Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewood Rehab And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, hallucinations, and wandering behavior entered another resident’s room on a locked dementia unit, where the second resident had dementia with agitation, a psychotic mood disorder, and a documented history of physical behaviors such as hitting and pushing. Staff heard yelling and found the two residents on the floor punching each other, with blood on both residents and the floor. The resident who wandered into the room sustained facial bruising, a cut above the eye, a skin tear on the thumb, and multiple contusions, while the other resident had a small cut below the lip. The facility’s investigation documented that most of the incident was unwitnessed, both residents were cognitively impaired, and the aggressive resident later could not recall the event, while the administrator characterized the altercation as territorial rather than intentional harm.
Two residents with dementia and psychiatric conditions were found by an OTA in a physical altercation, with one on top of the other and both throwing punches, resulting in minor cuts and facial bruising. Staff immediately intervened, separated the residents, and notified nursing leadership, including the ADON and the Administrator. Although the facility’s abuse policy required reporting incidents of abuse with significant injury to authorities within two hours, the Administrator, serving as the abuse coordinator, decided the event was territorial rather than abusive and chose not to report it, leading to noncompliance with the abuse reporting requirements.
Multiple residents with cognitive and behavioral health issues were not protected from abuse when staff failed to separate roommates after a physical altercation, resulting in ongoing fear and visible injuries. In another case, a resident sustained significant facial bruising after being pushed to the ground by another resident, with staff and family confirming the injuries were due to the altercation. The facility also did not prevent repeated aggressive behaviors from a resident with a known history of violence, leading to further incidents of physical abuse among residents.
A resident with complex behavioral and medical needs was transferred to a hospital for psychiatric evaluation due to aggressive behavior. The facility failed to provide proper discharge notice, did not notify the Ombudsman, and did not allow the resident to return after hospitalization, instead seeking alternate placement only after several days. Staff interviews revealed confusion and lack of coordination regarding the discharge process.
A resident with dementia, PTSD, and a history of aggression repeatedly exhibited physical and behavioral incidents, including striking other residents and wandering into their rooms. Facility staff did not consistently update the care plan with new interventions after each incident, nor did they ensure the IDT was involved in reassessing and addressing the resident's behavioral health needs. Documentation of staff training on behavior management and identification of behavioral triggers was lacking, and staff primarily relied on one-on-one observation or hospital transfers rather than individualized interventions.
Staff did not follow required Covid-19 testing schedules for two residents who had close contact with positive cases, waiting seven days between tests instead of the CDC-recommended intervals. Additionally, staff were observed entering and exiting isolation rooms without proper PPE or hand hygiene, and some did not wear masks correctly while on units with Covid-19 positive residents. These actions were inconsistent with both facility policy and CDC guidance, leading to a deficiency in the infection prevention and control program.
Staff failed to maintain two high/low adjustable beds and the surrounding flooring in a safe and sanitary condition. The beds were missing stoppers, exposing pipe edges that caused deep gouges and missing tiles in the floor, resulting in uncleanable surfaces and hazards to residents. The issues were not reported or addressed through the facility's maintenance system as required by policy.
A facility failed to provide adequate supervision and assistance, resulting in severe consequences for two residents. One resident with dementia was not checked on for several hours and was found deceased with a dislodged catheter. Another resident with hemiplegia was injured during a transfer when a CNA used a Hoyer lift alone, contrary to policy. Staff were distracted by external events, leading to insufficient checks and adherence to protocols.
A resident in a LTC facility was found deceased after not being checked on for seven hours due to inadequate staffing on the 3 North unit. The resident, who had severe cognitive impairment and required assistance, was found with blood and feces in the room and a dislodged catheter. Staffing levels were insufficient, with only one LPN and one CNA present after another CNA left due to a personal emergency. The facility's policy of two-hourly rounds was not followed, contributing to the deficiency.
A resident with mobility issues was injured during transport to dialysis when the facility van made an abrupt stop, causing the resident to slide out of the wheelchair due to improper securing with only a shoulder strap. The incident resulted in a femoral fracture requiring surgery, highlighting deficiencies in the facility's transport safety protocols.
The facility failed to maintain a clean, safe, and comfortable environment, with surveyors noting musty odors, stains, and debris in common areas. Observations included sticky floors, missing trim, and littered dining room floors. Interviews with staff revealed confusion over cleaning schedules and practices, with the DON and Administrator acknowledging unmet expectations for regular cleaning and maintenance.
