Rose Garden Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rose Garden Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 31, 2025

  Complaint # 2561976Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were protected from neglect after an aphasic, cognitively impaired resident (Resident #1), was left unattended on the outside patio in the heat and sun from approximately 12:50 PM until approximately 3:30 PM on 7/3/25 (two hours and forty minutes). Resident #1 was sent to the hospital, was diagnosed with heatstroke and sustained second degree burns. […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2025

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that washed utensils were dried in a manner to prevent contamination from foreign substances and potential for the development of food-borne illness; b.) maintain the kitchen equipment in a sanitary manner to prevent microbial growth; c.) store, label and date potentially hazardous foods to prevent food borne illness; and d.) ensure bottled drinking water supply was stored in a sanitary manner at least six inches from the floor. This deficient practice was evidenced by the following:On 9/11/2025 at 9:08 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following:1. […]

• No harm, potential for more than minimal, widespreadF725May 8, 2024

  Based on interview, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: During the initial tour on 04/23/2024 at 10:30 AM, Resident #32 was just getting morning care. Resident #32 said, They are short of nurses and aides all the time, especially on weekends. On 04/23/2024 at 10:30 AM, Resident #72 stated that they do not have enough aides on the weekends. […]

• No harm, potential for more than minimal, patternF880Sep 18, 2025

  Based on observation, interview, review of medical record and pertinent facility documentation, it was determined that the facility failed to a.) provide residents with appropriate products for hand hygiene during mealtime identified in 2 of 3 dining room observations (1st floor Tea [NAME] and the Main dining rooms) and b.) implement and maintain a resident with stage 3 pressure ulcer wound on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes identified in 1 of 1 resident (Resident #114) reviewed for pressure ulcer, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control… […]

• No harm, potential for more than minimal, patternF812May 8, 2024

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 09:23 to 10:04 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room on a middle shelf a quarter pan contained (7) bottles of Smucker's Breakfast syrup. (6) bottles had a best if used by date of [DATE]. The FSD removed the expired syrups from storage. 2. In the walk-in freezer on a middle shelf a plastic bag contained frozen hash brown potatoes. The product inside the bag was covered in ice. […]