Rose Haven Retreat

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all essential mechanical and electrical equipment in safe operating condition, for 1 of 1 commercial gas range and oven in the kitchen reviewed for food service in that:The facility did not ensure the commercial gas range and oven were in proper working order: Two of ten gas stove burners (far right front and back) did not light automatically, when the knobs were turned on. Eight of ten gas burners had carbon buildup. One (right oven) of two ovens did not heat properly. These failures could place residents who ate food from the kitchen at risk for under-cooked food and foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to provide notice to residents when changes in coverage were made to items and services covered by Medicare as soon as is reasonably possible to 2 of 3 residents (Resident #6 and Resident #10) who were provided skilled Medicare services, were discharged from services, and remained in the facility in that: 1. The facility failed to notify Resident #6 and Resident #10 at least 2 days before the end of Medicare Part A coverage. 2. The facility failed to notify Resident #6 and Resident #10 with a complete Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form before the end of Medicare Part A coverage. These failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and provide the resident and their representative with a summary of the baseline care plan for 2 of 4 (Resident #27 and Resident #61) residents reviewed for baseline care plans. 1. The facility did not ensure Resident #27 and Resident #61's baseline care plan was developed within 48 hours of admitting to the facility. 2. The facility did not ensure Resident #27, Resident #61, or their representatives were provided with a summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident that were complete and accurately documented for 2 of 4 residents (Resident #27 and Resident #61) reviewed for accuracy of medical records. 1. The facility failed to ensure Resident #27 and Resident #61's baseline care plans were dated. 2. The facility failed to ensure Resident #27's baseline care plan had the accurate family member listed as informed and delivered. 3. The facility failed to ensure LVN D's signature on Resident #27's baseline care plan was valid and accurate. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for incontinent care. (Resident #7)The facility failed to ensure CNA A changed her gloves and sanitized her hands after providing incontinent care to Resident #7 prior to touching Resident #7's clean fabric incontinent pad, her bare leg and shoulder, and her bedding. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #1)The facility failed keep Resident #1 free of misappropriation of property when staff discovered a missing card of 60 Hydrocodone-acetaminophen 10/325 milligrams (a Schedule II controlled substance used for pain management). This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure food items were not stored on the floor of the dry pantry. 2. The facility failed to ensure food items in the dry pantry were labeled and dated. 3. The facility failed to ensure plastic bags of what appeared to be hamburger patties, chicken tender strips, sausage patties, onions/green/red peppers, and French fries were labeled and dated in the large freezer. 4. The facility failed to ensure a plastic bag containing an unknown meat was labeled and dated in the white freezer. 5. The facility failed to ensure the white freezer did not have melted and refrozen substance in the bottom of freezer. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment allowing the resident to use his or her personal belongings to the extent possible for 1 of 5 residents (Resident #33) reviewed for cleanliness of the physical environment. The facility failed to ensure Resident #33's bed sheets were clean and free of stains. This failure could place residents at risk for a decreased quality of life and an unsanitary environment.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 16 residents (Resident #3) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #3's active diagnoses to not include a diagnosis of schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) on her 4/23/25 MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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 1 resident (Resident #28) reviewed for trauma-informed care. The facility failed to ensure Resident #28 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #28 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review the facility failed provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #36) reviewed for medication administration. The facility failed to ensure Resident #36 rinsed and spit after administration of an inhalation medication (Budesonide) for a diagnosis of COPD. This failure could place residents at an risk for inaccurate drug administration and not receiving the care and services to meet their individual needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Cart 4) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN E locked Cart 4 on the secured unit nurse medication cart, when it was not in use on 05/06/2025. 2. The facility failed to ensure two Albuterol Sulfate Inhalation Solution (inhalation solution used to open the airways for breathing) on Cart 4 was dated when opened. