Rock Haven

Inspectors wroteBased on observation and interview, the facility did not prepare and distribute food in accordance with professional standards for food service safety. This has the potential to affect all 91 residents. Surveyor observed a cook take the temperatures of food without properly cleaning the food thermometer probe. Evidenced by: Facility policy, entitled Food Temping, dated 10/8/25, states, in part: Purpose: To provide every resident adequate nutrition in a safe environment. Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Policy: Rock Haven will provide residents with meals that are safe. following infection prevention measures. Procedure: Service: . 9. [NAME] food to proper temperature. 10. Use a clean thermometer. [...]

Inspectors wroteBased on interview and record review the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 4 of 4 supplemental residents (R79, R43, R17, and R27). R79, R43, R17, and R27 were treated with antibiotics without meeting Loeb Criteria. R79, R43, R17, and R27 did not have an antibiotic stewardship conversation with the Provider. This is evidenced by: The Facilities Antibiotic Stewardship Policy and Procedure dated 10/20/25 documents in part: .Antibiotic stewardship will include an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 staff reviewed for background checks. MT C (Maintenance Tech) did not have a background check completed every 4 years. This is evidenced by:The facilities Policy and Procedure for Background Checks states in part. Wisconsin law requires caregiver background checks using a Background Disclosure Form mandating completion at hire and every four years. MT C (Maintenance Tech) hire date was 12/14/20. His last completed background check was completed on 1/28/26. MT C should have had a background check completed by 12/14/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 22 sampled residents (R53). R53 has a diagnosis of Congestive Heart Failure and the facility failed to recognize R53's severe weight gain as a significant change in condition, and the PCP was not notified. Staff failed to re-weigh, conduct assessments, and put appropriate interventions into place regarding R53's weight gain and increased edema. This is evidenced by: Facility policy titled, Weight Management, dated 6/10/15, states, in part, Procedure: . Residents will be weighed monthly unless otherwise ordered by the Physician or deemed necessary by the Interdisciplinary Team. Re-Weights will be obtained as soon as possible for any resident with a +/- five (5) lb. change from the previous weight. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 4 Sampled residents (R47) reviewed for trauma informed care. R47 did not have a Trauma Informed Care Assessment completed upon admission. Psychiatric notes written while admitted to the facility indicate R47 has a history of nightmares related to combat he experienced in Vietnam. R47's trauma was not identified, and no care plan approaches to mitigate triggers to prevent re-traumatization were put into place. This is evidenced by: The facility policy entitled, Trauma Informed Care, dated [DATE], states in part: [...]

Inspectors wroteBased on interview, record review, facility document and policy review, the facility failed to reassess the risk of elopement and identify interventions to prevent a resident from exiting the facility through the bedroom window for 1 (Resident #1) of 5 residents reviewed for accidents. Resident #1 was observed by staff packing their belongings in a bag and saying they were leaving the facility but was not reassessed for the risk of elopement. Resident #1 exited the facility on 07/03/2025 at 12:05 AM, unnoticed and unsupervised by staff, and was found after approximately ten minutes in the bushes outside the resident's bedroom window.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to prevent significant medication errors for 2 out of 7 residents (R1 and R4) reviewed for medication administration out of a total sample of 15 residents. R1 was administered medications prescribed for R2 on 04/16/25. This medication error caused R1 to be transferred to the hospital due to an accidental medication overdose. The facility's failure to prevent significant medication errors, continually assess the resident after the medication error, and immediately notify the physician of the medication errors created a finding of immediate jeopardy that began on 4/16/25. Surveyor notified the Administrator and Assistant Director of Nursing (ADON) of the immediate jeopardy on 6/5/25 at 10:20 AM. [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to follow professional standards for 1 of 3 residents (R8) reviewed for Power of Attorney (POA) status out of a total sample of 15.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure two residents (R) (R16 and R43) out of 22 residents reviewed for abuse/neglect were protected from potential physical abuse. The facility failed to ensure R16 was protected from potential physical abuse by Certified Nurse Aide (CNA) 2 by continuing to schedule CNA2 on the same unit that R16 resides. As a resident, R16 continued to be fearful. The facility failed to prevent physical and verbal abuse of R43 in which CNA3 prevented R43 from rising from a chair and was potentially verbally abusive during this same interaction by CNA3. (Cross Reference F610 and F730)

