Rosewood Heights

Inspectors wroteBased on observation, interview and record review the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries for 1 (Resident #1) of 5 residents reviewed for pressure injuries. The facility failed to prevent Resident #1 from receiving a shear to her right buttock, which ultimately became a stage 4 pressure ulcer that developed into sepsis (life-threatening condition caused by the body's extreme and dysregulated response to an infection, leading to organ dysfunction and potentially death) due to wound infection, infection due to polymicrobial wound flora, and osteomyelitis (infection that happens when bacteria or fungi infect the bone marrow) of sacrococcygeal wound. This failure placed residents at risk of developing pressure injuries, wound infections, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update periodically and follow menus in accordance with professional standards for 3 of 3 meals served. 1. The facility failed to update the facility menu since Fall/Winter 2024.2. The facility failed to follow the menu for week 5 of the Fall/Winter 2024. These failures could place residents at risk for weight loss, decreased nutritional intake, loss of desire, interest, and satisfaction in meals. Record Review on 8/12/2025 at 10:30 AM of Fall/Winter 2024 menus provided by facility revealed the following: Week 5, Day 31, Tuesday, lunch: Beef stew, mashed potatoes, mixed green salad, wheat bread, and baked apple slices. Week 5, Day 32, Wednesday, lunch: Lemon Pepper Chicken, lima beans, brussels sprouts, wheat bread, and chocolate tart. Week 5, Day 33, Thursday, lunch: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure that expired foods were discarded.2. The facility failed to ensure food items were labeled and dated.3. The facility failed to ensure that serving utensils and dishes were not stored in a clean area. These failures could place residents at risk for foodborne illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for one (Resident #1) of five residents reviewed for baseline care plans. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and supervision. The facility failed to ensure staff implemented Resident #1's hospital discharge order upon admission to be placed on fall precautions. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. The facility failed to ensure effective use of the [NAME] system as a reference tool by failing to ensure adequate staff knowledge in the updating and referencing of the [NAME]. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, which are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for documentation. 1-Resident #1's September 2024 MAR was documented inaccurately. Staff documented the resident received 2 enteral feedings at the same time. 2- Resident #1's weight record documentation was incomplete. Staff failed to document an admission weight, failed to document a weight on Wednesday as ordered by the physician, and failed to ensure documented weights were accurate. The RD assessment was incomplete with no weight documented. 3-Resident #1's September 2024 TAR documentation was incomplete. Staff did not document or sign off on the cleaning the j-tube, monitoring surgical site for infection, and cleaning skin tear to right arm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of five residents (Resident #1) reviewed for medications. The facility failed to remove Resident #1 discontinued order Of Labetalol HCL 300 MG from the med cart. This failure could place residents at risk for irregular heartbeat, low blood pressure, rapid or slow heartbeat, and lightheadedness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of five residents (Resident #1) reviewed for medications. The facility failed to remove Resident #1 discontinued order Of Labetalol HCL 300 MG from the med cart. This failure resulted in Med Tech A preparing to give and having to be stopped by LVN B from administering an additional 600 mg of Labetalol on 09/04/2024 that had been discontinued on 08/30/2024. This failure could place residents at risk for irregular heartbeat, low blood pressure, rapid or slow heartbeat, and lightheadedness.

Inspectors wroteBased on interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for treatment of pressure ulcers. The facility failed to recognize and provide treatment, and prevention measure for an open skin area on Resident #1. The area was first noted on 6/25/24 with admission, the first documentation of care being provided to the area was on 7/7/24. On 7/10/24 Resident #1 was diagnosed with a stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). The noncompliance was identified as PNC. The IJ began on 06/25/24 and ended on 07/26/24. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #17) of 4 residents reviewed for care plans The facility failed to update the comprehensive person-centered care plan for Resident #17's transfer status for use of the Mechanical lift. This failure could place residents of risk for not receiving appropriate care and treatment, falls, and injury related to improper transfer.

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 resident (Resident #1) of 8 residents reviewed for care plan accuracy. The facility failed to ensure Resident #1's care plan was updated to reflect a diabetic foot ulcer and treatment. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management is provided to resident who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #24) reviewed for pain management. The facility failed to administer pain medication to Resident #24 on 06/02/23, resulting in prolonged pain for the resident. This failure could result in worsening of pain and injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 4 of 4 residents (Resident #10, Resident #20, Resident #200, and Resident #202) reviewed for respiratory care. The facility failed to ensure Resident #202's 02 tubing and humidifier were dated. The facility failed to ensure Resident #10's, Resident 20's, and Resident #200's 02 tubing and humidifier were changed every 7 days on a Sunday. These failures could place all residents who use respiratory equipment at risk for respiratory infections.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents reviewed for Pain Management. (Resident #24) The facility failed to provide Resident #24 pain medication Hydrocodone-Acetaminophen Tablet 5-325 MG and Gabapentin Oral Capsule 300 MG as ordered. This failure placed the resident at risk of increased pain, poor sleep patterns, increased anxiety and depression, and decreased sense of wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents reviewed for the usage of Blood Pressure Monitors (Resident #45, Resident #202). The facility failed to ensure LVN A disinfected the blood pressure monitor between Resident#45 and Resident #202. This failure could place the residents at risk for cross contamination and infection.