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 Rose Lane Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that multiple residents on a memory care hall were living in rooms and bathrooms with visible feces on toilets and floors, urine puddled on toilet risers, sticky and soiled floors, and strong putrid odors, despite facility policies stating that rooms and bathrooms should be cleaned daily. A resident reported that the bathroom had not been cleaned for several days. The housekeeper assigned to the hall described using a “trash and dash” method in some rooms, only removing trash and not mopping unless floors appeared obviously sticky, and acknowledged that one aggressive resident’s room was not cleaned at all the prior day. The HS had not recently checked this housekeeper’s work on the hall, and CNAs and a UM/LPN confirmed that residents had not refused housekeeping services.
Kitchen sanitation was found deficient when multiple QUAT buckets tested below the required 150-200 ppm, and surveyors observed dust and grime on the juice dispenser, oven, steamer, fryer wall, and hood fire suppression wall. An unlabeled bulk sugar container and an open box of frozen hash browns with an unsealed inner bag were also found; the Dietary Manager verified the findings and stated QUAT buckets should be changed every 2 to 3 hours.
A facility failed to provide a dignified dining experience when meals were passed out unevenly at tables, with residents receiving trays at different times and staff standing over or feeding residents in a manner that disrupted the meal setting. The facility also failed to ensure a resident with intact cognition and dependence for bathing was treated with dignity and respect during shower care, as the resident was left wrapped in a bath blanket in a wheelchair in a doorway and was in view of others while the CNA was away.
Failure to provide meaningful activities to a resident with dementia and cognitive impairment on the MCU. The resident’s care plan called for 1:1 visits, independent leisure, group activities, and interaction with family and staff, but his documented participation was mostly limited to passive routines such as TV, radio, carts, and nails. Observations showed residents wandering or sitting with little engagement, minimal unit stimulation, no posted activity calendar in the common area, no music in rooms, and activity staff on the unit only briefly or not present for scheduled activities.
The facility failed to ensure a clean, safe, and homelike environment for several residents. One resident’s bedside commode contained dried urine and BM, and the bathroom had BM around the toilet and on the floor, with no housekeeping presence noted on the hall and nursing staff later confirming the commode remained soiled. Another resident’s bed linens had smeared BM, multiple blood spots, and other brown stains that a CNA acknowledged needed changing but had not noticed. A third resident’s room had a loose wall night light and a damaged baseboard heater with a loose front panel and bent coils that became caught on the resident’s rollator. These conditions conflicted with the facility’s stated resident rights to a safe, clean, and comfortable environment with appropriate housekeeping, maintenance, and clean linens.
A cognitively impaired resident with dementia, depression, anxiety, muscle weakness, and documented weight loss had a care plan identifying risk for poor nutrition and dehydration, with interventions to assist with meals and feed as needed. During a lunch meal, staff placed food in front of the resident while other residents were being assisted; when a staff member briefly placed a sandwich in his hand, he ate, but that staff member left and did not return. The resident then struggled to open crackers, ate only those, and left the rest of the meal untouched despite a verbal cue from across the table, eventually closing his eyes before a CNA removed the tray. Staff reported that the resident usually ate independently with verbal cues and that meal intake was recorded from memory, while leadership confirmed there was no specific ADL policy despite the care plan directive to assist with meals and feed as needed.
Delayed Response to Resident Call Lights: Staff failed to answer two residents' call lights in a timely manner. A CNA was charting at the nurse's station while call lights had been on for more than 34 and 43 minutes, and an RN verified the delay was too long. Interviews also confirmed that an LPN was occupied with med pass, another CNA was busy getting residents up for therapy, and one resident stated his call light was not answered timely because he could not reach his water and personal items.
A resident receiving dialysis had no documented post-dialysis assessments after repeated returns from an outside dialysis center. The resident had diagnoses including TBI, DM2, kidney disease, and nephritic syndrome, and the chart showed dialysis orders but no order for return assessments. Progress notes lacked post-dialysis assessments on multiple dialysis days, an LPN expected an assessment on return, and the DON stated the facility does not complete post-dialysis assessments.
Failure to follow EBP during catheter care. A resident with neurogenic bladder and an indwelling catheter was on EBP, with a sign indicating gown and gloves were required for catheter care. During observed catheter care, a CNA did not wear proper PPE, and later confirmed she should have worn a gown but had been told it was not needed. The facility catheter care policy only addressed hand hygiene and gloves, with no mention of EBP.
