Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Haven Nursing Center during CMS and state inspections, most recent first.
Infection Control Lapses During Medication Administration and Wound Care: An RN failed to sanitize hands, used improper glove technique, and discarded a lancet and blood-containing test strips in regular trash during a CBG. Another RN gave meds without proper hand hygiene or PPE, handled pills that fell onto a resident’s shirt and bed with bare hands, and then assisted with toileting without following precautions. During wound care for a resident with multiple blisters and bleeding wounds, two nurses placed supplies on a bedside table and bed, failed to wash hands or change gloves at key points, and handled a cell phone and dirty dressing materials during the procedure.
Infection control failures occurred during catheter care, medication administration, and wound care. Two residents had catheter bag drains that touched the floor, and one CNA initially handled a urine-filled bag without PPE. An RN failed to sanitize hands, used improper glove practices, and discarded a lancet and blood test strips in regular trash during CBG testing. Another RN administered meds without proper hand hygiene or PPE, picked pills up from a resident’s shirt and bed with bare hands, and touched the call light with dirty gloves. During wound care, staff placed clean supplies on a dirty bedside table and bed, handled dirty items and a cell phone, and missed required hand hygiene and glove changes.
A resident with flaccid bladder and ulcerative colitis had a urinary catheter and rectal tube. Observations showed both bags hanging off the side of the bed uncovered on day and evening shifts, and staff stated that bags containing bodily fluids must be covered for dignity.
A resident admitted with stroke and dysphagia had an incomplete admission assessment that failed to accurately document dentures. The annual MDS did not identify denture concerns, staff gave inconsistent reports about whether the resident had dentures, and interviews confirmed the initial nursing assessment and inventory were inaccurate and omitted the resident’s denture status.
Inaccurate MDS assessments affected multiple residents. One resident with CVA and hemiplegia/hemiparesis had a BIMS coded as unable to assess even though CNA and LPN staff said the resident could make needs understood, and the MDS coordinator described how the assessment should be completed. Another resident with CVA was missing that diagnosis from the annual MDS. A third resident with osteomyelitis had an admission MDS that failed to reflect ordered IV meropenem therapy and also incorrectly showed no tobacco use despite a smoking screen and resident statement indicating cigarette use.
A resident with CVA, hemiplegia/hemiparesis, and moderate cognitive impairment had an unwitnessed fall, but staff did not complete a full-body skin assessment after the event. An LPN said clothing was not removed to check for injuries, an RN later said a skin check missed leg injuries, and a unit manager said she expected full-body skin assessments after falls. Healing abrasions were later found on both knees, and the resident said the injuries happened when he/she fell out of the wheelchair.
A resident with chronic pain and major depressive disorder showed a PHQ-9 increase from minimal to moderate depression, and Social Services noted psychological services were needed. Staff gave mixed reports about the resident’s mood, while the resident said concerns had not been discussed and family support had decreased. The Administrator said no email notification was received to trigger a psych referral.
The facility failed to prevent accidents and ensure smoking safety for two residents. One resident, with impaired cognition and a fall risk, was left unsupervised, resulting in a fall and hip fracture. Another resident, with paraplegia and nicotine dependence, used electronic cigarettes in non-designated areas due to unclear smoking safety protocols. Staff were aware but did not enforce safety measures.
The facility failed to follow infection control standards, with multiple staff members not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene. A resident with necrotizing fasciitis was not placed on EBP, and staff did not follow proper procedures during dressing changes and handling of medical supplies. Housekeeping staff also failed to properly dispose of PPE, leading to potential contamination risks.
The facility failed to maintain accurate narcotic records and provide timely medications, affecting two residents. Narcotic log books showed missing staff signatures for verification, and two residents did not receive prescribed medications due to unavailability, with staff failing to notify the DNS.
The facility failed to provide adequate care for residents, including improper wound management, insufficient fall response, and delayed infection treatment. A resident with a venous wound did not receive required evaluations, another experienced multiple falls without proper neurological checks, and a third was not premedicated as prescribed before a painful dressing change. Additionally, a resident with a yeast infection faced delays in treatment due to inconsistent staff communication and care plan updates.
