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Complaint Investigation

Rosewood Nursing Center

March 31, 2026 · Lake Charles, LA · 534 15th Street
Citations 1
CMS Rating 1/5
Beds 150
Provider ID 195422
Healthcare Facility
Rosewood Nursing Center
Lake Charles, LA  ·  View full profile →
Inspection Summary

Rosewood Nursing Center in Lake Charles, LA — inspection on March 31, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

Review of the coffee temperature log at 6:30 a.m., 10:00 a.m., and 2:00 p.m. from 03/16/2026 through 03/30/2026 revealed temperatures were between 122 - 130 degrees F as per the facility's policy.

Observations on 03/30/2026 and 03/31/2026 revealed coffee was distributed in cups with lids.

Observation on 3/30/2026 of prepared carafes temperature prior to being served to residents was 120.3 degrees F. On 03/30/2026 at 2:22 p.m.

S9ACT was observed pouring coffee into blue cups and placing lids on the cups prior to giving it to the residents. On 3/30/2026 at 1:55 p.m., an interview and observation of coffee temperatures was conducted with S5DM.

She stated the coffee had already been prepared, temped.

Upon request S5DM obtained the temperatures again, readings were both 120.3.On 03/31/2026 at 8:30 a.m., several residents were observed in activity room drinking coffee from blue cups with lids.On 03/31/2026 at 11:38 a.m., observed resident #R8 in activity room with cup with lid. He stated he was drinking coffee.The facility implemented the following actions to correct the deficient practice: I. On 03/15/2026, the facility began an immediate investigation.On 03/16/2026, a suspension was immediately implemented for S8DA who temped the coffee on 3/12/26 at the incorrect temperature.On 03/20/2026, upon completion of the investigation, a termination was implemented for S8DA. II. On 03/16/2026, education and in-service for all clinical and dietary staff were re-educated on the Hot Beverage Policy.On 03/16/2026, an audit of all resident's plan of care was completed.On 03/16/2026, a skin audit of residents that had impaired cognition or nonverbal was conducted to ensure no other residents were affected.On 03/16/2026, a questionnaire was completed for all other residents who are verbal and hold a BIMS score of 13 or higher.Previously, on 03/02/2026, residents began complaining about the chilled temperature of the coffee because they wanted it hotter.

The administrator then called a Resident Council meeting on 3/2/2026 to educate residents on the Hot Beverage policy. III. On 03/16/2026, QAPI meeting was held by ID team to discuss progression of the investigation and why this past noncompliance was developed and implemented.On 03/16/2026, Community Medical Director notified of event.On 03/16/2026 through 03/17/2026, a mandatory meeting called at the facility for all clinical staff and dietary staff to in-service on the Hot Beverage Policy and Abuse, Neglect, and Timely reporting policy, and lids placed on all coffee drinks prior to serving.On 03/16/2026, reeducation completed with dietary manager and dietary staff on following Hot Beverage policy, temp requirement and who is responsible for temping hot beverage.Education will require staff return demonstration from dietary staff of temping hot beverage with the thermometer to validate competency.

Dietary staff will not be allowed to return to duty until completion of education and return demonstration. IV.

Quality Assurance plans to monitor facility compliance to make sure that corrections are achieved and permanent.Routine reviews will be completed 3 times a week for 90 days on sample selection of facility staff using abuse, neglect timely reporting quiz to assess knowledge base. To be completed by June 14, 2026.Routine reviews will be completed by S1ADM, S2DON, S5DM of dietary staff 3 times per week for 90 days.

Results of routine review will be reported during morning stand up meeting. To be completed by June 14, 2026 V.

Date of Compliance was 03/17/2026.Anticipatory monitoring completion date by 06/14/2026.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lake Charles, LA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Rosewood Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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