Rosegate Village

In the surveyor’s words

From the most serious findings on record at Rosegate Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 2, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were transferred per plan of care with the right amount of assistance to prevent falls for 3 of 3 residents reviewed for falls. This resulted in one resident sustaining a left distal femur fracture and a right proximal femur fracture. (Resident D, Resident C, Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/14/22 at approximately 12:00 p.m. when the facility failed to ensure a resident was transferred with a mechanical lift per plan of care. This resulted in the resident sustaining a left distal femur fracture and a right proximal femur fracture. The Director of Nursing was notified of the Immediate Jeopardy on 4/14/22 at 12:30 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 observations. Staff hair was not covered while in the kitchen, food preparation, and serving areas. (Cook 2, Culinary Aide 3) Findings include: During a kitchen observation, on 1/13/26 from 11:25 a.m. to 11:35 a.m., the following was observed:- [NAME] 2 was observed working at the steamtable that held the noon meal foods. [NAME] 2 was observed taking the starting food temperatures and plating the noon meal. [NAME] 2 was observed wearing a white hair net that covered the hair above his ears to the top of his head. He was also observed wearing a beard restraint that covered the facial hair near the jaw line, below the ears and surrounding the lip area. […]

• No harm, potential for more than minimal, patternF812Jun 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 4 of 5 observations. Cold food was not maintained at or below 41 degrees Fahrenheit, staff hair was not covered, food was not labeled and closed, and the dumpster lids were not closed. (Dietary Manager, Cook 2, Cook Aide 3) Findings include: 1. During the initial kitchen observation with Cook 2, on 6/20/23 from 11:20 a.m. to 12:20 p.m., the following starting temperatures were recorded for foods being held at the steam table unit for the noon meal: pureed bread was 130 degrees Fahrenheit (F); egg salad was 50 degrees F; pureed salad was 50 degrees F; and chopped hard boiled eggs were 52 degrees F During a follow up kitchen observation with Cook 2 and the… […]

• No harm, potential for more than minimal, isolatedF644Jan 20, 2026

  Based on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority contractor for a Level I screening Resident Review (PASARR) mental health assessment for new diagnosis for mental illness evaluation and determination for 2 of 2 residents reviewed for PASARR. (Residents 12, Resident 79) Findings include: 1. On 1/15/26 at 11:35 a.m., Resident 79's clinical record was reviewed. The diagnoses included, but were not limited to, chronic diastolic (congestive) heart failure and major depressive disorder. Resident 79 was admitted to facility on 9/24/24 with a PASARR (Pre-admission Screening and Resident Review) Level I completed. […]

• No harm, potential for more than minimal, isolatedF658Jan 20, 2026

  Based on record review and interview, the facility failed to hold blood pressure medications for a resident with low blood pressure per the physician orders for 1 of 26 clinical record reviews. (Resident 98) Finding includes: On 1/16/26 at 11:45 a.m., the clinical record of Resident 98 was reviewed. The diagnoses included, but was not limited to, venous insufficiency and hypertension. The Physician Orders included, but was not limited to: - Metoprolol succinate tablet, extended release 24 hour, 50 milligrams (mg), administer 50 mg, by mouth one time a day. Hold if systolic blood pressure is less than 110, or heart rate less than 60, initiated 1/8/26. - Lisinopril tablet 20 mg, by mouth one time a day, hold if systolic blood pressure is less than 110, initiated 1/8/26. […]