Resident-to-resident altercation causing facial injuries on dementia unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident on a locked dementia unit. One resident with unspecified dementia without behaviors, auditory hallucinations, and a psychotic disorder with hallucinations wandered into another resident’s room. The other resident had unspecified dementia with agitation, anxiety, a psychotic mood disorder, and a documented history of physical behaviors one to three days per week, including hitting, kicking, pushing, scratching, and grabbing others. Both residents were not cognitively intact and had moderate mood issues. On the day of the incident, staff heard yelling from the aggressive resident’s room. An occupational therapy assistant entered and observed the aggressive resident kneeling over the wandering resident, with both residents on the floor and punching each other. The assistant called for help, and a CNA and an LPN responded and separated the residents. Blood was observed on both residents and on the floor. The aggressive resident later stated that a person had come into the room claiming money was owed, that he was confused, and that after being hit on the shoulder he “let him have it,” though he was later unable to recall the incident. Following the altercation, assessments and documentation showed the wandering resident had bruising and bleeding above and below the left eye, a laceration to the left eyebrow, a skin tear on the left thumb, and multiple facial contusions, and received pain medication. The aggressive resident had a small cut below the lip that did not require first aid. The facility’s abuse investigation noted that most of the incident was unwitnessed, that both residents resided on the locked dementia unit with dementia histories, and that the aggressive resident could not recall the event. The administrator later described the event as territorial in nature, related to the wandering behavior of one resident and the newness of the other resident to the unit, and stated he did not believe either resident meant to harm the other.
Failure to Report Resident-to-Resident Altercation With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident‑to‑resident altercation that resulted in injuries, as required by its Abuse Prevention and Prohibition Program. The policy, revised 10/24/22, required the facility to report any incident of abuse that resulted in significant resident injury within two hours to all required entities, including the Department of Health and Senior Services. On 3/5/26 at approximately 11:30 A.M., an occupational therapy assistant (OTA) heard yelling from a resident’s room and found two residents on the floor, with one on top of the other, both punching each other. The OTA called for help, and a CNA assisted in separating the residents. The assistant director of nursing (ADON) assessed both residents and identified that one resident had a small cut on the left eyebrow, a small red area on the left side of the face, and the beginning of a bruise under the left eye, while the other resident had a small cut below the lip. Both residents involved had dementia and psychiatric diagnoses. One resident had unspecified dementia without behaviors, auditory hallucinations, and a psychotic disorder with hallucinations. The other resident had unspecified dementia with agitation, anxiety, a psychotic mood disorder, and a history of stroke. Staff, including the OTA and CNA, immediately reported the incident to the LPN and ADON, and the ADON then informed the Administrator, who was the abuse coordinator responsible for reporting. Despite being notified of the altercation and the injuries, the Administrator determined the event was territorial in nature, believed neither resident intended harm, and concluded it was not abuse. Based on this judgment, the Administrator did not report the incident to the required authorities, resulting in noncompliance with the facility’s abuse reporting policy.
Failure to Protect Residents from Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect multiple residents from abuse, specifically in cases involving resident-to-resident altercations. In one incident, two residents with cognitive impairments and behavioral health diagnoses engaged in a physical altercation in their shared room. Despite both residents expressing fear of each other after the incident, staff did not separate them in accordance with facility policy, and they remained roommates for 48 hours. Both residents sustained visible injuries, including skin tears and bruising, and one resident reported being scared to leave their side of the room. Staff interviews revealed a lack of clear instruction on how to ensure the safety of both residents following the altercation, and the facility's abuse policy requiring immediate separation was not followed. In another event, a cognitively impaired resident entered another resident's room, resulting in a physical altercation. The resident who entered the room was found on the floor with significant facial bruising, a hematoma, and other injuries. The resident's family reported that the resident became increasingly withdrawn and sad following the incident. Staff and LPNs confirmed that the injuries were a result of the altercation, and documentation indicated that the incident was not substantiated as abuse because it was unwitnessed, despite clear evidence of injury and statements from those involved. Additionally, the facility failed to protect several residents from a resident with a known history of verbal and physical aggression. Multiple reports and interviews documented incidents where this resident physically assaulted or attempted to assault others, including punching a resident in bed and attempting to swing at another. Despite these behaviors and the resident's documented history of aggression and mental health issues, the facility did not implement effective interventions to prevent further incidents. All affected residents resided on a locked memory care unit, and the facility census was 259 at the time of the survey.
Failure to Provide Proper Discharge Notice and Refusal to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to provide an appropriate discharge notice and did not allow a resident to return after a hospital transfer, nor did it secure an alternate placement. The resident in question had a complex medical and behavioral history, including dementia, metabolic encephalopathy, PTSD, selective mutism, chronic kidney disease, and suicidal ideations. The resident had a documented pattern of aggressive behaviors toward other residents, resulting in multiple incidents and interventions such as one-on-one observation and psychiatric evaluations. On the day of the incident, the resident was transferred to a hospital for medical clearance for psychiatric admission due to combative and aggressive behavior. The facility issued a discharge notice indicating the resident was being discharged to the hospital because his or her needs could not be met and for the safety of others. However, the discharge process was not handled in accordance with policy and regulatory requirements. The Ombudsman was not properly notified of the discharge, and there was confusion among staff regarding the type and timing of the discharge notice. The Social Services Director was unsure whether the notice was a 30-day or immediate discharge and did not initially send referrals to other facilities, believing the resident would return. Subsequently, the facility decided not to allow the resident to return after the hospital stay, and staff communicated this to the hospital and the resident's family. Referrals to other facilities were sent only after several days, and the hospital had difficulty finding a new placement for the resident. Interviews with facility staff, including the ADON, Social Services Director, Clinical Liaison, DON, and Administrator, revealed a lack of coordination and understanding of the discharge process, as well as an acknowledgment that the facility was required to allow the resident to return but did not do so.