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental services to meet the needs of 1 of 1 (Resident #33) residents reviewed for dental services. The facility failed to ensure Resident #33 received dental services when she had a broken tooth that caused her discomfort. This failure could place residents at risk of not receiving needed dental care and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 staff (Laundry Aide G) reviewed for infection control practices. The facility failed to ensure that Laundry Aide G covered the laundry cart while delivering the resident's clothing. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their own established smoking policy for the facility's only smoking area and 1 of 1 facility smoking area reviewed for smoking policies. The facility failed to ensure the smoking area had no cigarette butts on the ground and the red metal can was free of trash on 05/05/25. This failure could place residents at risk of an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 18 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to prevent Resident #1 from eloping (leaving the facility property) from the secured unit on 02/10/25. The noncompliance was identified as PNC. The IJ began on 02/10/25 and ended on 02/10/25. The facility had corrected the noncompliance before the survey began. This failure could place the residents at risk for serious injury, serious harm, serious impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure an opened bag of potato chips was securely closed or stored in a secure container. 2. The facility failed to ensure the tin pan with stuffed green peppers in beef sauce was securely closed in the freezer. 3. The facility failed to ensure two measuring cups were stored with the top openings facing down. 4. The facility failed to ensure there was minimal carbon buildup on approximately 7 baking sheet pans. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 12.5%, based on 4 errors out of 32 opportunities, which involved 4 of 6 residents (Resident #8, Resident #22, Resident #36, Resident #44) reviewed for medication administration. 1. MA L administered Acetaminophen-codeine 300-30mg (is a prescription pain medicine) at 10:30 a.m. instead of 8:00 a.m. as ordered on 04/15/24 for Resident #8. 2. MA L administered Aspirin 81mg (is an antiplatelet (make it harder for blood clots to form); effective at preventing heart attack or stroke) at 9:31 a.m. instead of 8:00 a.m. and without food as ordered on 04/15/24 for Resident #22. 3. MA L administered Esomeprazole Magnesium 20mg (is used to treat conditions where there is too much acid in the stomach) at 9:23 a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 16 residents reviewed for infection control. (Resident #35, Resident #6, Resident #7, Resident #103, Resident #18) 1. The facility failed to ensure CNA G changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #35. 2. The facility failed to ensure CNA G changed her gloves after providing incontinent care to Resident #35 prior to touching Resident #35's bare hip, bare leg, clean brief, clothing, bedding, pillow, 2 drinking cups, bedside table, and bed remote. 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the residents had the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 1 of 20 residents (Resident #102) reviewed for resident rights. The facility failed to obtain informed consent from Resident #102's RP prior to administering Prozac (antidepressant medication used to treat depression-persistent sadness) to Resident #102. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 16 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had access to a call light. This failure could place residents at risk for unmet needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 16 residents (Resident #6) reviewed for resident rights. The facility did not assist Resident #6 out of bed when he requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 16 residents reviewed for assessments. (Resident #36). The facility failed to complete an accurate resident assessment for Resident #36. Resident #36's resident assessment did not reflect that he was a tobacco user. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 4 residents (Resident #27) reviewed for PASRR. The facility failed to review Resident #27's PASRR level 1 assessment for accuracy. Resident #27 had a diagnosis of schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly) not reflected on PASRR Level 1. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 20 residents reviewed for care plans (Resident #36 and Resident #102). 1. The facility failed to develop the comprehensive person-centered care plan for Resident #36 indicating the resident was a smoker. 2. The facility failed to implement Resident #102's comprehensive person-centered care plan when LVN E did not notify the hospice agency of Resident #102's behavioral changes and moving her to the secured unit. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents (Resident #13) and 1 of 4 staff (CNA A) reviewed for transfer. The facility failed to ensure CNA A performed a safe mechanical lift transfer (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for Resident #13. This failure could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food according with professional standards for food service safety. Dietary staff failed to ensure food was at a safe temperature prior to serving food to residents. This failure could place the census of 47 residents who ate food from the kitchen at risk for food borne illness.