Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
66 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Jun 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin to the State Agency within the required 2-hour timeframe.
Findings
The facility failed to report an injury of unknown origin on Resident #1 to the State Agency within 2 hours as required by state law and facility policy. The resident had a red abrasion on the right hip, and the facility was unaware of how the injury occurred. The administrator confirmed the injury should have been reported timely.
Complaint Details
The complaint investigation found that the facility did not report an injury of unknown origin on Resident #1 within the required 2-hour timeframe. The allegation was substantiated based on interviews and record reviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to timely report an injury of unknown origin to the State Agency within 2 hours. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Total census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Interviewed regarding failure to timely report injury of unknown origin |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 7
Dec 8, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, safety, nutrition, medication management, respiratory care, staffing, and food safety at Rosewood Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, failure to implement registered dietitian recommendations for nutritional care, improper labeling of enteral feeding tubes, inadequate respiratory care with empty oxygen humidifier jars, failure to post daily nurse staffing information, lack of monitoring for side effects of psychotropic medications, and improper storage of opened food products.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide a clean, comfortable, and homelike environment for 1 resident (#33) with dirty tube feeding machine and oxygen concentrator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure registered dietitian recommendations for increased tube feeding rate were relayed and implemented for 1 resident (#44). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly label enteral feeding administration sets including flush bags for 2 residents (#34 and #35). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care; oxygen humidifier jars were empty for 3 residents (#11, #33, #37). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post daily nurse staffing information including resident census and hours worked by nursing staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor for side effects of psychotropic medications for 1 resident (#42). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly refrigerate opened food product (Concord Grape Jelly) in kitchen dry storage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Facility census: 63
Residents affected: 1
Residents affected: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S5RN | Registered Nurse | Confirmed unclean tube feeding machine and oxygen concentrator in Resident #33's room |
| S10RD | Registered Dietitian | Confirmed nutritional assessment and recommendations for Resident #44 |
| S2DON | Director of Nursing | Confirmed failure to implement RD recommendations and lack of policy for feeding tube labeling and medication monitoring |
| S7LPN | Licensed Practical Nurse | Confirmed unlabeled feeding tube flush bags and lack of medication side effect monitoring |
| S4LPN | Licensed Practical Nurse | Confirmed empty oxygen humidifier jar for Resident #11 |
| S8LPN | Licensed Practical Nurse | Confirmed empty oxygen humidifier jar for Resident #37 |
| S7LPN | Licensed Practical Nurse | Confirmed unlabeled feeding tube flush bags for Residents #34 and #35 |
| S6DM | Dietary Manager | Confirmed opened jelly container not refrigerated |
| S1ADM | Administrator | Confirmed failure to post nurse staffing information |
| S9PM | Payroll Manager | Confirmed failure to post nurse staffing information |
| S3RDO | Regional Director of Operations | Acknowledged failure to post nurse staffing information |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 15, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by a fall incident involving Resident #1 during a mechanical lift transfer without the required two-person assistance, resulting in injury.
Findings
The facility failed to ensure Resident #1 was free from accident hazards during a mechanical lift transfer, leading to a fall and a fractured right leg. The investigation found that a Certified Nursing Assistant (S3CNA) did not follow the care plan requiring two-person assistance and failed to assess the sling's functionality, resulting in the sling pad ripping and the resident falling. Immediate corrective actions were implemented, including staff re-education and monitoring, and the facility was found to be in substantial compliance by 08/09/2024.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell during a mechanical lift transfer on 08/08/2024 due to failure of staff to follow the two-person assist policy and improper sling assessment. The resident sustained a fractured right leg requiring surgery and hospitalization.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident was free from accident hazards during a mechanical lift transfer requiring two-person assistance, resulting in a fall and fracture. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents sampled requiring two-person transfer: 7
Residents affected: 1
Date of fall incident: Aug 8, 2024
Date of surgery: Aug 10, 2024
Date facility achieved substantial compliance: Aug 9, 2024
Monitoring period: 90
Additional monitoring extension: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | Failed to follow two-person assist policy and sling assessment, involved in resident fall |
| S4 LPN | Licensed Practical Nurse | Cared for Resident #1 on day of fall, confirmed transfer requirements and observed injury |
| S5 CNA | Certified Nursing Assistant | Observed S3 CNA transferring resident without assistance and intervened |
| S1 ADM | Administrator | Conducted investigation, confirmed findings, implemented corrective actions and monitoring |
Inspection Report
Deficiencies: 2
Jan 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's provision of dialysis care and services for residents requiring such services, specifically assessing compliance with professional standards of practice.