A facility failed to develop an individualized care plan for a resident with a colostomy and necrotizing fasciitis requiring a wound vac. The care plan did not address the necessary care and services for these conditions. Staff members were unaware of the specific care required, and the DNS acknowledged the care plan was not person-centered.
A resident with a history of stroke and dysphagia was inadequately monitored for dehydration, with fluid intake consistently below recommended levels. Despite showing signs of dehydration, such as dry mouth and poor skin turgor, staff failed to provide timely fluids and did not document the resident's condition properly. Interviews revealed staff were unsure how to assess dehydration, leading to inadequate care and increased risk for the resident.
The facility failed to manage pain effectively for two residents, one with chronic pain and spinal fusion, and another with diabetes and neuropathy. The first resident did not receive scheduled gabapentin and inconsistent application of Biofreeze, affecting pain management. The second resident received pain medications without documented pain levels, and their care plan lacked non-pharmacological interventions and monitoring for side effects. Both residents experienced inadequate pain management due to these deficiencies.
A facility failed to provide adequate care for a resident with dementia, who exhibited behaviors such as rejection of care and aggression. Despite a care plan outlining interventions, there was no documentation of attempts to reduce these behaviors or their success. Staff interviews indicated the resident's behaviors were linked to incontinence and being woken up early, but interventions were not consistently documented.
A resident with paraplegia and existing pressure ulcers was admitted to the facility, but the initial assessment failed to document a purple area on the right anterior ankle. This wound was not treated until it opened and was later identified as a Stage 2 pressure wound. The care plan also did not include this wound, leading to a delay in treatment.
A resident with heart failure and COPD was mistakenly provided with a CPAP machine instead of the physician-ordered BiPAP machine, leading to inappropriate respiratory care. The error was discovered after a complaint, and staff confirmed the wrong equipment was delivered by the respiratory company. The resident's oxygen saturation levels were affected until the issue was identified.
The facility failed to document the indication for use of antibiotics for two residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. One resident was prescribed multiple antibiotics without documented reasons, and another received Cephalexin without a documented indication. The DNS acknowledged the lack of documentation.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
The facility failed to ensure licensed nurses followed professional standards during medication administration and non-pressure wound care for four licensed nurses reviewed. The report states this placed residents at risk for cross contamination. The deficiency involved observations, interviews, and record review related to medication handling, hand hygiene, use of gloves and gowns, and disposal of contaminated items. One resident with depression and diabetes was observed receiving a CBG from an RN who did not sanitize hands before entering the room, wore only one glove, and disposed of the lancet and blood-containing test strips in a regular garbage can instead of a sharps hazard container. The RN repeated the finger-stick attempt after leaving the room to get more test strips. The administrator and regional nurse stated staff were expected to wear gloves and gowns and never throw lancets or test strips in regular garbage, and that hazardous materials must go into a sharps hazard material container. Another resident with abscess of the abdominal wall and vascular dementia was on EBP for chronic wounds, surgical wounds, and IV placement. An RN administered medication without sanitizing hands or donning gloves before entering, did not reposition the resident before giving medication while the resident was lying low in bed, and picked up pills that fell onto the resident’s shirt and bed with bare hands. The RN then assisted with toileting and a brief without sanitizing hands or donning a gown, and touched the call light with dirty gloves. A third resident with diabetes and bullous pemphigoid had multiple blisters and bleeding wounds on the body and extremities; during dressing changes, two nurses placed supplies on a bedside table with resident items, used the bed as a clean barrier, failed to wash hands or change gloves at key points, touched a cell phone while performing wound care, and handled dirty dressing wrappers and open dressing packages on the bed. The administrator and regional nurse stated nursing staff were to follow infection control procedures for wound care.
