Rose Haven Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 7, 2023

  Based 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. […]

• Actual harm, isolatedF689May 6, 2021

  Based on record review and staff interviews, the facility failed to provide a call system or provide proper supervision when leaving a resident alone in a recliner in an upright reclined position, allowing the resident to get up and fall sustaining a major injury for one of two residents reviewed with falls with major injuries. (Resident #90). The facility identified a census of 44 residents. Findings Include: Resident #90's Quarterly Minimum Data Set (MDS) Assessment Tool completed 1/31/21 documented the following diagnoses: fracture of the left femur, [CONDITION(S)] (an abnormal heart rhythm) and hip fracture. […]

• No harm, potential for more than minimal, widespreadF727Aug 30, 2023

  Based 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. Findings include: In an interview on 8/29/23 at 12:40 PM, the Administrator reported the facility did not currently employ a Director of Nursing (DON). She reported the previous DON and Infection Preventionist was staff I, Registered Nurse (RN). Staff I, RN went on leave and was to return on 6/12/23 into the Infection Preventionist role but did not plan to return to the DON role. She stated the facility had been without a DON since 3/9/23. […]

• No harm, potential for more than minimal, patternF761Oct 24, 2024

  Based 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. Findings include: 1. […]

• No harm, potential for more than minimal, patternF550Aug 30, 2023

  Based on observations, clinical record review, family, resident and staff interviews, and also facility document and policy review, the facility failed to provide privacy during personal cares, speak to residents in a respectful and dignified manner, and provide a dignity bag covering for a resident with an indwelling catheter for 4 of 5 residents reviewed (Residents #11, #18, #23 and #27). The facility reported a census of 45 residents. 1. During an observation on 8/27/23 at 2:06 PM, Resident #27 was lying in bed without clothes, no depend on, moaning loudly and the door to the hall was open. […]