A resident with significant medical needs was found to have multiple new hip fractures and a dislocation after being transferred to the hospital, with no witnessed injury or fall during their stay. Despite being informed by hospital staff, facility leadership did not report the injury of unknown origin to authorities as required by policy, instead attributing the injuries to infection based on physician input. The facility's own policy and state regulations mandate immediate reporting of such injuries, but this was not followed.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and homelike environment on the 300-hall memory care unit, affecting 12 residents out of 30 on that hall. During an observation period, surveyors and the Housekeeping Supervisor identified multiple resident rooms and bathrooms with visible feces on toilets, floors, and in open soiled briefs, as well as urine puddled on toilet risers, sticky floors, large amounts of food and fecal matter on floors, and strong putrid odors. Several toilets had visible buildup and rings, suggesting they had not been cleaned in some time, and fecal splatter remained in at least one toilet even after flushing. A resident reported that the bathroom was not cleaned often and that it had been a few days since the last cleaning. Interviews with housekeeping and nursing staff further described the practices that led to the unclean conditions. The housekeeper assigned to the memory care hall stated that he had cleaned all bathrooms the previous day but used a “trash and dash” approach for rooms that did not look bad to him, meaning he only removed trash and did not mop floors unless they were obviously sticky. He also reported that one aggressive resident’s room was not cleaned at all the previous day. The Housekeeping Supervisor acknowledged that all resident rooms and common areas were supposed to be cleaned seven days a week, but she had not checked this housekeeper’s work on the 300-hall and had last reviewed his work two weeks earlier on a different unit. CNAs and the Unit Manager/LPN reported that residents on the unit had not refused housekeeping services. Facility documents and the resident handbook stated that resident rooms and bathrooms were to be cleaned daily, with floors swept and mopped daily and more thorough weekly cleaning, which contrasted with the observed conditions and reported cleaning practices.
Kitchen Sanitation and Labeling Deficiencies
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner. During observation of the kitchen, the sanitizing level of a bucket of quaternary cleaner at the three-compartment sink was below the required 150-200 ppm, and additional QUAT buckets near the dishwashing station and in the main food preparation area were also below the required range. The observation also identified a layer of dust and grime on the top and side of the juice dispenser, dust and grime on top of the standing oven and steamer, grime on the wall near the fryer, and grime on the wall where the hood fire suppression system was mounted. Other findings included a bulk storage tub of sugar in the main food preparation area that was unlabeled and a box of frozen hash browns that was open with the interior bag unsealed. The Dietary Manager stated that QUAT buckets should be changed every two to three hours, that there is a cleaning schedule for the kitchen, and verified the findings. Review of the facility policies showed that sanitary conditions would be maintained and that supplies would be clearly labeled.
Dignity and Respect Failures During Dining and Personal Care
Penalty
Summary
The facility failed to provide a dignified dining experience on the Memory Care Unit. During observation, 22 residents were seated at seven tables while trays were passed from a cart in the hallway by two CNAs, with additional assistance from the AD and HR staff. At one table, one resident ate while another sat watching and then left the dining room without eating. At another table, a resident was fed by the AD while the AD stood over the resident for several minutes before sitting down, and the other residents at that table did not receive their meals at the same time. At a third table, residents received their meals at different times, with one resident not receiving a meal until 10 minutes after others at the table had already been served. Staff interviews confirmed there was no seating chart for the dining room and no specific facility policy for serving meals in the dining room. A CNA stated trays were taken from the cart in room order rather than being passed out by table. The Unit Manager confirmed there was not necessarily a seating plan and that meals were passed out as they were pulled off the cart, and she verified meals were not passed out at each table at the same time. The Administrator also confirmed there was no specific facility policy for serving meals in the dining room. The facility also failed to ensure Resident #9 was provided dignity and respect at all times. Resident #9 had diagnoses including type 2 diabetes, anxiety disorder, and chronic pain, and the quarterly MDS indicated intact cognition and dependence for showering and bathing. The resident reported being upset with a CNA after a shower because the CNA was not attentive and did not cover the resident well while traveling in the hallway. The resident’s witness statement described being completely undressed except for a blanket, showered on another hall, then left wrapped in a bath blanket sitting in a wheelchair in the doorway of the room for approximately 25 minutes while the aide was gone. The CNA confirmed the resident was left in the doorway in a bath blanket and acknowledged the resident was in visual view of other residents on the hall and sitting in a wheelchair with no other clothing on. The DON also confirmed the resident’s daughter had previously reported concerns about the same CNA providing care for the resident.