Rose Haven Retreat

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2023

  Based 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. Findings included: During an observation on 12/16/23 at 11:05 a.m., food trays had been delivered to residents. Review of a cooking temperature log dated 12/16/23 showed the temperature of the food from the breakfast meal and lunch meal had not been entered. […]

• No harm, potential for more than minimal, widespreadF925Jul 18, 2023

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests in one Secure Unit, one kitchen, 3 of 27 resident's rooms (rooms [ROOM NUMBER]) , and 2 of 4 hallways (Hall 100 and 400). The facility failed to treat the roaches in Hall 1 and Hall 4. The facility failed to treat the roaches in rooms [ROOM NUMBERS]. The facility failed to treat the roaches in the Secured Unit. The facility failed to treat the roaches in the kitchen. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: During an interview on 7/14/23 at 12:57 p.m., Resident #1 she said she had not seen roaches lately. […]