Infection Control Failures During Catheter Care, Medication Administration, and Wound Care
Penalty
Summary
The facility failed to follow proper infection control techniques for urinary catheter bags containing bodily fluid for two residents. One resident had a catheter and rectal tube with care plan interventions to keep the bags below bladder level and away from the door entrance, yet repeated observations showed both the catheter bag and rectal tube bag drains touching the floor. Facility staff later stated that any bag drains with bodily fluids should not touch the floor and that all bag drains containing bodily fluids must always be off the ground. Another resident with diagnoses including bladder neck obstruction, MRSA, and EBP had a catheter bag drain observed hanging off a wheelchair and touching the floor, dragging on the floor under the wheelchair, and laying on the floor in the resident’s room under the wheelchair. When staff went to empty the catheter bag, one CNA initially handled the bag and urinal without PPE before being stopped and then donning full PPE. The facility also failed to perform proper PPE use and disposal practices during medication administration for one resident with depression and diabetes and EBP. An RN observed administering a CBG without sanitizing hands before entering the room and wearing only one glove. The RN used a lancet to obtain blood, repeated the fingerstick attempts, and disposed of the used lancet and blood-containing test strips in a regular garbage can rather than a sharps hazard container. The RN stated he was not aware the items had been thrown into the regular garbage can. Facility leadership stated staff were expected to wear gloves and gowns and never throw lancets or test strips in a regular garbage can. The facility further failed to use proper infection control during medication administration for another resident with abdominal wall abscess, vascular dementia, chronic wounds, a surgical wound, IV placement, and EBP. An RN administered medications without sanitizing hands or donning gloves before entering the room, gave the resident pills while the resident was lying low in bed, and did not reposition the resident before administration. When pills fell out of the resident’s mouth onto the shirt and bed, the RN picked them up with bare hands and gave them back to the resident. After the resident needed toileting assistance, the RN did not sanitize hands before putting on gloves, did not don a gown, assisted with the brief and urinal, and touched the call light with dirty gloves. The facility also failed to maintain proper hand hygiene and clean technique during a dressing change for a resident with diabetes and bullous pemphigoid and multiple blisters and wounds. Staff placed clean supplies on a bedside table with other items, used the bed as a clean barrier, handled dirty dressing materials and a cell phone during the procedure, and were observed not washing hands or changing gloves at appropriate points during wound care.
Uncovered catheter and rectal tube bags
Penalty
Summary
The facility failed to ensure that a resident’s urinary catheter bag and rectal tube bag were covered for dignity. The resident was admitted with diagnoses including flaccid bladder and ulcerative colitis and had a care plan directing that the catheter bag and tubing be positioned below the bladder and away from the door entrance, along with interventions for the rectal tube. Random observations from 6/1/26 through 6/2/26 on day and evening shifts showed the resident’s urinary catheter bag and rectal tube bag hanging off the side of the bed uncovered. Staff later stated that urinary catheter bags and rectal tube bags, as bags containing bodily fluids, must be covered for dignity.
Incomplete Admission Assessment Omitted Denture Status
Penalty
Summary
The facility failed to accurately complete a comprehensive admission assessment for Resident 34, including the resident’s dentures. Resident 34 was admitted in 2/2025 with diagnoses including stroke and dysphagia. The 2/19/25 Nursing admission Evaluation and Inventory of Resident Personal Items documented no dental appliances. The 2/25/26 Annual MDS showed a BIMS score of 12 and did not identify any concerns related to dentures. A 3/30/26 progress note indicated an appointment was scheduled for the resident to obtain dentures, and the revised care plan dated 5/11/26 identified risk for alterations in dentition and included assistance with oral hygiene setup and supplies for tooth brushing. During the survey, Resident 34 stated on 6/1/26 that the dentures were lost, and no dentures were observed in the mouth. Staff interviews showed inconsistent awareness of the resident’s denture status: one CNA stated she was unaware the resident had dentures, another CNA stated she knew the resident had dentures and had seen them in a cup rather than in the resident’s mouth, and an RN did not recall observations from the admission assessment and acknowledged recent oral concerns. A unit manager acknowledged the initial nursing assessment was incomplete and inaccurate regarding dentures, and the regional director of clinical acknowledged the initial inventory assessment omitted the resident’s dentures and that facility audits were incomplete and needed revision.