Rosewood Rehabilitation Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to1) ensure medications were not stored in a resident room for one unsampled resident (Resident #91), 2) monitor and record medication refrigerator temperatures in 1 of 2 medication storage rooms, 3) remove expired medications from 1 of 2 medication rooms, 4) label and properly store an unused insulin pen, 5) store insulin pens in separate sections or individual containers for each resident in 2 of 2 inspected medication carts, 6) ensure a glucometer was not stored in the same section of the medication cart as used insulin pens, and 7) store a used insulin pen appropriately, as it was placed on top of lancets. This deficient practice had the potential to result in medication errors, compromised infection control, and increased risk of harm to residents due to improper medication handling and storage.

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure 1) residents on Enhanced Barrier Precautions (EBP) had bins placed inside the resident's room, near the door, for the disposal of used personal protective equipment (PPE), and staff received the training and education necessary to properly dispose of PPE after use, 2) Enhanced Barrier Precautions were implemented for a resident with an indwelling medical device for one unsampled resident (Resident #118) and 3) trends in infections in the facility were investigated for potential causes contributing to the trend, and interventions to control and prevent infections were implemented based on the outcome of the investigation. [...]

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure the Infection Preventionist (IP) 1) provided education related to the Antibiotic Stewardship Program (ASP) to residents and residents' representatives/families and 2) carried out infection surveillance, investigation, prevention and control processes according to facility policies and Centers for Disease Control and Prevention (CDC) recommendations. This deficient practice had the potential to result in antibiotic-resistance and widespread transmission of infectious organisms throughout the facility.

Inspectors wroteBased on observations, clinical record review, interview, and document review, the facility failed to ensure call light devices were kept within reach for 2 of 18 sampled residents (Resident #6 and #12). As a result, the residents were unable to request help with basic needs such as assistance with repositioning, discomfort, and thirst. This deficient practice had the potential to result in emotional distress related to the residents' loss of autonomy and had the potential to result in physical harm including dehydration, skin breakdown, pain, and discomfort.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident receiving an anticoagulant (blood thinning medication) with a history of epileptic seizures was assessed per facility policy after the resident reported vision changes and pain following a witnessed head injury for 1 of 10 resident's sampled for facility reported incident and complaint investigations. (Resident #28). This deficient practice had the potential for a resident to suffer an adverse outcome of intracranial bleeding or delayed seizure activity due to not receiving timely treatment because of the facility's failure to perform neurological checks or assess vital signs. Resident #28 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and unspecified atrial fibrillation. [...]

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to develop a baseline care plan to address care and interventions for dialysis treatments for 1 of 18 sampled residents (Resident #116). This deficient practice had the potential to deprive a resident of necessary care and services related to dialysis and placed the resident at risk for not receiving appropriate treatment.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1) a resident with a care plan addressing the resident's preferences for female caregivers to mitigate potential triggers for re-traumatization was implemented for 1 of 10 residents sampled for facility reported incident and complaint investigations (Resident #11). This deficient practice had the potential to result in a resident experiencing re-traumatization causing psychosocial harm, 2) 1 of 18 sampled residents (Resident #12) had a care plan related to the positioning and monitoring of a call light device for use by individuals with limited mobility. [...]

