Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosebud Village during CMS and state inspections, most recent first.
Failure to provide foot care for two residents: one resident with dementia, hemiplegia, CHF, and osteoporosis was repeatedly observed in bed without ordered heel protectors, and her toenails were very long and curved over the toes with no recent podiatry follow-up documented. A second resident with schizophrenia and diabetes reported long toenails and no nail trim for months; RN verified the nails were long, and the DON stated nursing was responsible for nail care or podiatry referral when indicated.
A resident with cerebral palsy and neurogenic bladder used an indwelling urinary catheter, and the care plan directed staff not to allow any part of the drainage system to touch the floor. Surveyors observed the catheter drainage bag contacting the floor on multiple occasions while the resident was lying in bed. An RN stated the bag should be kept off the floor and obtained a basin to prevent contact.
Improper Storage of Prescription Cream: A resident with cerebral palsy and neurogenic bladder had a prescribed medicated cream left on an over-bed table during multiple observations while she was in bed. RN verified the cream should have been kept in the treatment cart, and the facility policy required medications and treatment items to be stored in a locked cabinet/cart or locked med room inaccessible to residents and visitors.
A QMA was observed removing and concealing controlled medications intended for two residents with significant pain management needs. In both cases, required documentation in the EMAR and controlled substance logs was missing or incomplete, resulting in unaccounted-for narcotic pain medications. The facility's policies for medication administration and documentation were not followed, leading to discrepancies in medication counts and records.
A resident with a history of cancer and dementia received PRN hydrocodone-acetaminophen on several occasions, but staff failed to document the administration in the EMAR and did not complete required pain assessments to evaluate medication effectiveness, as required by facility policy and the care plan.
The facility failed to ensure that residents had water or beverages of choice available, affecting four residents. Multiple observations revealed that residents were without fluids in their rooms, despite the facility's protocol requiring CNAs to provide fresh water once per shift. The deficiency was confirmed by the Director of Nursing.
The facility failed to provide scheduled activities, implement individualized care plans, and redirect a wandering resident. Observations revealed that scheduled group activities were not occurring, and staff were unaware of the contents of activity boxes for residents. Additionally, a resident with a history of wandering was not redirected, causing distress to other residents. Interviews confirmed the deficiencies and highlighted the need for staff education.
The facility failed to document and address a grievance regarding missing items for a resident with unspecified dementia. Despite the family reporting the missing dentures and tennis shoes to the Dementia Care Director, no grievance was filed, and no progress notes were entered into the resident's record.
The facility failed to prevent sexual abuse of two residents by another resident with a history of inappropriate behaviors and verbal abuse of a resident by an Activity Assistant. Despite known risks and interventions, the facility's measures were insufficient to prevent these incidents.
A resident with heart failure had compression stockings applied with wrinkles on multiple occasions, despite a physician's order and care plan intervention. The resident was unable to smooth out the wrinkles himself, and the facility lacked a specific policy for TED hose application, leading to the deficiency.
The facility failed to implement a fall intervention for a resident at moderate risk for falls, despite a recent fall and a care plan intervention to place a sign in the resident's room to encourage the use of a call light. Multiple observations and interviews confirmed the absence of the sign.
The facility failed to provide adaptive eating equipment, fortified juice, and whole milk to three residents, leading to deficiencies in their nutritional care. Observations and interviews revealed that the prescribed nutritional interventions were not followed, as evidenced by the lack of divided plates and fortified juice for two residents and the absence of whole milk for another resident.
A resident with Alzheimer's and dementia fell from a mechanical lift during a transfer, resulting in cervical and thoracic fractures. The incident involved two CNAs, one under 18, who connected the sling to the lift. During the transfer, a hook came undone, causing the resident to fall and sustain injuries. Immediate care was provided, and the resident was sent to the hospital for further evaluation.
