Inspection Reports for
Rosewood

Complaint 24-AS-20260127111350 triggered the investigation. The complaint involved failure to report incidents where residents were trapped in elevators on 11/07/2025, 11/11/2025, and 11/25/2025. The deficiency was substantiated based on documentation and interviews.

The investigation found that the facility failed to report multiple incidents involving residents being trapped in elevators on three separate occasions in November 2025. These incidents were not reported to CCLD as there were no injuries or need for medical care.

The facility was generally found to be clean and in good repair with required equipment and supplies. However, deficiencies were cited in areas including hospice care plans, incidental medical and dental care, oxygen administration, and storage space and access for medications and cleaning supplies.

The facility was generally found clean and in good repair with required equipment and supplies. However, deficiencies were cited in areas including Hospice Care for Terminally Ill Residents, Incidental Medical and Dental Care, Oxygen Administration, and Storage Space and Access.

The inspection found multiple deficiencies including an unsupervised steak knife in the kitchen, accessible disinfecting spray in a resident's room, and incomplete or outdated medical assessments for residents diagnosed with dementia.

The visit was triggered by complaint allegations. Technical Violations were issued, but no deficiencies were cited during the inspection.

During the investigation, Licensing Program Analysts toured the facility, reviewed medication carts, staff training records, and documentation. Technical Violations were issued for some regulations, and Technical Assistance was provided for hospice care plans and other areas. No deficiencies were cited on this case management inspection.

The inspection identified several deficiencies including unsafe storage of a steak knife and disinfecting spray accessible to residents, a resident with dementia lacking a recent medical assessment, and a resident's medical assessment missing primary and secondary diagnoses.

The complaint investigation was substantiated for medication administration and ADL documentation deficiencies. Other allegations regarding stage 2 pressure injuries and emergency call button access were found to be unfounded and dismissed.

The investigation substantiated that facility staff failed to administer medication as prescribed, specifically noting missed doses of Acetaminophen for one resident. Additionally, 3 out of 8 residents sampled had Activities of Daily Living logs that did not match their basic services as documented. Other complaints regarding pressure injuries and emergency call buttons were found to be unfounded.

The complaint was substantiated based on evidence including interviews and record reviews. The allegations of financial abuse and improper fee increase were confirmed.

The investigation substantiated that staff member S1 financially abused resident R1 by receiving checks from them, and the facility increased R1's monthly fee for January and February 2021 without providing the required 60 days advance written notice.

Complaint was substantiated based on evidence that staff financially abused a resident and the facility failed to provide proper notice for fee increases.

The investigation substantiated that staff member S1 financially abused resident R1 by receiving checks from them, and the facility increased R1's monthly fee for January and February 2021 without providing the required 60 days advance written notice.