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure Licensed Practical Nurses (LPNs) who performed Peripherally Inserted Central Catheter (PICC) line dressing changes for 1 of 18 sampled residents (Resident #96), received training and were deemed competent to perform the dressing change. This deficient practice had the potential to result in insertion site and blood stream infections for residents due to inaccurate technique when performing a sterile procedure.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line dressing changes were performed according to physician orders for 1 of 18 sampled residents (Resident #96). This deficient practice had the potential to result in insertion site and bloodstream infections for residents.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) monitor a resident for significant weight loss and initiate timely interventions in accordance with facility policy and professional standards of practice for 1 of 18 sampled residents (Resident #16) and 2) ensure that 1 of 18 sampled residents (Resident #15) was weighed upon admission and weekly for four weeks, the Interdisciplinary Team (IDT) evaluated the resident following decreased oral intake to determine the cause and necessary interventions, and the physician was notified of the change in the resident's nutritional status. This deficient practice placed the residents at risk for compromised nutritional status and significant changes in weight without adequate oversight, monitoring, and intervention by facility staff.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enteral nutrition was labeled according to professional standards and facility policy for 1 of 18 sampled residents (Resident #12). This deficient practice had the potential to compromise patient safety by increasing the risk of contamination and infections, and improper hydration management, potentially leading to adverse health outcomes.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the oxygen was administered and saturation levels were monitored according to a physician order for 1 of 18 sampled residents (Resident #8). This deficient practice had the potential to cause exacerbation of the resident's underlying health conditions.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to maintain completed dialysis communication forms for 1 of 18 sampled residents (Resident #116). This deficient practice had the potential to result in a lack of critical information shared between the facility and the dialysis provider with the potential to have lead to delays and errors in care, adversely having affected resident health and safety.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a resident with a documented history of trauma received trauma informed care based on the triggering factors identified in the trauma assessment for 1 of 10 residents sampled for facility reported incident and complaint investigations (Resident #11). This deficient practice had the potential to result in a resident experiencing re-traumatization and experiencing an intense reaction causing psychosocial harm.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure staff received training and were deemed competent by the facility to provide care to Peripherally Inserted Central Catheters (PICCs) prior to being assigned to care for 1 of 18 sampled residents (Resident #96). This deficient practice had the potential to result in insertion site and blood stream infections for residents due to lack of knowledge of correct technique for dressing changes and signs and symptoms of potential complications.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a medication ordered for the relief of shortness of breath and pain was available for a resident receiving hospice services for 1 of 10 residents sampled for facility reported incident and complaint investigations (Resident #86), This deficient practice had the potential to result in a resident not receiving timely relief from pain or shortness of breath and experiencing unnecessary and prolonged suffering at the end of life, and 2) maintain accurate controlled substance logs for four unsampled residents (Resident #81, # 1, #7, and #63) in 2 of 2 reviewed narcotic logs. This deficient practice had the potential to result in medication errors, inaccurate documentation of controlled substances, and increased risk of harm to residents due to improper handling of medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility by not honoring diets, preferences, and not notifying residents of a menu change.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an opened bottle of hand sanitizer was removed from a resident food storage area. This deficient practice had the potential to affect all residents in the facility by increasing the risk of food contamination and illness.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure resident information was not visible on an unattended computer screen at a nursing station facing a public area. This deficient practice had the potential to result in unauthorized access to residents' Protected Health Information (PHI).

Inspectors wroteBased on interview and document review, the facility failed to ensure education regarding the facility's Antibiotic Stewardship Program (ASP) was provided to residents and residents' representatives/families. This deficient practice had the potential to affect all residents in the facility and placed residents at risk of developing antibiotic-resistance.

Inspectors wroteBased on employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 1 of 20 sampled employees (Employee #11). The deficient practice had the potential to place residents at risk for abuse and neglect. Findings Include: Employee #11 Employee #11 had a title of Licensed Practical Nurse (LPN) and a hire date of 04/01/2025. Employee #11's record lacked documented evidence abuse training had been completed. On 12/10/2025 at 12:37 PM, the Human Resources Payroll Representative confirmed Employee #11 had worked 29 shifts as a contract LPN and had not completed abuse training, as required. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure current nursing hours were posted for the facility. This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing staff on duty.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment included staffing requirements based on the average census of the facility. The deficient practice could result in the facility not being able to determine what resources were necessary to care for its residents competently.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure an allegation of neglect was thoroughly investigated for 1 of 10 sampled residents (Resident #2). This deficient practice had the potential for physical and/or emotional harm to residents due to allegations of neglect not being thoroughly investigated and protections not put in place to prevent future neglect.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure tube feeding was administered to a resident per physician order and a physician's order for tube feeding was complete prior to administration for 1 of 10 sampled residents (Resident #8). This deficient practice had the potential to result in malnutrition, dehydration, inadequate and inappropriate caloric intake.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure a clinical record was complete for 1 of 10 sampled residents (Resident #1). This deficient practice had the potential for care provided to residents, resident response to care provided, and refusals of care to not be documented and available for review as necessary.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure residents were informed both orally and in writing prior to or upon admission of the rules related to leaving on pass. This deficient practice had the potential to affect the entire facility population of 87 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine was free of buildup and refrigerated foods were covered, labeled and dated. The deficient practice could potentially expose residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was informed in advance of the menu options and alternative meal choices for 1 of 18 sampled residents (Resident #44). This deficient practice had the potential to result in a resident experiencing frustration due to a lack of choice and the resident having to wait longer to eat due to not wanting the offered meal and needing to request an alternative after the meal had been delivered.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to report resident to resident abuse to the State Agency (SA) within the required timeframes for 1 of 18 sampled residents (Resident #23).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was developed to address side effects and necessary monitoring for a resident receiving an anticoagulant and experiencing symptoms of a gastrointestinal bleed and low hemoglobin (a protein carrying oxygen in red blood cells) and hematocrit (a measurement of the proportion of red blood cells in the blood) levels for 1 of 18 sampled residents (Resident #71); and failed to develop a care plan for a resident's diagnosis of hypoxemia and the administration of oxygen for 1 of 18 sampled residents (Resident #134). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for further signs of active bleeding.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure laboratory (lab) results were monitored for timely completion and staff caring for a resident were informed of the resident's signs and symptoms of active bleeding while on anticoagulant therapy for 1 of 18 sampled residents (Resident #71). This deficient practice had the potential to result in a resident suffering a severe adverse health outcome because of blood loss.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to provide care to prevent Moisture Associated Skin Damage and a pressure injury for 1 of 4 closed records reviewed (Resident #184). This deficient practice led to a skin injury.

