Lifeceare Roseau Manor

In the surveyor’s words

From the most serious findings on record at Lifeceare Roseau Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 21, 2025

  Based on interview and document review the facility failed to adequately supervise and respond to an alarm sounding exit door for 1 of 3 residents (R1) reviewed for elopement risks. R1 exited the facility without staff knowledge and was found by a visitor on the ground with WC next to them outside the facility door. R1 had abrasions and bent glasses. The immediate jeopardy began on 3/13/25, at approximately 12:45 p.m., when R1 was found outside the facility on the ground next to his wheelchair. The IJ was identified on 3/21/25, and the administrator was notified of the IJ on 3/21/25, at 12:50 p.m. The immediate jeopardy was removed on 3/17/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. […]

• No harm, potential for more than minimal, isolatedF689Mar 25, 2026

  Based on observation, interview and document review the facility failed to ensure utilization of appropriate sling sizes assessed for use with mechanical lift/stand devices for 3 of 4 residents (R1, R3, R4) reviewed for safe transfers with mechanical lift/stand devices.Findings Include:R1R1's Transfer/Discharge Report indicated she admitted to the facility 6/30/21. R1's diagnoses included Multiple Sclerosis, dementia, weakness and dysphagia.R1's quarterly Minimum data set (MDS) dated [DATE], Identified moderate cognitive impairment and indicated she was dependent on staff for transfers.R1's Balance and Transfer assessment dated [DATE], indicated all transfers were completed with a total body lift and two staff. R1 was unable to safely or consistently bear weight. […]

• No harm, potential for more than minimal, isolatedF585Feb 19, 2026

  Based on interview and document review, the facility failed to follow through on a grievance regarding medication found in recliner for 1 of 1 resident (R2) reviewed for grievances.Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses included dementia, anxiety, and depression. R2's care plan revised 2/10/26, identified R2 preferred medications crushed in vanilla pudding.An e-mail dated 2/12/26 at 5:31 p.m., identified family member (FM)-B reported to registered nurse (RN)-B that FM-B reported to the charge nurse two whole pills were found on R2's chair (one with an imprint C) and R2's Wanderguard (device to monitor exiting) was found on R2's bed footboard. […]

• No harm, potential for more than minimal, isolatedF744Feb 19, 2026

  Based on interview and document review, the facility failed to complete a comprehensive assessment following resident to resident incidents to maintain safety of the residents for 1 of 5 residents (R2) reviewed for dementia care.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses included dementia, anxiety, and depression. R2 exhibited physical behaviors directed towards others (for example: hitting, kicking, pushing, grabbing) 4-6 days, verbal behavioral symptoms directed towards others 4-6 days, other behavioral symptoms not directed towards others such as hitting/scratching self 1-3 days, rejection of care 4-6 days, and wandering 4-6 days. […]

• No harm, potential for more than minimal, isolatedF761Feb 19, 2026

  Based on observation, interview, and document review, the facility failed to ensure a schedule 2 narcotic (a medication with a high potential for abuse) was stored in a manner to prevent diversion for 1 of 3 units (Maple Unit); and failed to monitor temperature on a medication refrigerator temperatures of 1 of 2 medication fridges (Maple Unit) reviewed for medication storage. Findings include:During observation on 2/19/26 at 8:25 a.m., the director of nursing (DON) did a tour of the medication room on the Maple unit (memory care unit). Upon entering the locked medication room on the unit, it was observed there were keys in a lock on one of the cupboards. The DON reached up and pulled the cupboard door open as it was not locked. […]