Failure to Provide Consistent Behavioral Health Services and Update Care Plans After Resident Aggression
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of physical aggression, PTSD, dementia, and wandering. Despite the resident's documented behavioral health needs and repeated incidents of aggression towards other residents, the facility staff did not consistently implement or update individualized care plans with new interventions after each behavioral incident. The care plan lacked timely updates and did not reflect changes in the resident's condition or the effectiveness of interventions, even after multiple altercations and hospitalizations. Staff interviews and record reviews revealed that the interdisciplinary team (IDT) was not consistently involved in assessing the resident's behavioral needs or in developing and implementing new strategies following each incident. Documentation was incomplete regarding IDT meetings, staff training on behavior management, and the identification of triggers or effective interventions for the resident. Staff often relied on one-on-one observation or sending the resident to the hospital, rather than developing and applying individualized, non-pharmacological interventions as outlined in facility policy. The resident continued to display aggressive behaviors, including entering other residents' rooms, taking food, and physically striking or attempting to strike other residents. These behaviors resulted in repeated emergency room visits, hospitalizations, and ultimately transfer to a psychiatric facility. The facility's failure to provide consistent, person-centered behavioral health care and to update care plans and interventions after each incident contributed to ongoing safety concerns for both the resident and others.
Failure to Follow Covid-19 Testing and Infection Control Protocols
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by both its own policies and CDC guidance. Staff did not follow the recommended Covid-19 testing protocol for residents who had close contact with Covid-19 positive individuals. Specifically, two residents who shared rooms with Covid-19 positive residents were not retested according to the CDC's recommended schedule of testing at day 1, day 3, and day 5 after exposure. Instead, staff waited seven days between tests for these residents, which was inconsistent with both facility policy and CDC guidelines. This lapse was confirmed through record review and staff interviews, where it was acknowledged that the testing schedule was not followed as required. Additionally, staff failed to adhere to infection control practices related to hand hygiene and the use of personal protective equipment (PPE) when working in areas or rooms with Covid-19 positive residents. Observations showed that staff entered and exited Covid-19 isolation rooms without donning appropriate PPE or performing hand hygiene, despite clear signage and available supplies. Some staff were also observed not wearing masks or not wearing them properly while on units with Covid-19 positive residents. These actions were in direct violation of both facility policy and CDC recommendations, which require the use of N95 masks, gowns, gloves, and eye protection, as well as strict hand hygiene protocols. Interviews with various staff members, including CNAs, LPNs, the Infection Preventionist, and the Director of Nursing, revealed inconsistent understanding and implementation of infection control procedures. While staff were generally aware of the policies, their actions did not consistently align with the required practices. The failure to follow established protocols for testing, PPE usage, and hand hygiene contributed to the deficiency cited in the facility's infection prevention and control program.
Failure to Maintain Safe and Sanitary Beds and Flooring
Penalty
Summary
Facility staff failed to maintain two high/low adjustable beds and the surrounding flooring in a safe, functional, and sanitary condition. Observations revealed that the beds were missing stoppers or brakes, resulting in exposed pipe edges at the base of the beds. These exposed edges caused deep gouges and areas of missing tile beneath and around the beds in two resident rooms. The damaged flooring was not a cleanable surface, and the beds, without the necessary stoppers, were identified as hazards to residents. Staff interviews confirmed that the condition of the beds and floors had not been reported to maintenance prior to the survey, and the issues had not been entered into the facility's electronic work order system. According to facility policy, the maintenance department is responsible for ensuring all equipment and building areas are maintained in a safe and operable manner, including regular inspections of bed frames. However, the required maintenance and reporting procedures were not followed, resulting in the continued use of hazardous beds and uncleanable flooring. Staff, including CNAs, the Unit Manager, and the DON, acknowledged the deficiencies and confirmed that the beds and floors in the affected rooms did not meet safety and sanitation standards at the time of the survey.
