Rosewood Health Facility

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This failure resulted in ineffective infection surveillance (continuous method to collect, analyze, monitor and reduce infections) and antibiotic stewardship program (a program to monitor the use of antibiotics - medications used to treat infections in healthcare settings) and had the potential to increase the spread of infectious diseases to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner for two of three sampled residents (Resident 24 and Resident 29). This failure resulted in Resident 24 and Resident 29 waiting up to one hour for staff to respond to their needs.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Obtaining a Fingerstick [using a small needle (lancet) to draw a few drops of blood from the fingertip for immediate analysis] Glucose [sugar that is the body's main energy source] Level for 15 of 15 sampled residents (Resident 16, Resident 5, Resident 75, Resident 83, Resident 60, Resident 35, Resident 47, Resident 53, Resident 87, Resident 81, Resident 57, Resident 88, Resident 4, Resident 1, and Resident 73). This failure resulted in nursing staff conducting procedures on residents without a physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention practices when: Three of three clean laundry bins had dirt-like debris at the bottom. This failure had the potential for contaminating clean laundry and spread of infectious diseases to the residents. Three of three personal laundry transport carts had thick dust-like debris along the bottom frame of the cart. This failure had the potential for contaminating personal laundry and spread of infection and diseases to the residents. The facility did not follow its policy and procedure (P&P) titled, Surveillance of Infections. This failure had the potential for unidentified increase and spread of infectious diseases to the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a program to monitor the use of antibiotics - medications used to treat infections in healthcare settings) for four of five sampled residents (Resident 26, Resident 4, Resident 3, and Resident 24). This failure had the potential for residents to receive unnecessary antibiotics and to place them at risk for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three laundry dryer filters were free of thick lint build up. This failure had the potential to increase the risk of a fire affecting residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs- routine daily self-care tasks to maintain basic physical health, hygiene, and independence) was provided to one of two sampled dependent residents (Resident 53). This failure resulted in Resident 53 being embarrassed due to not receiving assistance with her toileting needs and had the potential for her current level of bowel continence to decrease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs- routine daily self-care tasks to maintain basic physical health, hygiene, and independence) was provided to one of two sampled dependent residents (Resident 53). This failure had the potential for Resident 53's current level of bowel continence to decrease.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI - a program that monitors quality of care at the facility and addresses system deficits) committee failed to monitor and evaluate infection prevention and control performance data for two of 12 months (August and September) in 2025. This failure placed facility residents at risk for infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a noncompliance care plan (CP- documents the resident's needs based on an identified problem, documents interventions necessary to be implemented by the whole healthcare team to meet the established goal) for one of three sampled residents (Resident 1) identified as a high risk for developing pressure injuries (PI-is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing an unstageable pressure injury (obscured full-thickness skin and tissue loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) met to discuss if one of three sampled residents (Resident 1) who was high risk for falls (move downward, typically rapidly and freely without control from a higher to a lower level), had a history of falls, and had a diagnosis of Dementia (a progressive state of decline in mental abilities), was safe to have one-on-one monitoring (1:1- a type of care where a healthcare professional provides constant supervision to a resident) discontinued. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure on change of condition for one of three sampled residents (Resident 1). This failure resulted in a delay in care and had the potential for negative medical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Water Management Program for 71 of 71 sampled resident's when the facility cooling tower (device that removes heat from water and used to cool a building) tested positive for Legionella (bacteria causing lung infection). This failure had the potential to spread a highly contagious, infectious bacteria to residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Catheter Care, Urinary, for one of two sampled residents (Resident 49) when timely nursing assessment and interventions were not provided when Resident 49 complained of pain. This failure resulted in Resident 49 experiencing discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Labeling and Storage for two of 32 sampled residents (Resident 219, Resident 58) and two of two medication carts when: 1. Medications were at the bedside for two of 32 sampled residents (Resident 219, Resident 58). This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. Four of 14 insulin (medication to lower sugar levels in the blood) vials were expired on two of two sampled medication carts. This failure had the potential to result in a loss of medication potency (strength), inaccurate test results, and adversely affect the residents' health.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Resident Informed Consent for the use of Psychotherapeutic [medication to treat mental disorders] Drugs, for two of six sampled residents (Resident 48 and Resident 217) when their informed consents were not complete. This failure had the potential for Resident 48 and Resident 217 to receive psychotropic medication without knowing the risks and benefits of the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered medication was available for one of six sampled residents (Resident 217). This failure resulted in Resident 217's pain not being controlled as evidenced by Resident 217's statement of pain of 6 to 7 out of 10 (on a 10 point pain scale 0 is no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 unbearable pain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Repositioning for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Psychotropic Medication Use, for one of seven sampled residents (Resident 217), when the facility did not monitor changes in behavior and side effects for physician ordered medications, Mirtazapine (to treat depression) and Temazepam (to treat inability to sleep). This failure had the potential to affect the health and safety of Resident 217.