Failure to Provide Heel Protectors and Nail/Podiatry Foot Care
Penalty
Summary
The facility failed to ensure appropriate foot care for two residents. One resident with dementia, hemiplegia and hemiparesis, congestive heart failure, chronic pain, and osteoporosis had a care plan and physician order for heel protectors while in bed, but was observed in bed without heel protectors on multiple occasions and was wearing fuzzy socks instead. During one observation, the resident stated she did not remember staff putting anything else on her feet. When CNA 4 later applied heel protectors, the resident’s blue heel protectors were found on top of a wardrobe closet and could not be reached. The Skin Management Program policy indicated residents at risk for pressure ulcers or injury were to have individualized prevention interventions communicated to direct care givers. The same resident’s weekly skin assessment documented lotion applied to her feet, but the foot care section was not marked to indicate warm/dry feet, trimmed nails, no reddened or discolored areas, or a podiatry referral. During observation, the resident’s right foot had four very long toenails, three of which curved over the ends of her toes. CNA 4 stated nursing or podiatry was responsible for trimming her toenails. The most recent podiatry note, dated months earlier, documented routine foot care for atherosclerosis of the extremities, pedal edema, hammertoes, xerosis, and onychomycosis, and stated non-professional treatment was hazardous to the patient. No subsequent podiatry visits were found in the record. A second resident with schizophrenia and diabetes also had long toenails and had not received nail care or a recent podiatry visit. The resident stated she had not had her toenails trimmed in a few months and was unsure why the podiatrist had not seen her. RN 2 later verified the toenails were long and was unsure when the resident was last seen by podiatry. The DON stated nursing staff was responsible for nail care for residents without complications or for making podiatry referrals for residents with medical complications such as diabetes. A nursing assessment template provided by the facility indicated nails should be trimmed as needed or a podiatry referral made.
Catheter drainage bag contacted the floor
Penalty
Summary
The facility failed to ensure an indwelling catheter drainage bag was kept free from contact with the floor for Resident 86, who had diagnoses of cerebral palsy and neurogenic bladder and used an indwelling urinary catheter. The quarterly MDS dated 7/3/2025 indicated the resident was cognitively intact, did not refuse care, was dependent on toilet hygiene, partially to moderately dependent on staff for personal hygiene, and utilized an indwelling catheter. The resident’s catheter care plan, last revised on 7/16/2025, directed staff not to allow tubing or any part of the drainage system to touch the floor, and a physician’s order dated 9/29/2021 directed use of the indwelling urinary catheter. During observations on 7/22/2025 at 1:15 p.m., 7/28/2025 at 1:20 p.m., and 7/28/2025 at 1:30 p.m., Resident 86 was lying in bed and the indwelling urinary catheter bag drainage system was noted contacting the floor. During the 7/28/2025 observation and interview, RN 2 stated the drainage bag should be free from contact with the floor and obtained a basin to prevent contact. The facility policy provided by the Executive Direction stated urinary drainage bags should have a barrier such as a urinary drainage bag cover or a wash basin underneath them to prevent catheter bags or tubing from touching the ground.
Improper Storage of Prescription Cream
Penalty
Summary
The facility failed to ensure appropriate storage of a medicated cream for Resident 86, who had diagnoses of cerebral palsy and neurogenic bladder. The resident’s quarterly MDS dated 7/3/2025 indicated she was cognitively intact, did not refuse care, was dependent on toilet hygiene, partially to moderately dependent for personal hygiene, and used an indwelling catheter. A physician’s order dated 9/29/2021 directed the resident to use a medicated cream routinely for pain control. During observations on 7/22/2025 and 7/28/2025, a tube of the prescription medicated cream was noted on the resident’s over-bed table while she was lying in bed. During an interview and observation on 7/28/2025, the resident again had the tube on the over-bed table, and RN 2 verified the cream should have been stored in the treatment cart and was unsure why it was in the resident’s room. The facility policy stated medications, including treatment items, should be stored in a locked cabinet/cart or locked medication room inaccessible to residents and visitors.
