Rosepine Retirement & Rehab Center, LLC

In the surveyor’s words

From the most serious findings on record at Rosepine Retirement & Rehab Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 12, 2024

  Based on interview and record review, the facility failed to ensure facility staff used a mechanical lift with two person assist during transfer from the bed to chair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for accidents. The facility census was 84. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on 05/19/2024 between 10:00 a.m. and 11:00 a.m., when S3 CNA attempted to transfer Resident #2, who required a Mechanical lift with 2 person assistance, without the use of the lift and assistance of another staff. Resident #2 sustained a fall during the attempted transfer by S3 CNA. Resident #2 was sent to the local ER following the fall due to complaint of pain to both knees. […]

• No harm, potential for more than minimal, patternF585Jan 22, 2026

  Based on observation, interview and record review, the facility failed to ensure prompt efforts to resolve grievances/complaints, voiced in The Resident Council, were addressed and acted upon for 2 (11/2025 and 12/2025) of 3 months reviewed for grievances/complaints. The facility census was 88. Findings: Review of an undated facility policy on 01/22/2026 at 4:04 p.m. titled, Grievances/Complaints revealed the following .4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; ensure that immediate action is taken if necessary to prevent further violations of any resident rights while the allegation is under investigation. Review of an undated facility policy on 01/21/2026 at 10:49 a.m. […]

• No harm, potential for more than minimal, patternF692Oct 16, 2024

  Based on record review, observation, and interview the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (#11) of 2 (#11 and #23) residents reviewed for nutrition. The facility failed to provide ordered dietary supplements for a resident with significant weight loss. Findings: Resident #11 Review of the Resident #11's medical record revealed an admitted [DATE] with a reentry date of 03/18/2022. Diagnoses included .Parkinson's Disease, Mild Protein-Calorie Malnutrition, Dysphagia - Oropharyngeal Phase, and Muscle Wasting and Atrophy. Review of Resident #11's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 13, which indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF880Oct 16, 2024

  38894 44315 Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, to help prevent the development and transmission of infection for 3 (#26, #45, and #72) of 4 (#26, #45, #72, and #83) residents reviewed for infection control. The facility failed to: 1. Ensure staff wore proper PPE while providing wound care to Resident #26; 2. Ensure staff wore proper PPE while proving personal hygiene to Resident #45; and 3. Ensure staff performed proper hand hygiene and maintained a clean technique while performing wound care for Residents #26 and #72. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions read in part . […]

• No harm, potential for more than minimal, patternF803Nov 1, 2023

  Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The Facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 70 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facility's approved Menu Matrix revealed: Lunch: Fried Chicken 4oz. Instructions read in part Serve 4oz breaded portion=3oz meat 1 Breast or 1 Thigh + 1 Drumstick An observation on 10/30/2023 at 12:00 p.m. in the dining room during lunch revealed dietary staff preparing resident plates in the kitchen area. The meal included fried chicken. […]