Findings
The facility failed to ensure that residents requiring dialysis received appropriate care, specifically failing to conduct comprehensive post dialysis assessments and failing to communicate dialysis provider concerns to staff, as evidenced by incomplete post dialysis documentation and lack of response to a request for a sitter during treatment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failing to conduct comprehensive post dialysis assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failing to ensure that communication received from the dialysis provider was addressed and communicated with staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for dialysis services: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Interviewed regarding communication failures and acknowledged incomplete post dialysis documentation |
| S3LPN | Licensed Practical Nurse | Confirmed failure to complete post dialysis documentation and failure to communicate dialysis provider concerns |
Inspection Report
Annual Inspection
Deficiencies: 8
Dec 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, staffing, infection control, and record keeping at Rosewood Nursing Center.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to maintain updated hospice records, inadequate respiratory care, insufficient RN staffing coverage, incomplete narcotic drug reconciliation, storage of expired medications, lack of proper documentation for release of deceased residents, and failure to follow infection control practices during wound care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| 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 of 30 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hospice agencies communicated with facility staff and maintained updated medical records reflecting services provided for 1 of 2 residents receiving hospice services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary respiratory care by not administering oxygen as ordered for 1 resident out of 30 reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a registered nurse was on duty for 8 consecutive hours per day for 7 days per week. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services that were in order and accounted for drug record reconciliation of all controlled drugs during shift changes for medication carts A and B. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired medication/biologicals were properly discarded and not available for use; expired influenza vaccines were found in medication refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately maintain resident records by failing to have a written order to release body to funeral home for 1 sampled death resident record. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective infection prevention and control program by failing to ensure staff performed hand hygiene according to accepted standards during wound care for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 30
Residents receiving hospice services sampled: 2
Residents affected by inaccurate MDS coding: 1
Residents affected by hospice documentation issues: 1
Residents affected by respiratory care deficiency: 1
Days with no RN coverage: 4
Residents affected by pharmaceutical service deficiency: 52
Missing narcotic reconciliation signatures: 4
Missing narcotic reconciliation signatures: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S4MDSLPN | Licensed Practical Nurse | Confirmed resident #28 was a smoker and MDS was coded incorrectly |
| S3DON | Director of Nursing | Confirmed hospice plan of care expired and no new documentation for resident #31; confirmed missing order to release body for resident #51 |
| S8LPN | Licensed Practical Nurse | Stated hospice nurse responsible for documentation; facility staff responsible for ensuring hospice binder was up to date |
| S7LPN | Licensed Practical Nurse | Confirmed oxygen was not administered as ordered for resident #153; confirmed missing narcotic reconciliation signatures on B Hall |
| S6LPN | Licensed Practical Nurse | Confirmed missing narcotic reconciliation signatures on A Hall |
| S1ADM | Administrator | Confirmed no RN coverage on specific days; confirmed missing narcotic reconciliation signatures; confirmed expired medications found in refrigerator |
| S9RN | Registered Nurse | Observed failing to change gloves during wound care for resident #46 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide basic life support, including CPR, to a resident (Resident #1) who was a full code and required emergency care according to advanced directives and physician's orders.
Findings
The facility failed to ensure that CPR was administered to Resident #1 when found unresponsive, despite the resident's full code status. The nurse (S2LPN) did not initiate CPR and instead notified hospice staff. The nurse resigned prior to suspension. The facility implemented corrective actions including staff re-education, audits of code status, mock codes, and ongoing monitoring.
Complaint Details
The complaint investigation found that Resident #1, a full code hospice resident, did not receive CPR when found unresponsive. The nurse (S2LPN) failed to verify code status and did not initiate CPR, following instructions from the attending physician to call hospice instead. The nurse resigned before suspension. The facility opened an investigation and implemented corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic life support, including CPR, to a full code resident requiring emergency care according to advanced directives and physician's orders. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Staff interviewed: 12
Audit frequency: 3
Audit duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Licensed Practical Nurse | Failed to provide CPR to Resident #1 and resigned prior to suspension |
| S1ADM | Administrator | Conducted investigation and corrective action plan after learning CPR was not administered |
| S3CNA | Certified Nursing Assistant | Assigned CNA to Resident #1 on the night of death; reported resident unresponsive and no CPR initiated |
| S4MD | Physician | Attending physician who instructed nurse to call hospice and did not recall events of the night |
Inspection Report
Routine
Deficiencies: 6
Mar 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including care planning, pressure ulcer prevention, accident hazards, nutrition, and staff training.
