. […]

• No harm, potential for more than minimal, isolatedF583Jul 16, 2026

  Based on record review, observation, and staff interviews, the facility failed to protect Residents private healthcare information (PHI) by leaving confidential medical information unattended, visible, and accessible to others on top of medication carts for 2 of 3 medication carts observed (100 hall medication cart and 400 hall medication cart).The findings included: a. On 07/16/2026 a continuous observation occurred from 8:12 AM to 8:25 AM of the medication cart on the 100-hall. […]

• No harm, potential for more than minimal, isolatedF761Jul 16, 2026

  Based on record review, observation and staff interviews, the facility failed to secure medications and lock the medication cart for 1 of 3 medication carts observed for medication administration (100 Hall medication cart).The findings included:On 07/16/2026 at 8:25 AM, Nurse #1 placed the medication cart against the wall to the side of a resident's doorway. Nurse #1 then prepared medications to be administered to a resident. Nurse #1 removed 8 medication blister packets from the medication cart drawer, placed them on the top of the medication cart, and dispensed the medications into a medication cup for the resident. […]