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a Certified Nurse Aide (CNA) 1 reported allegations of physical abuse by Licensed Practical Nurse (LPN) 3 against Resident (R) 93 immediately to the Administrator for 1 out of a sample of 22 residents reviewed for abuse. This failure increased the risk of other vulnerable residents for further physical abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that allegations of abuse were thoroughly investigated for two residents (Resident (R)16 and R43) out of a sample of 22 residents reviewed for abuse. This lack of investigation had the potential to lead to continued episodes of physical and verbal abuse.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify the resident and resident's representative (RR) of a transfer or discharge in writing for one of one resident (Resident (R) 6) reviewed for hospitalization. This created a potential for the resident or their resident representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of one Resident (R) (R34's) clinical records out of a sample of 22 residents contained evidence the resident and/or her representative participated in the development or revision of her care plan.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 3 of 5 Residents (R90, R243, R89) reviewed for catheters as catheter bags were observed to be uncovered and resting/touching on the floor.

Inspectors wroteBased on interview, personnel file review, and policy review, the facility failed to ensure 1 of 2 Certified Nurse Assistant (CNA) (CNA2) reviewed was provided an annual performance review. This failure had the potential for decreased quality of life or quality of care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for one (Resident (R) 43) of five residents reviewed for unnecessary medications out of a total sample of 24. The facility failed to ensure staff did not administer as needed (PRN) lorazepam (Ativan, a psychotropic anxiolytic medication) to R43 without indication for use and failed to ensure the PRN lorazepam was not prescribed beyond 14 days without documented rationale.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records were complete and accurate for 1 resident (R), R89, of 22 residents sampled. The facility failed to ensure R89 had orders for an indwelling urinary catheter. This had the potential to cause R89's care needs to go unmet.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents reviewed for flu/pneumonia vaccinations (Resident (R) 71) and/or their representatives, the opportunity for the residents to be vaccinated with Pneumococcal 20-valent Conjugate Vaccine PCV 20 or Pneumococcal polysaccharide vaccine 23 (PPSV23), in accordance with nationally recognized standards out of a total sample of 22 residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 89 residents (R) in the facility. The facility's water management plan did not identify/assess through text and flow diagrams areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This is evidenced by: The facility policy titled, Legionella Plan, undated, indicates, in part: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a Discharge Summary, with a recapitulation of the resident's stay includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 1 sampled residents (R94) reviewed for discharge summary/recapitulation. R94 did not have recapitulation of stay or a discharge care plan prior to being discharged from the facility.

Inspectors wroteBased on observation, interview, and record review the facility did ensure residents unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good grooming by developing and implementing interventions in accordance with the residents' assessed needs, goals for cares, preferences, and recognized standards of practice that address identified limitations in residents' ability to perform ADLs for 1 (R20) of 21 residents reviewed for ADL care. - The facility failed to implement a care plan intervention to establish R20's grooming preferences. This is evidenced by: On 7/12/23, at 10:08 AM, Surveyor requested a facility policy for grooming to include nailcare and shaving from Nursing Home Administrator A (NHA). NHA A indicated that the facility does not have a grooming policy. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents received care consistent with professional standards of practice to promote healing of pressure ulcers/injuries (PI) for 1 (R20) of 2 residents reviewed for PI's. -The facility failed to measure and document R20's wounds for 19 days from 6/21/23 to 7/10/23. -The facility failed to implement a care plan intervention to redistribute pressure to R20's left and right buttock pressure ulcers while in wheelchair. This is evidenced by: The Facility policy, entitled Skin Care and Pressure Injury Management, dated 5/21/2015, states: Nurses will conduct a weekly skin assessment to identify changes . if wound is present, assess after cleansing for: . size. [...]

Inspectors wroteBased on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 2 of 5 residents (R14 and R19) reviewed for immunizations of 22 sampled residents. R14 did not have pneumococcal immunization offered and no documentation. R19 did not have pneumococcal immunization offered and no documentation. This is evidenced by: The facility's Pneumococcal Vaccine Policy and Procedure with a revision date of 2/27/23, states, in part: I. Purpose: [...]