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Resident Food and Dining Preferences for two of six sampled residents (Resident 58 and Resident 48) when: 1. One of six sampled residents (Resident 58) was not offered an alternative food item. 2. One of six sampled residents (Resident 48) tie preference for dinner was not honored. These failures had the potential for Resident 48 and Resident 58's nutritional needs to be not be met and the potential for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide safe transportation for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being dropped off alone at a wrong address and had the potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was treated with dignity and respect. This failure had the potential for Resident 1 experiencing psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living [tasks people do to manage one's basic needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating]) care assistance for one of four sampled residents (Resident 2) when Resident 2's fingernails were not cleaned and trimmed. This failure had the potential to result in Resident 2 developing infection due to the spread of germs from fingernails.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) on dental services was followed for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1's weight loss due to difficulty eating.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for one of three sampled residents (Resident 1) when staff was not removed from resident care when an allegation of abuse was made. This had the potential to put the Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the privacy of two of four sampled residents (Resident 1 and Resident 2). This failure resulted in violation of Resident 1's rights to privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the attending physician (AP). This failure had the potential for Resident 1's infection to worsen and PICC (peripherally inserted central - is a long, thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line to become clogged.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate staff was available to provide medications intravenous (IV- giving medicines or fluids through a needle or tube inserted into a vein) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's infection and healing to be negatively affected.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication irregularities noted by the consultant pharmacist in the Medication Regimen Review (MRR-a comprehensive pharmacy evaluation of the residents' medications) for 11 of 29 sampled residents (Resident 6, Resident 9, Resident 10, Resident 15, Resident 16, Resident 24, Resident 39, Resident 42, Resident 46, Resident 61, and Resident 165) were reviewed and acted upon by the attending physician and the Director of Nursing (DON) promptly. This failure had the potential to place residents at risk for adverse consequences and other medication-related problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices when one of one sampled staff member (Activities Staff- AS) did not wear hair net properly upon entering kitchen. This failure had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when: 1. Occupational Therapist (OT) exited Resident 366's Room, on transmission-based precaution (a set of practices specific for patients with known or suspected infectious agents to prevent transmission), and laid down contaminated equipment, barbell and a long stick, on top of the Personal Protective Equipment (refers to gowns, gloves, masks, face shields, or goggles to protect the wearer from infection or injury) cart outside of Resident 366's room. OT held the contaminated equipment with bare hands, and walked away without performing hand hygiene. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Advance Directive (AD-written statement of persons' wishes regarding medical treatment and end-of-life) for six of 29 sampled residents (Resident 16, Resident 31, Resident 39, Resident 42, Resident 9, and Resident 49). This failure had the potential to result in procedures and treatment to be implemented against residents' rights and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on Departmental Policy (Respiratory Therapy) -Prevention of Infection when the water of the humidifier bottles were not monitored for three of three sampled residents (Resident 40, Resident 49, and Resident 165). This failure had the potential for the residents to experience nasal, throat, and mouth dryness while inhaling dry oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when: 1. Diltiazem CD (medication to treat blood pressure and chest pain) 120 mg (milligram, a unit of measurement) PO (oral), Furosemide (water pill) 80 mg, Glimepride (medication to lower blood sugar) 4 mg were omitted for one of six sampled residents (Resident 35). 2. Licensed Vocational Nurse (LVN) 2 did not follow the manufacturer's direction to administer Linzess (medication to treat abdominal pain, bloating, and helps with bowel movement) 290 mcg (microgram, a unit of measurement) for one of six sampled residents (Resident 5). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 8) was assessed and determined appropriate to self-administer medication. This failure had the potential to result in undetected adverse effect from the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess the need for denture care for one of 29 sampled residents (Resident 19). This failure resulted in Resident 19 having loose dentures and being unable to chew properly, and the potential for Resident 19 to experience difficulties in maintaining nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Social Services performed annual and quarterly resident assessments for three of 29 sampled residents (Resident 39, Resident 42, and Resident 54). This failure had the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 29 sampled residents (Resident 19). This failure resulted in Resident 19 having unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) on Repositioning when one of two sampled resident (Resident 316) was not turned every two hours. This failure had the potential to worsen Resident 316's deep tissue injury (DTI- injury to underlying tissue) on left ankle and contribute to the worsening of her right buttocks pressure injury (area of tissue damage that develops from prolonged pressure to skin) to stage II (two - skin breaks open and extends into deeper layers).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven staff members (Certified Nursing Assistant (CNA) 3 and Housekeeper 1) were trained in fall prevention measures. This failure had the potential to increase the frequency of resident falls and resident injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure poured medications temporarily held were appropriately labeled and secured for three of six sampled residents (Resident 27, Resident 368 and Resident 5) in the medication cart. This failure had the potential for adverse consequences in the health condition of the residents. 2. Ensure medications were available for one of six sampled residents' (Resident 35) use. This failure had the potential for Resident 35 to miss her medications and not receive its therapeutic benefits. 3. Ensure Licensed Vocational Nurse (LVN) 2 signed/initialed the Medication Administration Record (MAR) after giving the medications for two of six sampled residents (Resident 35 and Resident 6). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental service for one of 29 sampled residents (Resident 19) promptly. This failure had the potential for the delay of dental care and provision of services.