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess residents for unnecessary medications for 3 of 5 sampled residents. Resident 6 was admitted with diagnoses including cerebrovascular accident with hemiplegia and hemiparesis. The resident’s MDS Section C BIMS assessment dated 5/1/26 indicated the resident was rarely or never understood with a score of 99, meaning unable to assess. However, staff interviews showed Staff 15, a CNA, and Staff 16, an LPN, both stated they understood Resident 6 when the resident expressed needs. The MDS Coordinator stated that if a resident was able to make himself/herself understood at least 50% of the time, Section C should be completed, and that if the resident refused to respond, the assessor should try again later or ask another staff member to assist. The Social Services Assistant stated she was trained that a BIMS assessment could not be completed when a resident was rarely or never understood or if the resident declined to respond, and the Administrator stated she expected the MDS to be completed accurately. Resident 34 was admitted with a diagnosis including CVA, but the 3/2026 annual MDS did not list CVA in Section I. The MDS Coordinator acknowledged the diagnosis was not listed and stated it should be in the MDS, and the Administrator stated she expected the MDS to be completed accurately. Resident 103 was admitted with diagnoses including osteomyelitis and muscle weakness. Physician orders dated 5/27/26 directed staff to change the resident’s PICC line and dressing and to administer meropenem 2 grams IV three times daily for treatment of osteomyelitis, but the 5/29/26 admission MDS indicated the resident did not receive IV antibiotic therapy. The resident stated she/he received IV therapy for an infection, and the MDS Coordinator acknowledged the MDS was inaccurate. The same admission MDS also indicated Resident 103 was cognitively intact and did not use tobacco products, despite a 5/28/26 smoking screen showing tobacco use two to five times per day and the resident stating she/he smoked cigarettes and was assessed for smoking; the MDS Coordinator again acknowledged the MDS was inaccurate.
Incomplete Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to thoroughly assess a resident after an unwitnessed fall. Resident 34 was admitted in 2/2025 with diagnoses including cardiovascular accident with hemiplegia and hemiparesis and had a BIMS score of 12, indicating moderate impairment. The clinical record showed an unwitnessed fall with no injuries reported on 5/27/26. On 6/1/26, the resident stated he/she had fallen in the room and skinned the knees, and healing scabs were observed below the right knee. Staff interviews and record review showed the resident was not fully assessed after the fall. Staff 16 stated she found the resident after the fall but did not remove clothing to assess for injuries. Staff 6 stated he completed a skin check on 6/3/26 but did not know how he could have missed injuries on the resident’s legs. Staff 3 stated nursing staff were expected to complete a full-body skin assessment after a fall and record weekly skin checks, and also stated a CNA told her on 6/1/26 that the resident had abrasions from a fall the previous week, but she did not assess the resident. On 6/5/26, Staff 19 identified two small healing abrasions on the right knee and one small healing abrasion on the left knee, and the resident stated the injuries occurred when he/she fell out of the wheelchair the previous week.
Failure to Address Resident Behavioral Health Needs
Penalty
Summary
The facility failed to address the behavioral health needs of one resident with chronic pain and major depressive disorder. The resident’s 5/1/26 Quarterly MDS showed a PHQ-9 score of 13, indicating moderate depression, and the Social Services Quarterly and Annual Evaluation noted an increase from minimal to moderate depressive symptoms and that psychological services were needed. A revised care plan dated 5/20/26 directed staff to arrange psychological consultations when indicated and provide opportunities for the resident to express concerns, but the resident later stated that no staff had discussed these concerns with him/her, that the family member visited less frequently, and that staff spoke with him/her less often. During interviews, staff gave differing accounts of the resident’s mood and behavioral concerns. A CNA stated the resident’s mood remained consistent and relied on the family member and others for emotional support, while the Unit Manager-LPN said she did not observe recent mood changes and relied on Social Services to address mood-related concerns. A Social Services Assistant acknowledged the resident experienced a mood change during the most recent care conference and quarterly review and that the family member had personal issues at home and was unable to visit as frequently. The Administrator stated she was responsible for referring residents for psychological services, but no email notification was received indicating the resident needed a psychological referral.
