Rose Villa Health Care Center

In the surveyor’s words

From the most serious findings on record at Rose Villa Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 13, 2021

  Based on observation, interview, and record review the facility's staff failed to address pain and discomfort for three of three sampled residents (Resident 1, 2, and 3) by failing to: a. Ensure timely ordering of [MEDICATION(S)] (medication used to treat severe pain) for Resident 1. Resident 1 had chronic pain but did not receive her pain medication for three days. b. Ensure Resident 3 who was complaining of leg pain, was referred to the orthopedic doctor as ordered by the physician. c. Ensure Resident 2 who had a vaginal itching was assessed timely and provided prompt care. These deficient practices caused Residents 1, 2, 3 to suffer unnecessary pain, discomfort, and stress. Findings: a. […]

• No harm, potential for more than minimal, patternF697Aug 7, 2026

  Based on observation, interview, and record review, the facility failed to ensure three of nine sampled residents (Resident 28, Resident 45, and Resident 4) who complained of frequent pain, as indicated in Minimum Data Set (MDS-a resident assessment tool), received effective pain management, as evidenced by:a. Failing to obtain the physician ordered pain medication for moderate pain (pain level 4-6), to administer and document pain medication administration according to the prescribed parameters, and to implement and document non pharmacological interventions (uses physical, mental, and lifestyle therapies to reduce discomfort without relying on prescription or over-the-counter drugs) prior to administering pain medication, as required by the physician's orders for Resident 28.b. […]

• No harm, potential for more than minimal, patternF755Aug 7, 2026

  Based on observation, interview and record review, the facility failed to:a. Ensure rectal hydrocortisone was available for administration on 8/4/2026 and 8/5/2026 for one of six observed sampled residents during medication administration (Resident 64).b. Follow the facility's policy and ensure the registered nurse witness signed with the pharmacist on the controlled substance (medications with a high potential for abuse) destruction log for destroyed controlled medications on 8/2/2026 for two of two sampled controlled drug records (formal log used to track the receipt, use, waste, and current balance of regulated medications and controlled substances).These failures had the potential to result in continued rectal pain and discomfort for Resident 64 and risk for missing controlled… […]

• No harm, potential for more than minimal, patternF803Aug 7, 2026

  Based on observation, interview and record review, the facility failed to follow the facility's recipe instructions documented on Cooks Spreadsheet: Summer Menus, when parsley was not placed on the breakfast plate on 8/4/2026 for 32 of 45 residents receiving a regular texture diet.This failure had the potential to result in residents not finding the food appealing or appetizing and resulting in decreased intake and nutrition.Findings:During a record review of the Cooks spreadsheet: Summer Menus for 8/4/2026, the Cooks spreadsheet indicated regular texture diets should have received a parsley sprig garnish.During an observation on 8/4/2026 at 7:20 a.m., in the kitchen during breakfast service preparation, there was no parsley present on the food assembly line (Trayline). […]

• No harm, potential for more than minimal, patternF812Aug 7, 2026

  Based on observation, interview and record review, the facility failed to follow the Juice Shelf Life policy to dispose of pineapple blend juice after one month of opening affecting 42 of 45 residents receiving thin liquids (drinks that pour and flow quickly).This failure had the potential to result in residents experiencing stomach discomfort or not receiving adequate nutritional needs.Findings:During a concurrent observation and interview on 8/3/2026 at 8:25 a.m. in the kitchen with dietary aide (DA) 1, the juice machine and boxes were inspected. DA 1 stated the juice bag-in-the boxes are used for one month after connecting the juice bag. DA 1 stated the pineapple juice blend had an open date of 6/4/2026. […]