Failure to Prevent Misappropriation of Resident Medications
Penalty
Summary
The facility failed to prevent the misappropriation of residents' medications for two residents. For one resident with a history of squamous cell carcinoma and dementia, a Qualified Medication Aide (QMA) was observed by staff and on camera placing pills into a bottle and then into her pocket. Upon questioning by the Executive Director, the QMA produced a bottle containing multiple pills, including hydrocodone tablets that matched the resident's prescribed medication. Review of the controlled drug administration record showed that the resident was documented as having received hydrocodone-acetaminophen on several dates, but there was no corresponding documentation in the Electronic Medication Administration Record (EMAR) for those administrations. The Director of Nursing confirmed that the QMA was omitting documentation of the resident's PRN pain medication in the EMAR. For another resident with chronic pain and multiple comorbidities, a discrepancy was found in the controlled substance count for hydrocodone-acetaminophen. The Director of Nursing noted that one pill was missing from the controlled substance record, and although it could not be verified that the QMA had taken the narcotic, the count was incorrect. The EMAR indicated that the QMA had administered the medication to the resident, but the controlled substance log did not reflect this administration, resulting in a missing pill. The facility's policies required that all administrations of controlled substances be recorded both in the Medication Administration Record and in the controlled substance inventory at the time of administration. The abuse policy also prohibited misappropriation of resident property, including medications. In both cases, the QMA failed to follow these procedures, resulting in unaccounted-for controlled substances and lack of proper documentation.
Failure to Complete Pain Assessments After PRN Narcotic Administration
Penalty
Summary
The facility failed to complete required pain assessments for a resident with a history of squamous cell carcinoma of the skin and dementia, who had a physician's order for hydrocodone-acetaminophen to be administered as needed for moderate to severe pain. Despite documented administration of this narcotic pain medication on multiple occasions, there was no corresponding documentation in the Electronic Medication Administration Record (EMAR) of the medication being given, nor were pain assessments completed to evaluate the effectiveness of the medication. The plan of care for the resident specifically included interventions to document the effectiveness of PRN pain medications, but these were not followed. Interviews with the Director of Nursing revealed that the facility's process required a Qualified Medication Aide (QMA) to report the need for PRN pain medication to a nurse, who would then authorize administration, ensure documentation in the EMAR, and complete a follow-up pain assessment. However, the QMA failed to document the administration in the EMAR, which prevented the nurse from being prompted to perform the required pain assessment. As a result, no pain assessments were completed for the resident on the dates when the medication was administered, contrary to facility policy and the resident's care plan.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure that residents had water or beverages of choice available, affecting four residents. Resident 2, who was cognitively impaired and needed assistance with eating tasks, was found without any drink available in her room on multiple occasions. Despite a care plan intervention to encourage fluids, Resident 2 expressed feeling very thirsty and hungry during an observation. Similarly, Resident 54, who had multiple diagnoses including osteoarthritis and cognitive communication deficit, was observed multiple times without any fluids available in his room, including an empty medication cup on the bedside table during several observations. Resident C reported that the facility did not provide fresh water daily and was observed multiple times with a water pitcher that was half full and warm to the touch, indicating the water was not fresh. Resident 89, who had diagnoses including diabetes and dementia, was also observed multiple times without any fluids available in her room. The Director of Nursing confirmed that CNAs were responsible for ensuring residents were provided with fresh water once per shift, as per the facility's hydration management policy. However, this protocol was not followed, leading to the deficiency.
Failure to Implement Scheduled Activities and Individualized Care Plans
Penalty
Summary
The facility failed to provide their scheduled activity program on the Cottage Unit, implement and educate staff regarding residents' individualized activity care plans, and redirect a resident with a history of wandering into other residents' rooms. Observations on multiple dates revealed that scheduled group activities were not occurring as planned. For instance, on 5/31/24, no group activities were observed despite the activity schedule indicating 'Dining Room Helpers' at 11:30 a.m. Similarly, on 6/4/24, scheduled activities such as 'Baking' and 'Paint & Polish' did not take place. Interviews with family members and staff confirmed the lack of consistent activity programming, attributed to a shortage of activity assistants and recent staff turnover. The Dementia Care Director (DCD) acknowledged the issue and mentioned that the activity program on the Cottage Unit was more routine and geared towards residents with dementia, but recent staffing challenges had impacted the delivery of these activities. Resident 6's activity care plan indicated she enjoyed independent activities such as watching television, reading, listening to music, and coloring. However, during an observation on 6/4/24, Resident 6 was found lying in bed with the television on but not audible, and she expressed a need for a magazine, which was not provided. Similarly, Resident 49's activity care plan included an independent activity box with fidget toys, a deck of cards, a blanket, and a stuffed animal. However, observations revealed that the activity box was incomplete, missing the blanket and stuffed animal. Staff were unaware of the contents that should be in the activity box, indicating a lack of proper education and implementation of the care plan. Additionally, Resident 49, who had a history of wandering into other residents' rooms, was observed entering Resident 92's room on multiple occasions without staff intervention. This caused distress to Resident 92, who loudly asked Resident 49 to leave. The care plan for Resident 49 included approaches to redirect him away from others' rooms and to use snacks as a distraction, but these measures were not observed being implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed the deficiencies and acknowledged the need for staff education on these issues.
