Rose Meadows Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Rose Meadows Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 9, 2023

  Based on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse and/or neglect. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of 18 of 184 residents reviewed. This failure created an Immediate Jeopardy situation for 18 of 184 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. […]

• Immediate jeopardy, patternF607Nov 9, 2023

  Based on review of facility provided policies and documentation, provided reports, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. […]

• Immediate jeopardy, patternF725Jun 4, 2021

  Based on facility documents, observations, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents; failed to ensure that dependent residents received showers for six of 46 residents reviewed (Resident R48, R62, R90, R112, R121 and R173); failed to make certain that seven of 11 residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening (Residents R78, R93, R114, R130, R120, R164, and R183), and failed to prevent pressure ulcer development resulting in actual harm for one of 17 residents reviewed (Resident R117). […]

• Immediate jeopardy, isolatedF689Jun 2, 2023

  Based on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 176 residents (Resident R1). Findings include: Review of facility policy Elopement Prevention reviewed 10/18/22, indicated that elopement is defined as when a resident leaves the premises or a safe area without authorization and/or a supervision and places the resident at harm or risk for injury. […]

• Actual harm, isolatedF689Feb 19, 2026

  Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include:Review of the facility policy Abuse Policy-Prevention and Identification, dated 4/17/25, indicated it is the facility's policy to deploy staff on each shift in sufficient numbers and assure staff assigned have knowledge of the individual residents' care needs. […]