Rosewood Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Swedish meatballs, parsley noodles, roasted broccoli, wheat roll, and chilled fruit cup.Observation on 8/12/2025 at approximately 12:45 PM of test tray reflected a bowl of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Observation on 8/12/2025 at 8:30 AM of the walk-in refrigerator reflected the following:- Lemons in a black container with no date had mold on them.- Raspberries dated 8/4/2025 on the box in their original container were molded.- Bell Peppers in a black container with no date had mold on them.- Grapes in a box dated 7/11 were in their original bag and had mold on them.- Half a squash wrapped in plastic was undated.Observation on 8/12/2025 at 8:30 AM of the pantry reflected the following:- hot dog buns had an expiration date of 5/11/2025.- Tortillas had expiration date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures could result in inaccurate records, errors in care, decline in health and quality of life. Findings included: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included diabetes (pancreas not producing enough insulin) and Essential Primary Hypertension (high blood pressure). Record review of Resident #1's care plan initiated 08/21/2024 and revised 09/06/2024 reflected Resident #1 had diabetes and was at risk for complications associated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included diabetes (pancreas not producing enough insulin) and Essential Primary Hypertension (high blood pressure). Record review of Resident #1's care plan initiated 08/21/2024 and revised 09/06/2024 reflected Resident #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #17's undated face sheet reflected he was a [AGE] year-old male who was admitted on [DATE] with diagnosis of arteriosclerotic heart disease (narrowing of the arteries), unspecified abnormality of gait, weakness, depression, and hypertension (elevated blood pressure). Record review of Resident #17's admission MDS dated [DATE] reflected he had a BIMS score of 7 indicating he had severe cognitive impairment. Resident #17 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of Resident #1's undated face sheet printed 09/30/23 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes(condition in the way the body regulates and uses sugar as a fuel), chronic kidney disease stage 3(loss of function in the kidneys), osteoarthritis(wear down of protective tissue), and hyperlipidemia(excess fat in the blood). Record review of Resident #1's undated care plan reflected that Resident #1 did not have a care plan for wound care treatment. Record review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #10's 06/01/2023 face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity with other behavioral disturbance, major depressive disorder, recurrent, unspecified, acute kidney failure, unspecified, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the face sheet for Resident #24 dated 07/28/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Transient Cerebral Ischemic Attack (stroke), Hypertension (High blood pressure), Weakness, Pain in right shoulder, Need for assistance with personal care, Unspecified abnormalities of gait and mobility, Unspecified mononeuropathy (nerve damage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #202's face sheet dated 06/01/23reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE].The diagnoses included Abdominal pain, Nausea with vomiting, Hypokalemia ( Low potassium level in blood), Rectal abscess, Generalized Anxiety disorder, Hypertension (High Blood pressure), Parkinson's disease, Seasonal allergy, Hyperlipidemia ( High level of fat in Blood), Kidney failure, Dementia, Psychotic disturbance, Mood disturbance, Restless legs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.