Failure to Prevent Accidents and Ensure Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment for Resident 25, who was at risk of falls due to impaired cognition and difficulty walking. Despite the care plan indicating that the resident's bed should be in a lowered position, Staff 42, a CNA, did not follow this directive. As a result, Resident 25 fell and sustained a hip fracture, requiring surgery. The incident investigation revealed that the resident was left unsupervised during a bed change, leading to the fall. Staff 42 acknowledged the resident's need for two-person assistance, yet left the resident alone, resulting in the accident. Resident 283, who was admitted with paraplegia and nicotine dependence, was also subject to inadequate supervision regarding smoking safety. The resident was observed using electronic cigarettes in non-designated areas, contrary to the facility's smoking agreement, which was reportedly not signed by the resident. Staff were aware of the resident's smoking habits and assisted them in and out of the building, yet failed to enforce the smoking safety protocols. The facility's smoking contract did not clearly address electronic cigarette use, leading to a lack of proper oversight and potential safety hazards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards, as observed in multiple instances involving staff and residents. Resident 77, who was admitted with necrotizing fasciitis and had a wound vac and colostomy, was not placed on Enhanced Barrier Precautions (EBP) as required. During a dressing change, Staff 40 did not follow proper infection control procedures, such as wearing a gown, setting up a clean field, or changing gloves and sanitizing hands between tasks. This led to contamination risks as clean dressing supplies were placed on a dirty bed, and the staff member handled the wound and other items with dirty gloves. In another instance, Staff 33, an agency CNA, failed to perform hand hygiene before and after entering rooms with EBP and Droplet Precautions, and continued to handle items and enter other rooms without sanitizing hands. Similarly, Staff 34 did not sanitize hands after handling soiled linen. Resident 43 expressed discomfort with having blood sugar taken in the dining room, which was not addressed. Staff 35, an agency LPN, was unaware of the EBP requirements and did not don a gown before handling a resident's tube feeding supplies, despite signage indicating the need for PPE. Additionally, Staff 24 from housekeeping did not follow proper procedures for removing and disposing of PPE, mixing soiled gowns with clean ones outside the resident's room. This was due to confusion about the process, as confirmed by Staff 25, the Housekeeping Manager, and Staff 10, the Infection Preventionist. The facility's administrator acknowledged that staff were expected to wear and discard PPE appropriately, but these expectations were not consistently met, leading to potential infection control breaches.
Failure to Maintain Accurate Narcotic Records and Provide Timely Medications
Penalty
Summary
The facility failed to maintain accurate narcotic drug records and provide timely pharmaceutical services, as evidenced by the review of medication carts and resident records. The narcotic log books for five medication carts showed numerous instances where staff did not sign to verify the narcotic count, with missing signatures ranging from 17 to 65 out of possible counting opportunities. This lack of verification was acknowledged by Staff 2, who confirmed that two staff members were required to count and sign off on the narcotics, and that the counts were not correct. Additionally, two residents were affected by the facility's failure to provide necessary medications. One resident, admitted with depression, did not receive prescribed antidepressants for several days because the medications were unavailable, and staff failed to alert the DNS about this issue. Another resident, with severe pressure wounds, did not receive prescribed nutritional supplements for wound healing over several days due to unavailability, and again, staff did not notify the DNS. These lapses in pharmaceutical services placed residents at risk for unmet pharmaceutical needs.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and services for several residents, leading to deficiencies in wound management, fall response, medication administration, and infection treatment. Resident 6, who was admitted with heart failure and chronic kidney disease, had a venous wound on the left lateral calf that was not properly evaluated or documented after the initial assessment. Despite the facility's guidelines requiring weekly wound assessments, no further evaluations were conducted, and staff incorrectly stated that evaluations were not needed until scabs fell off. Resident 35, who had a history of stroke and difficulty walking, experienced multiple falls, including unwitnessed ones, without proper neurological checks being documented. The facility's protocol for unwitnessed falls was not followed, as evidenced by the lack of documentation for the required neurological checks after each fall. This oversight was confirmed by staff during interviews, indicating a failure to adhere to established procedures for monitoring residents after falls. Resident 77, diagnosed with necrotizing fasciitis, was not premedicated as prescribed before a dressing change, resulting in the resident experiencing pain during the procedure. The medication was administered less than an hour before the dressing change, contrary to the order. Additionally, Resident 55, who had severe obesity and diabetes, experienced delays in treatment for a yeast infection. The resident's symptoms were not addressed promptly, and there was a lack of timely implementation of physician orders for antifungal treatment. Staff communication and care plan updates were inconsistent, contributing to the delay in treatment and inadequate management of the resident's condition.
