Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Rosegate Village during CMS and state inspections, most recent first.
Improper Hair Restraints in Kitchen Food Service Areas: During kitchen observations, a Cook and a Culinary Aide were seen working near the steamtable and plating the noon meal while parts of their hair and facial hair were not fully covered by hair nets or beard restraints. The Dietary Mgr stated dietary staff were to keep their hair covered, and the facility policy required hair and beard restraints that effectively cover all hair.
Two residents had new psychotic disorder diagnoses added to their records after admission, but no new PASARR Level I was completed for either resident. One resident had moderate cognitive impairment and the other had severe cognitive impairment on quarterly MDS assessments. The ED acknowledged that PASARR Level I should have been completed with the new diagnoses, and the facility policy stated PASARR assessments were to be updated with significant changes in mental or physical status.
A resident with HTN and venous insufficiency had orders for metoprolol and lisinopril to be held if SBP was below 110, but the MAR showed both meds were given when the resident's SBP was 90. The DON stated the meds should have been held and the facility could not provide a specific policy for following physician orders.
A facility audit revealed that an RN signed out narcotic medications for two residents who were hospitalized at the time, indicating misappropriation. The RN tested positive for opioids and benzodiazepines and was terminated. Resident D, cognitively intact, and Resident E, with severe cognitive impairment, were both affected.
A CNA at a long-term care facility was terminated after spitting in a resident's face during care. The resident, who was severely cognitively impaired, had been aggressive and combative, leading to the incident. The facility's abuse prohibition policy was violated, and the incident was reported and investigated, resulting in the CNA's termination.
A facility failed to follow its abuse policy by not immediately removing a CNA who allegedly spit in a resident's face after the resident was aggressive. The CNA was unsupervised for a period before being escorted out, contrary to the facility's policy requiring immediate removal of staff implicated in abuse.
The facility failed to provide complete written notices of transfer and discharge to three residents and their representatives. The notices lacked essential information about appeal rights and the bed-hold policy. The Director of Nursing confirmed the omission of critical details, leaving residents and their representatives uninformed about their rights and procedures during facility-initiated transfers.
The facility failed to maintain accurate documentation for two residents. A resident with end-stage renal disease had missing daily weight records, despite physician orders for daily monitoring. Another resident, with bone density disorders, lacked documented weekly skin assessments, even after a fracture and bruising were noted. The DON confirmed these documentation lapses.
Improper Hair Restraints in Kitchen Food Service Areas
Penalty
Summary
The facility failed to ensure foods were served in a sanitary and safe manner during kitchen observations of the noon meal. During the first observation, Cook 2 was working at the steamtable, taking starting food temperatures, and plating the noon meal while wearing a white hair net and beard restraint; however, facial hair approximately one-half inch in length in front of the ears was not covered. Culinary Aide 3 was also observed walking throughout the kitchen area and near the steamtable while wearing a white hair net, but hair in front of the ears and in the middle of the forehead, approximately 2 inches in length, was not covered. During a follow-up observation later the same day, Cook 2 was again observed at the steamtable plating the noon meal and taking ending food temperatures with the same facial hair in front of the ears not covered. Culinary Aide 3 was again observed in the kitchen area and near the steamtable with hair in front of the ears and in the middle of the forehead not covered. The Dietary Manager stated dietary staff were to keep their hair covered while in the kitchen, and the facility policy required a clean hair restraint that effectively covers all hair and a beard restraint that effectively covers all facial hair.
Failure to Complete PASARR Reassessments After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that two residents were referred to the State-designated authority contractor for a Level I PASARR mental health assessment after new diagnoses of mental illness were added to their records. Resident 79 was admitted with a PASARR Level I completed, and on 9/24/24 a new diagnosis of psychotic disorder with hallucinations due to known physiological condition was added without a new PASARR Level I completed. Resident 79's quarterly MDS dated 12/9/25 indicated moderate cognitive impairment. Resident 12 was admitted with a PASARR Level I completed, and on 5/1/25 a new diagnosis of psychotic disorder with hallucinations was added without a new PASARR Level I completed. Resident 12's quarterly MDS dated 10/22/25 indicated severe cognitive impairment. During interview, the Executive Director stated that a PASARR Level I should be completed with any new diagnoses and acknowledged that it was not completed for Resident 79 or Resident 12. The facility policy provided during the interview stated that PASARR assessments were to be updated with significant changes in mental or physical status.
