Roscoe Gardens Skilled Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Roscoe Gardens Skilled Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 14, 2024

  Based on observation, medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of the facility's abuse policy titled Abuse, Neglect and Misappropriation of Property, and interviews with staff, residents and the authorities, the facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. This resulted in Immediate Jeopardy and physical and psychosocial harm on 04/21/24 at approximately 7:45 A.M., when Resident #2, was physically abused/assaulted by Resident #3. Resident #3 struck Resident #2 multiple times resulting in two facial lacerations with bleeding, a laceration to the lower lip, and multiple hematomas (bruises) to the resident's bilateral arms, upper portion of her breasts, and upper chest wall. […]

• Actual harm, isolatedF686Dec 30, 2025

  Based on observation, medical record review, hospital record review, review of radiological studies, interview, and policy review, the facility failed to ensure appropriate care, services and interventions were in place to prevent the development of an avoidable pressure ulcer for Resident #8. Actual Harm occurred on 10/24/25 when Resident #8 developed an avoidable suspected deep tissue injury (DTI) (a severe pressure-related wound damaging skin and underlying soft tissues, often starting under intact skin as a bruise-like purple or maroon area, that rapidly deteriorates to reveal significant tissue death-necrosis) to the left heel following a fall with a fracture to the right fibula, which impaired the resident's mobility and increased her dependence and need for assistance with… […]

• No harm, potential for more than minimal, widespreadF812Dec 30, 2025

  Based on observations, interviews, review of facility policy, and review of the United States Department of Agriculture (USDA) website, the facility failed to store and serve food under sanitary conditions. This had the potential to affect all 59 residents residing in the facility, who ate food from the kitchen. Findings Include:1. Observation of the kitchen on 12/15/25 from 8:55 A.M. to 9:14 A.M. revealed in the over the tray foodservice serving area, there were two dirty exhaust fans with a large amount of a brown and gray fuzzy substance on them. The white paint on the ceiling over the food serving area was also chipping and bulging from the ceiling. An interview with [NAME] #117 on 12/15/25 at 9:06 A.M. […]

• No harm, potential for more than minimal, widespreadF921Dec 30, 2025

  Based on observation, staff interview, and review of facility policy, the facility failed to ensure smoking regulations were being adhered to in accordance with NFPA 101 - 2012 Edition, Section 19.7.4 per the regulations. This deficient practice had the potential to affect all 59 residents residing in the facility. Findings Include: Observation on 12/18/25 during a tour of the facility at 8:56 A.M. with the Director of Maintenance (DM) #131 noted the designated smoking area in the central enclosed courtyard was not being properly maintained. Thirty-seven cigarette butts were on the ground. Three butts were in a pine bush and had burned some of the needles. A cigarette receptacle was also present. An interview with the DM #131 verified the findings at the time of observation. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2025

  Based on medical record review, observations, staff interviews, and facility policy review the facility failed to maintain sanitary conditions in the kitchen during meal service by not wearing facial hair covering and handling food with bare hands. This affected one resident (Resident #5) and had the potential to affect all residents residing in the facility. The facility census was 54. Findings Include: A review of the medical record for Resident #5 revealed an admission on [DATE] with diagnoses including but not limited to dementia, weakness, and indigestion. Resident #5 required assistance from staff to complete activities of daily living (ADL) tasks and was independent with eating. […]