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide meaningful activities to a resident on the Memory Care Unit. The resident had been admitted with diagnoses including intracranial injury with loss of consciousness of unspecified duration, dementia, dysphagia, aphasia, and major depressive disorder. The annual MDS showed cognitive impairment and that he was independent with walking. His preferences indicated snacks were very important, while reading and animals were not important and music was somewhat important. His activity assessment, completed by his wife, documented no participation in activities, that he enjoyed motorcycle riding, watched TV, would be interested in pet visits, and would respond with prompts and cues. The resident’s care plan included goals for engaging in activities such as 1:1 visits, independent leisure, and group activities with assistance or set-up as needed, as well as interacting with family, significant others, and staff. Interventions included offering conversation, making eye contact, providing 1:1 visits, and encouraging participation in activities. Despite these care plan goals, the resident’s activity participation record for the prior 30 days showed mainly passive or routine items such as coffee cart, juice cart, radio, TV, daily chronicle, and nails, with only one beach ball activity and one new monthly activity calendar entry. Observations on the unit showed residents sitting in TV lounges with little engagement, residents wandering the hallways, and staff redirecting wandering residents without offering activities or tasks to engage them. The unit had minimal decorations, no posted activity calendar in the common area, and no evidence of music playing in resident rooms, including the resident’s room. Activity staff were observed on the unit briefly passing hydration carts or milkshakes, and one scheduled arts and crafts activity was not observed. Interviews with family and staff reflected concern that the resident was not being provided enough activities and that activity staff were usually on the unit only briefly or two to three times on the MCU.
Failure to Maintain Cleanliness and Safe Room Conditions for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment for multiple residents. For one resident, surveyors observed a bedside commode containing dried urine and bowel movement, and the resident’s bathroom had bowel movement around the toilet riser, toilet base, and on the floor while the resident was out of the room. When the resident returned, she stated she takes herself to the bathroom and had used the bedside commode a few days earlier. Although an RN cleaned the bathroom, a later observation the same day showed the bedside commode still had not been cleaned. Housekeeping staff reported that resident rooms are cleaned daily when a housekeeper is assigned to the hall, but on weekends there may not be a housekeeper on each hall. The RN later verified that the bedside commode still contained dried urine and bowel movement and stated it should have been cleaned by housekeeping or the CNA on the hall. Another resident’s bed linens were found with dried brown spots that appeared to be dried blood, and later observations confirmed smeared bowel movement on the incontinence pad and multiple blood spots and other brown areas on the flat sheet, top sheet, and covers. The resident reported not knowing when his sheets were changed. A CNA stated linens are changed on bath days and as needed but acknowledged the sheets needed to be changed and that she had not noticed their condition during her shift. A third resident, who had been in his room about a week, had a loose night light on the wall and an electric baseboard heater in disarray, with the front panel partially off, coils bent, and the panel caught on the resident’s rollator. A maintenance staff member later verified the loose night light and the disarrayed baseboard heater. The facility’s resident handbook states residents have the right to a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services and clean bed and bath linens in good condition.
Failure to Follow Care Plan for Meal Assistance for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide meal assistance in accordance with the care plan for a cognitively impaired resident who required set-up or clean-up assistance with eating and was dependent for all other ADLs. The resident had dementia, depression, anxiety, hypertension, muscle weakness, and a documented need for assistance with personal care. Nutritional assessments and orders showed he was on a regular diet with thin liquids and a house supplement twice daily, with documented weight loss over several months. His care plan, initiated shortly after admission, identified risk for decreased nutritional status and dehydration and included interventions to assist him with meals and feed as necessary, as well as to monitor intake and weight. During a lunch observation in the memory care unit dining room, staff placed the resident’s meal in front of him while two CNAs, the Activity Director, and Human Resources staff were present passing trays and assisting others. HR staff verbally discussed whether the resident needed food placed in his hand or just in front of him; when HR handed him a sandwich, he began eating, but HR then left and did not return. The Activity Director continued assisting another resident and only gave a verbal cue from across the table, which did not prompt the resident to use his utensils. The resident struggled for several minutes to open a cracker packet, ate the crackers, but left soup, potato salad, and fruit untouched, then closed his eyes and attempted to push back from the table. His nose was dripping when a CNA asked if he was done, then removed his largely untouched meal. Staff interviews indicated they believed he usually ate independently and needed only verbal cues, and that meal intake was documented from memory rather than at the time of the meal. The DON confirmed there was no specific ADL policy and that the care plan included assisting with meals and feeding as needed.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure residents received timely assistance to meet their needs. During observation of the 500-hall nurse's station, CNA #909 was seated at the desk charting on the computer next to the call light monitor and then stated she had to answer the call lights. At that time, the call light for Resident #181 had been on for 34:54 minutes and the call light for Resident #180 had been on for 43 minutes. This was verified by LPN #971. RN #821 stated that 35 minutes was too long and identified that CNA #884 was on the hall and should have answered the call light. RN #821 also stated Resident #181 used the call light frequently. Additional interviews confirmed delayed response to call lights and resident needs. LPN #902 stated her pager was on the desk at the nurses station and she had not checked it because she was passing medications, and that when she is not passing medications she looks at her pager and answers call lights. Resident #180 stated his light had been on for a very long time because he could not reach his water and personal items since the side table was too far away, and he stated his call light is not answered timely. CNA #942 stated she was making her way to Resident #180 while getting four residents up for therapy and said call lights need to be answered as soon as they can. CNA #909 later stated she had seen on the call light monitor that two call lights needed to be answered and that she should have gotten up to answer the call lights for room [ROOM NUMBER] and 610 because they had been on for more than 35 minutes. RN #821 verified that 43 minutes was too long for a resident to wait to have a call light answered.