Failure to Hold BP Medications per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for blood pressure medications for one resident with diagnoses including venous insufficiency and hypertension. The resident had orders for metoprolol succinate 50 mg daily, to be held if systolic blood pressure was less than 110 or heart rate was less than 60, and lisinopril 20 mg daily, to be held if systolic blood pressure was less than 110. A vital sign record showed the resident's systolic blood pressure was 90, but the medication administration record indicated that both lisinopril and metoprolol were administered anyway. During interviews, the DON stated the medications should have been held based on the physician's orders and later stated the facility was unable to provide a specific policy for following physician orders, noting the facility was to follow state and federal regulations.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to protect residents' rights from misappropriation of property, specifically involving the wrongful use of narcotic medications. During a facility-wide audit, it was discovered that narcotic count sheets, initially thought to be correct, showed medications signed out for residents who were not present in the facility at the time of administration. RN 3 was identified as the nurse who signed out these medications for Resident D and Resident E, both of whom were hospitalized at the time. A drug screening test conducted on RN 3 revealed positive results for opioids and benzodiazepines, leading to the suspicion of drug diversion. Resident D, who was cognitively intact, had a hydrocodone-acetaminophen prescription, with a tablet signed out by RN 3 after Resident D had been transferred to the hospital. Similarly, Resident E, who had severe cognitive impairment, had an oxycodone prescription, with a tablet signed out by RN 3 while Resident E was also hospitalized. Despite RN 3's denial of taking the medications, the evidence from the narcotic sheets and the positive drug test led to RN 3's termination for misappropriation of resident medications.
CNA Spits in Resident's Face During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a Certified Nursing Assistant (CNA) spit in the resident's face. The incident involved Resident B, who was severely cognitively impaired and had a history of stress compression fracture and chronic obstructive pulmonary disorder. On the evening of the incident, Resident B was being aggressive and combative with staff, leading to a situation where the resident slapped CNA 1 in the face. In response, CNA 1 retaliated by spitting back in Resident B's face, which was witnessed by Licensed Practical Nurse (LPN) 1 and other staff members. The incident was reported to the Administrator by LPN 1, and an investigation was conducted. CNA 1 admitted to the act in a written statement, acknowledging that they lost control momentarily. The facility's policy on abuse prohibition, reporting, and investigation, which aims to provide an environment free from abuse, was violated in this instance. The incident was documented in a facility reportable incident and an Employee Communication Form, leading to the termination of CNA 1 for violating the resident abuse policy.
Failure to Immediately Remove CNA After Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately removing a Certified Nursing Assistant (CNA) implicated in an alleged abuse incident. The incident involved CNA 1 spitting in the face of Resident B after Resident B had been aggressive and combative, slapping CNA 1 and spitting in her face. Although Licensed Practical Nurse (LPN) 1 removed CNA 1 from Resident B's room, CNA 1 was not immediately escorted out of the facility. Instead, CNA 1 was unsupervised for a period, during which she went to the restroom before being asked to write a statement and then escorted out. The facility's policy, as provided by the Director of Nursing (DON), clearly states that any staff member implicated in alleged abuse should be removed from the facility at once. However, this protocol was not followed as CNA 1 was not immediately removed from the premises, leading to a deficiency in the facility's handling of the situation. This incident was part of a complaint investigation, highlighting a lapse in the facility's adherence to its own abuse prevention and response policies.
Failure to Provide Complete Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide written Notice of Transfer and Discharge to three residents and their representatives, as required. The deficiency was identified during a review of the clinical records and interviews with the residents and staff. Resident 42, who was severely cognitively impaired, was transferred to the hospital emergency department without receiving a transfer form that included specific details about appeal rights and the bed-hold policy. Similarly, Resident 107, also severely cognitively impaired, was transferred without the necessary information on appeal rights being provided. Resident 279, who was cognitively intact, was transferred to the hospital, and both the resident and their representative reported not receiving any written documentation of the transfer or the bed-hold policy. The Director of Nursing Services confirmed that the transfers were facility-initiated and that the ASC Hospital-ER Transfer Form was provided to the residents and their representatives. However, the form lacked critical information regarding the appeal process, including contact details for the State entity handling appeals, instructions on obtaining and submitting an appeal form, and contact information for the State Long-Term Care Ombudsman. This omission resulted in the residents and their representatives not being fully informed of their rights and the procedures available to them in the event of a transfer or discharge.
Documentation Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents, Resident B and Resident C. For Resident C, the clinical record review revealed a lack of documentation for daily weights as ordered by the physician. The orders specified that Resident C's weight should be recorded daily, with instructions to notify the medical doctor if there was a significant weight gain. However, the records only showed a weight entry for one day, and the Director of Nursing confirmed that the weights should have been documented daily in the electronic healthcare record. For Resident B, the facility did not document weekly skin assessments as required. Resident B had a history of disorders of bone density and structure, and a hospice note indicated bruising and pallor of the right lower extremity, with a stat x-ray ordered. A subsequent physician's progress note confirmed a fracture and traumatic bruising. Despite the care plan indicating a risk for skin breakdown and the need for weekly assessments, the clinical record lacked documentation for several weeks. The Director of Nursing acknowledged that these assessments should have been recorded.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southpointe Healthcare Center | 1 mi | ★★★★★ | 13 | 0 |
| Hawthorne Healthcare Center | 2.3 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Southport | 2.7 mi | ★★★★★ | 5 | 0 |
| University Heights Health And Living Community | 3.3 mi | ★★★★★ | 3 | 0 |
| Greenwood Health And Living Community | 3.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.