Findings
The facility was found deficient in developing and implementing comprehensive care plans addressing residents' risks, conducting timely skin assessments to prevent pressure ulcers, ensuring adequate supervision to prevent accidents, properly restraining residents during transport, maintaining residents' nutritional status, and completing initial orientation training for nurse aides.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Actual harm: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to develop a care plan addressing elopement risk for 2 residents and failed to apply bilateral heel protectors as ordered for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct weekly skin assessments for 2 residents, resulting in delayed identification and treatment of pressure ulcers. | Level of Harm - Actual harm |
| Failed to provide adequate supervision for a resident at risk for wandering, resulting in a fall with injury. | Level of Harm - Actual harm |
| Failed to properly restrain a resident in a wheelchair during transport, resulting in a motor vehicle accident and fracture. | Level of Harm - Actual harm |
| Failed to maintain acceptable nutritional status and provide therapeutic diet to a resident with significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete initial orientation training for 2 certified nursing assistants. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 16
Residents reviewed for pressure ulcers: 4
Residents assessed for wandering: 7
Weight loss percentage: 10.31
Weight loss in pounds: 12.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Confirmed elopement risk assessments and care plan deficiencies; confirmed missed skin assessments; confirmed staff counseling responsibilities |
| S3ADON | Assistant Director of Nursing | Confirmed missed skin assessments and responsibility for running reports; failed to verify heel protector orders |
| S15CNA | Certified Nursing Assistant | Responsible for applying heel protectors; admitted only one heel protector was available and used on elbow |
| S14RN | Registered Nurse | Observed resident without heel protectors; searched for heel protectors |
| S11CNA | Certified Nursing Assistant | Only CNA on hall where resident fell; involved in searching for wandering resident |
| S12CNADriver | Certified Nursing Assistant Driver | Failed to secure resident with seat belt during transport resulting in motor vehicle accident; terminated |
| S2DON | Director of Nursing | Confirmed termination of S12CNADriver; confirmed weight monitoring practices; responsible for employee in-service trainings |
| S1ADM | Administrator | Confirmed facility van totaled and replacement van obtained |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 30, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Rosewood Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to provide correct therapeutic diets, improper labeling of enteral feeding bags, inadequate respiratory care including oxygen delivery and tubing changes, poor food storage and cleanliness in nourishment refrigerators, and failure to document monitoring of dialysis fistula sites. These deficiencies had the potential to affect multiple residents but were generally classified as minimal harm or potential for actual harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident received the correct therapeutic diet including nectar thick fluid consistency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident's enteral feeding bag was properly labeled with contents, date, and time. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care by not changing nasal cannula tubing as ordered and delivering oxygen at the correct rate. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain cleanliness and discard expired food items in a unit nourishment refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately document monitoring of a resident's dialysis fistula for thrill and bruit every shift. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for nutrition: 37
Residents affected by diet deficiency: 13
Residents receiving continuous tube feedings: 6
Residents reviewed for respiratory care: 37
Residents reviewed for respiratory care with deficiencies: 2
Unit nourishment refrigerators observed: 2
Expired food items found: 1
Dialysis residents reviewed: 4
Dialysis resident with documentation deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S3DON | Director of Nursing | Confirmed lack of enteral feeding policy and proper labeling requirements; confirmed oxygen tubing change policy and deficiencies; confirmed dialysis site monitoring requirements |
| S1CNA | Certified Nursing Assistant | Confirmed resident #11 received thin liquids instead of nectar thick fluids |
| S2LPN | Licensed Practical Nurse | Confirmed resident #11 received thin liquids; confirmed oxygen delivery rate discrepancy for resident #31 |
| S4LPN | Licensed Practical Nurse | Confirmed unlabeled enteral feeding bag; confirmed dialysis site monitoring documentation deficiency |
| S5LPN | Licensed Practical Nurse | Confirmed nasal cannula tubing date and change requirements for resident #48 |
| S6HSK | Housekeeping Supervisor | Confirmed nourishment refrigerator cleanliness and expired food findings |
| S12LPN | Licensed Practical Nurse | Reported dialysis site assessment and documentation requirements |
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