Rose Haven Nursing Home

Inspectors wroteBased on staff interviews, clinical record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement transmission based precaution procedures, monitor, and test residents with symptoms or exposure to COVID-19 virus for 2 of 4 residents reviewed for infection control. The facility failed to ensure that criteria was followed to reduce the risk of COVID-19 transmission when Resident #2 tested positive for COVID-19 on 2/19/26 at the hospital, then returned to the facility on 2/25/26 (7 days), the facility did not provide additional precautions for Resident #2 who continued to have respiratory symptoms. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to determine that it was clinically appropriate and safe for a resident to self-administer medications for 1 of 1 residents reviewed for the self-administration of medications(Resident #13). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure residents were free from physical abuse for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to carry out a gradual dose reduction(GDR) or ensure the provider documented why the reduction would be clinically contraindicated for 1 of 5 residents reviewed for psychotropic medications(Resident #35). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to separate an alleged perpetrator of abuse from residents for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to administer insulin in a timely manner with respect to the obtainment of the resident's blood sugar(BS) for 1 of 2 residents(Resident #2) reviewed for insulin(an injectable medication used to lower blood sugars). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to assess and intervene in a timely manner after a resident complained of signs and symptoms of an infection for 1 of 2 residents reviewed for a change in condition(Resident #26). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews and facility policy review the facility failed to treat one out of four residents reviewed in a dignified manor (Resident#5). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, resident interviews, and facility policy review the facility failed to report an allegation of abuse in a timely manner for 1 out of 4 residents reviewed for abuse ( Resident#2). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, resident interviews, and facility policy review the facility failed to do a thorough investigation into an allegation of abuse for 1 out of 4 residents reviewed Resident#2). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, resident and staff interviews and facility policy review the facility failed to transfer 3 out of 4 residents safely Resident#1, #2, and #5). The facility reported a census of 49 residents.

Inspectors wroteBased on staff interview, facility record review and facility policy review the facility failed to address previously cited deficiencies in the Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 49 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and facility policy review the facility failed to store medication in the packaging the medications came in, in the medication cart and stored held in a medication cup for one out of one resident s reviewed, the facility failed to keep one out of one refrigerators locked for 1 out of 3 days and failed to date one out of one insulin pens after staff opened it. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to follow the facilities abuse policy and procedures after identifying a missing narcotic medication for 1 of 1 resident reviewed (Resident#24). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews and facility policy review the facility failed to do a thorough investigation into medications found in a medication cup that failed to include a prescribed narcotic for 1 out of 1 resident reviewed Resident#24. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, observations, State Climatologist Report, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision to prevent hazards during a temporary modification of a safety intervention. The Maintenance Supervisor turned off the alarm to the southeast outside door to allow workers access to resident areas for repairs and failed to notify nursing staff for 2 1/2 hours. A confused, independently mobile resident exited the door in his wheelchair and was found outside in 36-degree weather at the time of his exit from the building with wind gusts of 24 mph causing a Wind Chill of 27 degrees and no coat to protect him. Estimated time outside of the building was 10-15 minutes. The failure resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 44 residents. [...]

Inspectors wroteBased on staff interview and Facility Assessment review, the facility failed to employ a Registered Nurse (RN) to serve as the Director of Nursing (DON) since March 9, 2023. The facility reported a census of 45 residents.

Inspectors wrote2. The MDS Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. The MDS documented the resident's BIMS score as 15 out of 15, indicating intact cognition. A clinical record review revealed a Physician Order for colostomy care, with colostomy bag changes twice weekly on shower days. The Care Plan directed staff to assist with emptying the colostomy bag every shift and as needed. During an interview on 8/28/23 at 9:34 AM, the resident stated there are times the colostomy bag will pop off due to a gas build up. The resident stated that when this happens Staff D, CNA has yelled at him to stop playing with the bag. [...]

Inspectors wroteBased on observation, staff and resident interviews, and facility document review the facility failed to promote resident choice in their morning schedule for 1 of 1 residents in the sample (Resident #11). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. Total dependence is required for transfers. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an observation on 8/27/23 at 11:00 AM, Resident #11 found to be in his bed resting. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility document review, the facility failed to provide follow up on a discovery of missing personal items for 1 of 2 residents in the sample (Resident #18). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #18 included: essential tremor, anxiety disorder, and polymyalgia rheumatica (muscle pain and stiffness around shoulders and hips). The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. [...]

Inspectors wroteBased on clinical record review, Consultant Pharmacist and staff interviews the facility failed to revise care plans, after a hospitalization and resident falls for 2 of 3 residents in the sample (Residents #21, and #26). The facility reported a census of 46 residents Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #21 included: depression, and anxiety disorder. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. During an interview on 8/27/23 at 2:50 PM, Resident #21 stated in June 2023 she had been hospitalized for a problem with her medications. A 6/10/23 Nurse's Note revealed a Certified Nursing Assistant (CNA) reported the resident seemed off. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to implement interventions in a timely manner after a resident made suicide threats for 1 of 1 residents (Resident #18). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #18 included: essential tremor, anxiety disorder, and polymyalgia rheumatica (muscle pain and stiffness around shoulders and hips). The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan included a focus area on Mood/Behavior, with the following interventions: A. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure catheter tubing and bag are situated in a manner to provide possible infection for 1 of 2 residents in the sample (Resident #23). The facility reported a census of 46 residents Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #23 included: Type 2 diabetes mellitus, and amputation of left lesser toe (not the big toe). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan revealed Resident #23 admitted to the facility with an indwelling Foley catheter During an observation on 8/29/23 at 10:40 AM, noted the resident's catheter bag hooked on to the side of her garbage can, with tubing resting on the floor. [...]

Inspectors wroteBased on staff interview and the Infection Control Policy review, the facility failed to employ an Infection Preventionist at least part time as required. The facility reported a census of 45 residents Findings Include: In an email dated 8/28/23 at 5:18 PM, the Administrator stated Staff I, Registered Nurse (RN) went on leave on 3/9/23. Staff I, RN was the Infection Preventionist at that time and she planned to return to the position on 6/9/23, but was unable to return due to health concerns. Staff J, RN was the previous Infection Preventionist and had been assisting with Infection Control. The facility hired Staff K, RN as the facility's Assistant Director of Nursing (ADON) and Infection Preventionist on 8/21/23. In an interview in 8/29/23 at 12:40 PM, the Administrator reported the previous Director of Nursing (DON) and Infection Preventionist was staff I, RN. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to have the required members present at their Quarterly Quality Assurance (QA) Meetings. The facility reported a census of 45 residents. Findings Include: QA Committee Meetings were conducted on the following dates; 7/21/22, 10/20/22, 1/19/23, 4/20/23, and 7/20/23. Review of the Attendance Sheets for the QA meetings revealed the required members attended the QA meetings on 7/21/22, 10/20/22 and 1/19/23. The Attendance Sheets for the QA Meetings held on 4/20/23 and 7/20/23 revealed the Director of Nursing (DON) and Infection Preventionist (IP) were not in attendance. In an interview on 8/29/23 at 12:55 PM, the Administrator stated it was the expectation that required members attend the meetings when they have active staff in the roles to attend. [...]