Rosewood Nursing Center

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents were free from hazards for 1 (Resident #1) out of 8 sampled residents. This deficient practice resulted in actual harm on 03/12/2026 during the 10:00 a.m. group activity when Resident #1 spilled hot coffee on her lap. The dietary staff failed to follow the facility's hot beverage policy when S8DA distributed coffee for residents at an unsafe temperature. As a result, Resident #1 sustained a 2nd degree and a 3rd degree burn to her left thigh and received treatment at the facility. The facility implemented a corrective action plan on 03/15/2026 and was in substantial compliance at the time of the state agency's investigation on 03/31/2026; thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record reviews and interviews, the facility failed to report an injury of unknown origin to the State Agency no later than 2 hours later in accordance with State law for 1 (#1) of 8 (#1 ,#2, #3, #4, #R1, #R2, #R3, #R4) sampled residents. The deficient practice had a potential to affect a total census of 66 residents.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information in a prominent place, readily accessible to residents and visitors. The information should be posted on a daily basis and include the resident census and total number of actual hours worked by RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and CNA (Certified Nurse Assistant) staff directly responsible for resident care per shift. The facility census was 63.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 3 (#11, #33, #37) out of 3 (#11, #33, #37) residents reviewed for respiratory care, with the potential to effect 7 residents receiving oxygen therapy.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean, comfortable, and homelike environment for 1 (#33) out of 35 sampled residents. The deficient practice had the potential to affect a census of 63.

Inspectors wroteBased on interview and record review, the facility failed to ensure RD (Registered Dietitian) recommendations in response to identified weight loss were relayed to the physician for review and implementation for 1 (#44) of 9 (#3, #5, #23, #33, #34, #35, #44, #46, #212) residents that receive nutrition from enteral feedings.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure that residents' enteral feeding was properly labeled for 2 (#34 and #35) out of 2 (#34 and #35) sampled residents reviewed for tube feeding. The deficient practice had the potential to affect a total of 9 residents that received tube feedings.

Inspectors wroteBased on record review and interview the facility failed to ensure that each residents' medication regimen was free from unnecessary medications by failing to monitor for side effects for antipsychotropic medications for 1 (#42) of 5 (#11, #24, #27, #42, #47) residents reviewed for unnecessary medications. The deficient practice had the potential to affect a total census of 63.

Inspectors wroteBased on observation and interview, the facility failed to ensure food products were properly refrigerated after being opened. This deficient practice has the potential to effect the 56 residents that eat meals from the from the facility's kitchen.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a mechanical lift transfer for 1 (#1) of 7 (#1, #2, #3, R1, R2, R3, and R4) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 08/08/2024 at 2:15 p.m., when S3CNA (Certified Nursing Assistant) attempted to transfer the resident from a shower bed to residents bed while utilizing the mechanical lift without assistance of another qualified staff person. Resident #1 fell from the lift sling during the transfer and landed on the floor resulting in a fractured right leg. Resident #1 was transferred to the hospital on [DATE]. X-ray report dated 08/08/2024 at 4:53 p.m. showed a suspected nondisplaced fracture of the distal fibula. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (#1) out of 2 (#1, #2) residents sampled for dialysis services as evidenced by: 1. Failing to conduct comprehensive post dialysis assessments; and 2. failing to ensure that communication received from the dialysis provider was addressed and communicated with staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week.

Inspectors wroteBased on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for smoking for 1 (#28) of 30 residents reviewed in the initial pool.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure hospice agencies communicated with facility staff, and maintained and updated the residents' medical record that reflected the services provided for 1 (#31) of 2 (#31, #51) sampled resident that were provided Hospice Services.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered for 1 (#153) out of 1 (#153) resident reviewed for respiratory care out of a total sample of 30 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services that were in order and accounted for the drug record reconciliation of all controlled drugs during shift changes for medication carts A and B. This deficient practice had the potential to affect the 52 residents residing in the facility.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that expired medication/biologicals were properly discarded and not available for use. This was evidenced by having expired Influenza vaccinations stored in a medication refrigerator.

Inspectors wroteBased on record review and interview, the facility failed to accurately maintain resident records by failing to have a written order to release body to funeral home for 1 (#51) out of 1 (#51) sampled death resident records.

Inspectors wroteBased on observations, record review and interview, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff performed hand hygiene according to accepted standards of practice during wound care for 1 (#46) out of 1 (#46) residents sampled for pressure wounds.