Failure to Document and Address Grievance for Missing Items
Penalty
Summary
The facility failed to fill out a grievance regarding missing items for Resident 92. Family Member 9 reported that Resident 92 was missing her bottom dentures and a pair of tennis shoes. These items were reported to the Dementia Care Director, who acknowledged being aware of the missing items but did not fill out a grievance form. The Dementia Care Director indicated that she was new and unaware of the policy regarding grievance documentation. The Executive Director confirmed that anyone, including residents, family, or staff members, could fill out a grievance and that the facility aims to address grievances promptly, typically within 72 hours. However, no grievance was filed for Resident 92, and no progress notes were entered into the resident's record for the month of May regarding the missing items. The clinical record review for Resident 92, who has a diagnosis of unspecified dementia, showed no documentation of the missing items. Additionally, a review of the resident grievance reports for May 2024 indicated no grievances were filed for Resident 92. The facility's Resident Concerns and Grievance policy states that grievances should be responded to promptly and reviewed by the Executive Director or Grievance Official. Despite this policy, the facility did not document or address the grievance related to Resident 92's missing items as required.
Failure to Prevent Sexual and Verbal Abuse
Penalty
Summary
The facility failed to prevent sexual abuse of two residents, Resident C and Resident F, by Resident E. Resident E, who has a history of sexually inappropriate behaviors, grabbed Resident C's breast while she was sitting at the nursing station. Despite being placed on 1:1 supervision, Resident E had previously grabbed Resident F's breast in the common area. Both incidents were reported, and the residents were separated immediately. Resident C and Resident F did not show signs of psychosocial distress following the incidents, but the facility's failure to prevent these occurrences is evident. Resident E's clinical record indicates diagnoses including vascular dementia, psychotic disturbance, mood disturbance, depression, bipolar disorder, and a high risk for heterosexual behavior and sexual inappropriate behaviors. Despite these known risks, the facility's interventions, such as increased medication and frequent checks, were insufficient to prevent further incidents. The care plan for Resident E included measures like providing space between him and female residents, room changes, and medication adjustments, but these were not effectively implemented to prevent the abuse. Additionally, the facility failed to prevent verbal abuse of Resident B by an Activity Assistant (AA 3). Resident B, who has Alzheimer's disease, major depressive disorder, bipolar disorder, and anxiety, was verbally abused when AA 3 raised her voice and used inappropriate language towards him. Multiple staff members witnessed the incident, and the Administrator confirmed that AA 3 admitted to raising her voice and using a curse word. This incident highlights the facility's failure to maintain an environment free from verbal abuse, as required by their policy.
Failure to Properly Apply Compression Stockings
Penalty
Summary
The facility failed to ensure that a resident's compression stockings were applied without wrinkles, as observed in 3 out of 4 instances. Resident 94, who has a medical diagnosis of heart failure, had a physician's order to wear thigh-high bilateral lower extremity TED hose in the morning and remove them at night. Despite this order, observations on multiple occasions revealed that the resident's compression stockings were wrinkled at various points, including the knee joints and areas between the ankle and knee. The resident indicated that while he could smooth out the wrinkles at the top, he was unable to do so for the lower parts of his legs. Interviews with the resident confirmed that the wrinkles were a common occurrence and that he was unable to fix them himself. The Director of Nursing acknowledged that there was no specific policy for TED hose but stated that the expectation was for them to be applied without wrinkles to prevent skin impairments. Despite this expectation, the facility staff failed to ensure the compression stockings were applied correctly, leading to the observed deficiencies.
