Rock Haven

In the surveyor’s words

From the most serious findings on record at Rock Haven, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 18, 2025

  Based 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. […]

• Actual harm, isolatedF580Mar 28, 2023

  Based on observation, interview, and record review the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 2 of 5 sampled residents (R3 and R1). R3 was seen in the emergency roiagnom on [DATE] and diagnosed with a urinary tract infection (UTI) and bleeding from her bladder. On 3/5/23 R3's active bleeding from R3's bladder continued throughout the day. R3's physician was not updated on R3's continued bleeding. […]

• Actual harm, isolatedF689Jan 3, 2022

  Based on observation, interview and record review, the facility did not ensure each resident received staff assistance to prevent accidents for 1 of 3 residents (R1) reviewed for incidents/accidents out of a total sample of 3. R1 has severe cognitive impairment, and requires extensive assist of two staff with mechanical lift for transfers. Staff did not follow R1's care plan and attempted to transfer R1 with 1 staff member into a chair rather than with the assistance of 2 staff members. R1 fell resulting in a [CONDITION(S)] that required staples. This is evidenced by: The facility Policy, titled, Transfer Manual and/or Mechanical lift, Updated 12/13/21, states in part: . […]

• No harm, potential for more than minimal, widespreadF812Jan 29, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jul 13, 2023

  Based 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. […]