Inadequate Supervision and Assistance Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate supervision and assistance to two residents, leading to severe consequences. One resident, who had a diagnosis of dementia and a history of pulling out their indwelling catheter, was not checked on from midnight until 7:00 A.M. The resident was found deceased, lying on the floor in a pool of blood, urine, and feces, with the catheter dislodged and the balloon still inflated. Interviews revealed that staff were distracted by car break-ins in the parking lot, leading to inadequate staffing and failure to perform regular checks on the residents. Another incident involved a resident with hemiplegia following a stroke, who was injured during a transfer with a Hoyer lift. A CNA attempted to transfer the resident alone, contrary to the policy requiring two staff members for such transfers. The resident's foot was injured when it got caught on the control box of the lift. The CNA admitted to being aware of the two-person requirement but proceeded alone due to the resident's agitation and the absence of immediate assistance. The facility's policies on resident rounding and mechanical lift usage were not adhered to, resulting in these deficiencies. Staff interviews indicated a lack of sufficient personnel to meet the needs of the residents, especially during the night shift when the incidents occurred. The failure to follow established protocols and ensure adequate supervision and assistance contributed to the adverse outcomes for the residents involved.
Inadequate Staffing Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the care needs of a resident, resulting in a severe deficiency. On the night in question, a resident was not checked on for approximately seven hours due to insufficient staffing on the 3 North unit. The resident was found deceased in their room, with blood and feces smeared around, and their indwelling catheter dislodged and on the floor. The facility's census was 275 residents, with 45 residents on the 3 North unit, which was noted to have a high level of care needs. Interviews with staff revealed that CNA A left the facility during the night shift due to a personal emergency, leaving only one LPN and one CNA to care for the residents on the unit. The staff did not replace CNA A, and the remaining staff were unable to meet the needs of the residents, as evidenced by the lack of two-hourly rounds as per facility policy. The resident, who had severe cognitive impairment and required assistance with personal care, was not checked on between midnight and 7:05 AM, contrary to the facility's rounding policy. The facility's staffing coordinator and other staff members acknowledged that the staffing levels were inadequate to provide the necessary care. The facility's assessment indicated that the 3 North unit required more staff due to the high care needs of its residents. Despite this, the staffing levels were not adjusted to meet these needs, leading to the tragic outcome for the resident.
Resident Injury Due to Inadequate Transport Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment for a resident during transport, resulting in a significant accident. On 5/20/24, a resident was being transported to dialysis in a facility van when the driver had to make an abrupt stop to avoid a collision. The resident, who was secured only with a shoulder strap and not a lap belt, slid out of the wheelchair and onto the floor of the van, sustaining a femoral fracture that required surgical repair. This incident highlighted a deficiency in the facility's transport safety protocols. The resident involved had a history of mobility issues, including dependence on a wheelchair and mechanical lift for transfers, and was at risk for falls due to impaired mobility. Despite these known risks, the resident was not adequately secured in the van, as the lap belt was not used. The van driver, during an interview, admitted to using only the shoulder strap because the resident was too large to be placed in the back of the van where both shoulder and lap belts could be used. This oversight directly contributed to the resident's injury. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the lap belt should have been used to prevent the injury. The resident's spouse also expressed concerns about the lack of proper restraints and training for safe transport. The facility's failure to ensure the resident was properly secured in the van led to a preventable accident, resulting in a serious injury that extended the resident's stay and impacted their recovery.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. On several occasions, surveyors noted musty odors, stains, and debris in the common carpeted areas on the second, third, and fourth floors. Specific observations included debris scattered over carpets, large stains, and sticky floors, indicating a lack of regular and effective cleaning. Interviews with family members and staff corroborated these findings, with reports of floors feeling unclean and sticky, and uncertainty about the last time certain areas were cleaned. Further observations revealed missing or unattached trim in hallways, with exposed nails posing potential safety hazards. The dining room floor was found littered with food and debris, and the floor at the fourth-floor south nurses' station was stained and dirty. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), highlighted a lack of clarity and responsibility regarding cleaning schedules and maintenance duties. The Environmental Services Supervisor (EVSS) and Director of Environmental Services acknowledged issues with cleaning practices, such as the mixing of chemicals leading to sticky floors and uncertainty about carpet cleaning schedules. The Director of Nursing (DON) and the facility Administrator expressed expectations for regular cleaning and maintenance, including daily floor cleaning and weekly carpet shampooing. However, the report indicates that these expectations were not being met, as evidenced by the conditions observed during the survey. The lack of a provided policy on carpet and floor cleaning further underscores the facility's failure to ensure a clean and safe environment for its residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Independence Manor Care Center | 0.9 mi | — | 0 | 0 |
| Maywood Terrace Living Center | 1.1 mi | — | 2 | 0 |
| Carmel Hills Wellness & Rehabilitation | 1.8 mi | — | 1 | 0 |
| Abode Health And Wellness Center | 3.5 mi | — | 3 | 0 |
| Rehabilitation Center Of Independence, The | 3.6 mi | — | 1 | 0 |
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