Failure to Implement Fall Intervention for Resident
Penalty
Summary
The facility failed to implement a fall intervention for Resident 88, who was at moderate risk for falls and had a recent history of falling. The clinical record indicated that Resident 88 had a fall on 5/19/2024, and an intervention was put in place to have a sign in the resident's room to encourage the use of a call light for assistance. However, during multiple observations and interviews conducted on 5/20/2024, 5/31/2024, and 6/3/2024, it was noted that no such sign was present in Resident 88's room. Resident 88 himself confirmed that he had never seen the sign, and LPN 1 also indicated that she had never seen the sign in the resident's room. The facility's Fall Management Policy, provided by the Administrator, stated that comprehensive, resident-centered fall prevention plans must be implemented for each resident at risk for falls. Despite this policy, the facility did not follow through with the specific intervention for Resident 88, who had a medical diagnosis of malignant neoplasm of the kidney and was cognitively intact. This failure to implement the fall intervention as planned led to the deficiency noted in the report.
Failure to Provide Prescribed Nutritional Interventions
Penalty
Summary
The facility failed to provide adaptive eating equipment, fortified juice, and whole milk to three residents, leading to deficiencies in their nutritional care. Resident 58, diagnosed with dementia, severe protein calorie malnutrition, and dysphagia, was observed without a divided plate and fortified juice during her lunch meal, despite physician orders and care plans specifying these requirements. Similarly, Resident 6, who also has dementia and dysphagia, was served her meal on a regular plate instead of a divided plate as per her care plan. The LPN was initially unaware of this requirement until reviewing the care plan during the observation. Resident 65, with diagnoses including dementia, severe protein calorie malnutrition, and dysphagia, did not receive whole milk with her meal as ordered by her physician. The LPN confirmed the omission upon reviewing the resident's meal ticket and electronic health record. The facility's policies on adaptive eating devices and supplements were not followed, resulting in these deficiencies. The lack of adherence to prescribed nutritional interventions was evident in the observations and interviews conducted during the survey.
Resident Falls from Mechanical Lift During Transfer
Penalty
Summary
The facility failed to ensure a fall from a mechanical lift did not occur during a transfer from the bed to the chair, resulting in cervical and thoracic fractures of the spine for a resident. The incident involved two CNAs, one of whom was under 18 years old and therefore not permitted to operate the mechanical lift. During the transfer, one of the hooks on the sling came undone, causing the resident to fall approximately 4 to 5 feet and land on his head, resulting in a laceration and fractures to his spine. The resident, who had diagnoses including Alzheimer's disease, dementia, and other conditions, was being transferred by two CNAs. One CNA, who was under 18, connected one of the hooks to the mechanical lift, while the other CNA connected the remaining hooks and operated the lift. During the transfer, the hook on the top left of the sling came undone, causing the resident to flip in midair and land on his head. Immediate care was provided, and the resident was sent to the hospital, where he was diagnosed with fractures and a scalp hematoma. Interviews with the staff involved and the Assistant Director of Nursing revealed that there was confusion regarding the policy on whether staff under 18 could assist with mechanical lifts. The facility's policy indicated that staff under 18 could assist but not operate the lift. The incident led to a review of the mechanical lift, staff training, and an inspection of all mechanical lifts in the facility. However, the root cause of the incident could not be definitively determined, with possibilities including equipment failure or human error.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Of Richmond | 0 mi | ★★★★★ | 1 | 0 |
| Springs Of Richmond, The | 0.5 mi | ★★★★★ | 14 | 0 |
| Brickyard Healthcare - Richmond Care Center | 2.7 mi | ★★★★★ | 14 | 0 |
| Forest Park Health Campus | 3.4 mi | ★★★★★ | 12 | 0 |
| Arbor Trace Health & Living Community | 3.8 mi | ★★★★★ | 1 | 0 |
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