Missing Post-Dialysis Assessments for a Resident Receiving Dialysis
Penalty
Summary
The facility failed to ensure Resident #110 was properly assessed after returning from an outside dialysis center. Resident #110 was admitted with diagnoses including traumatic brain injury, type 2 diabetes, kidney disease, nephritic syndrome, and need for assistance with personal care. The physician orders showed the resident received dialysis every Tuesday, Thursday, and Saturday, but there was no order to assess the resident on return from dialysis. The care plan identified dialysis care with a goal of being free from complications related to dialysis and included monitoring vital signs as needed. Review of the progress notes from 11/29/25 through 01/28/26 showed no post-dialysis assessment documented for multiple dialysis return dates, and there was no evidence that Resident #110 refused such an assessment. An LPN stated they would expect an assessment when the resident returned from dialysis, and verified the absence of post-dialysis assessments in the dialysis communication binder. The DON stated the facility does not complete post-dialysis assessments. The facility policy stated licensed nursing staff will provide appropriate dialysis-related treatments and notify the physician and dialysis center of any abnormal findings.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were followed during catheter care for Resident #181, who had a diagnosis of neurogenic bladder and orders for an indwelling catheter and Enhanced Barrier Precautions. Observation of the resident’s door showed a sign indicating EBP and that a gown and gloves were to be worn while providing urinary catheter care. During observation of catheter care, CNA #884 did not wear proper personal protective equipment while providing indwelling catheter care. The resident stated that staff never wear a gown when providing catheter care, and CNA #884 later verified that the resident was on EBP and that she should have worn a gown during catheter care, but said she had asked prior to completing care and was told she did not need to wear one. Review of the facility’s Catheter Care Policy dated 09/2023 showed instructions to wash hands and don gloves, with no mention of EBP during catheter care.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin for a resident who was admitted with multiple complex medical conditions, including an abscess of the right hip, MRSA infection, and Alzheimer's Disease. The resident was dependent on staff for all activities of daily living and was always incontinent. During the resident's stay, there was a documented change in condition, including a high fever, which led to the resident being sent to the hospital. Hospital staff later informed facility staff that the resident had multiple new fractures and a dislocated right hip, with no reported falls or witnessed injuries during the resident's stay. Despite being notified by the hospital of the fractures and dislocation, the facility did not report the injury as an injury of unknown origin to the state agency. The DON initiated an internal investigation, including staff interviews and skin sweeps of all residents, but discontinued the reporting process after the facility physician suggested the injuries could be attributed to infection rather than trauma. The facility's own policy defined an injury of unknown source as one not observed or explained, and suspicious due to its extent or location, which applied to this case. Interviews with facility staff, including the DON, RN, and Administrator, confirmed that injuries of unknown origin are required to be reported within two hours according to both facility policy and state regulations. However, the injury was not reported as required, and not all relevant staff were interviewed during the initial investigation. The deficiency was identified during a complaint investigation and was based on interviews, record reviews, and facility policy review.
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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.
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|---|---|---|---|---|
| The Pavilion At Canal Fulton For Nursing And Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Altercare Of Nobles Pond, Inc | 2.3 mi | ★★★★★ | 7 | 0 |
| Laurels Of Massillon, The | 3.1 mi | ★★★★★ | 1 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 3.3 mi | ★★★★★ | 2 | 0 |
| Chapel Hill Community | 3.7 mi | ★★★★★ | 0 | 0 |
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