Inspectors wroteBased on clinical record review, observation, interview, and document review, the facility failed to ensure a known tripping hazard was corrected to prevent potential falls by residents and visitors using the outside courtyard.

Inspectors wroteBased on clinical record review, observation, interview, and document review, the facility failed to obtain a physician's order for the administration of oxygen for 1 of 18 sampled residents (Resident #134).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure medications were not left unsecured in a medication cart. The deficient practice could have facilitated unauthorized access to medications in the cart.

Inspectors wroteBased on clinical record review, observation and interview, the facility failed to ensure a resident's diet order was followed for 1 of 18 sampled residents (Resident #134).

Inspectors wroteBased on interview and document review, the facility failed to ensure water samples were collected and submitted for Legionella testing on a five-year basis as per the facilities water management policy. This deficient practice had the potential to result in resident illnesses from undetected bacteria in the facility water lines.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure annual elder abuse training was completed for 1 of 25 sampled employees (Employee #9).

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure a Care Plan related to an indwelling catheter and catheter care was developed and implemented for 1 of 19 sampled residents (Resident #1).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a high temp dishwasher was operating appropriately, and expired food items were discarded. This had the potential to affect the entire facility census.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1) 2 of 5 sampled residents (Resident #308 and #55) were administered a pneumonia vaccine after the vaccine was requested by the residents, 2) 25 of 82 residents residing in the facility were screened for eligibility to receive a pneumococcal vaccination, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined, and 3) 12 of 82 residents requesting to receive an influenza vaccine were administered the vaccine. The failure resulted in 45.11 percent (%) of the facility's residents either not being screened and offered the vaccine or not receiving the vaccine after eligibility was determined and the vaccine was requested. [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the privacy of resident health information was maintained for 3 of 3 residents whose names were visible under the wounds tab of the electronic health record (EHR) on an unstaffed and open computer screen (Residents #300, #309, and #311).

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to prevent resident to resident abuse for 2 of 6 Facility Report Incident (FRI) residents (Resident #45 and #79) and failed to prevent resident neglect for 1 of 6 FRI residents (Resident #47).

Inspectors wroteBased on document review and interview, the facility failed to submit a Facility Reported Incident (FRI) final report to the State Survey Agency (State) within the five-day requirement for 1 of 7 FRIs investigated.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 5 of 5 sampled residents reviewed for Resident Assessment (Resident #8, #9, #11, #41, and #46).

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure 1) care planned interventions related to cognitive functioning were completed and person centered, and care planned interventions related to communication were implemented for 1 of 18 sampled residents (Resident #26), 2) care planned interventions regarding psychotropic medications were medication specific and included the behaviors to be monitored for 1 of 18 sampled residents (Resident #40), 3) a care plan related to the use of bedrails was developed for 1 of 18 sampled residents (Resident #31), and 4) care plans were developed following resident abuse and neglect for 2 of 18 sampled residents (Resident #47 and #45).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure professional standards of practice were followed during medication preparation and administration for 2 of 3 residents observed during medication administration (Residents #56 and #7) and the practitioner adhered to professional standards of quality for assessing and diagnosing a resident with schizoaffective disorder for 1 of 18 sampled residents (Resident #40).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to offer a non-English speaking resident a communication device and/or provide translation services for 1 of 18 sampled residents (Resident #26).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure resident care was coordinated with a hospice agency for a resident receiving hospice services for 1 of 18 sampled residents (Resident #34).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's pain level and location was assessed prior to the administration of an as needed (prn) narcotic pain medication for 1 of 3 residents observed for medication administration (Resident #56).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure residents with bedrails had appropriate alternatives attempted and implemented prior to usage for 1 of 18 sampled residents (Resident #31).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident on a psychotropic medication had an assessment addressing why the medication was prescribed for 1 of 18 sampled residents (Resident #40).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate of less than 5 percent (%). There were 33 opportunities and 11 medication errors. The medication error rate was 33.33%.

Inspectors wroteBased on observation, document review, and interview, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify influenza vaccines were not administered in a timely manner after receiving the influenza vaccine supplies. The facility's failure to identify areas in need of performance improvement related to resident vaccinations resulted in 45.11 percent (%) of the facility's residents not being vaccinated for influenza with the potential to affect the health and safety of the residents during the influenza season.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure appropriate infection control practices were adhered to when preparing an insulin pen for insulin administration for 1 of 3 residents observed for medication administration (Resident #7).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure a COVID-19 (COVID) vaccine was administered as requested for 1 of 5 residents sampled for vaccination administration (Resident #308).

Inspectors wroteBased on personnel record review, interview, and document review, the facility failed to ensure elder abuse training was completed timely for 7 of 20 sampled employees (Employee #4, #12, #20, #21, #22, #23, and #24).