Failure to Develop Individualized Care Plan for Resident
Penalty
Summary
The facility failed to develop an individualized plan of care for a resident admitted with diagnoses including a colostomy and necrotizing fasciitis, requiring a wound vac. The care plan, last revised on February 10, 2025, did not address the necessary care and services for the resident's colostomy or wound vac. Interviews with staff members revealed that they were not aware of the specific care and services required for the resident's conditions, and these were not included in the care plan. The Director of Nursing Services acknowledged that the care plan was not person-centered and needed more details related to the colostomy and wound vac.
Failure to Monitor and Address Resident Dehydration
Penalty
Summary
The facility failed to adequately monitor, assess, and document signs and symptoms of dehydration for a resident with a history of stroke, muscle weakness, and dysphagia. The resident was admitted in 2019 and had a care plan that required staff to ensure adequate hydration and nutritional intake. Despite this, the resident's fluid intake consistently fell below the recommended levels for 26 out of 29 days, as documented in the fluid monitor records. Observations revealed that the resident frequently exhibited signs of dehydration, such as dry mouth, dry lips, and poor skin turgor. The resident repeatedly expressed thirst and requested water, yet staff failed to provide adequate fluids in a timely manner. On multiple occasions, the resident was found with empty or half-empty cups and continued to show signs of dehydration, including a coated tongue and difficulty speaking. Staff interviews indicated a lack of awareness and appropriate response to the resident's hydration needs. CNAs and LPNs were unsure how to assess for dehydration and did not consistently provide the necessary fluids. Despite the resident's clear signs of dehydration, staff did not take immediate action to address the issue, and documentation of the resident's condition was incomplete. The facility's failure to monitor and respond to the resident's hydration needs placed the resident at risk for dehydration.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to accurately assess and manage pain for two residents, leading to deficiencies in their care. Resident 24, admitted with chronic pain and spinal fusion, experienced frequent severe pain that impacted sleep and therapy. Despite a care plan to anticipate and respond to pain, the resident did not receive scheduled gabapentin due to delays in medication delivery and lack of administration. Additionally, Biofreeze, a topical pain relief, was not consistently applied as ordered, with staff citing the resident's sleep as a reason for missed applications. The resident expressed that inconsistent application of Biofreeze affected their pain management. Resident 55, with diagnoses including diabetes with neuropathy and kidney disease, was at risk for decline due to frequent moderate to severe pain. The resident received oxycodone-acetaminophen and acetaminophen without documentation of pain levels, and their care plan lacked details on non-pharmacological interventions. There was no monitoring for side effects of pain medications, and staff confirmed the care plan's inadequacy in addressing the resident's pain management needs. The resident reported persistent pain, rarely below a level of three on a scale of zero to ten.
Failure to Document and Implement Interventions for Resident with Dementia
Penalty
Summary
The facility failed to provide adequate care and services for a resident diagnosed with dementia and borderline personality disorder. The resident, who was readmitted to the facility, was noted to have behaviors such as rejection of care, yelling, and physical aggression. Despite these behaviors being documented multiple times across different shifts, there was no evidence in the clinical record of what interventions were attempted to reduce these behaviors or if they were successful. The care plan for the resident included administering medications, anticipating needs, providing cues, and monitoring for danger to self or others, but the documentation did not reflect the implementation or effectiveness of these interventions. Interviews with staff revealed that the resident exhibited behaviors when incontinent or when woken up earlier than desired. Staff members noted that speaking to the resident sometimes helped calm them down. However, the Director of Nursing Services confirmed that staff needed to offer and document interventions for the resident's behaviors, which was not consistently done. This lack of documentation and follow-through on interventions placed the resident at risk for unmet needs.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, implement, and maintain pressure ulcer treatments and care plans for a resident admitted with pressure ulcers and paraplegia. Upon admission, the resident had a coccyx pressure wound and a wound to the left gluteal fold, but the admission assessment did not document a purple area on the right anterior ankle. The care plan created later also failed to mention this wound. It was only on a progress note that the discoloration on both ankles was acknowledged. The wound on the right anterior ankle was not treated until it opened, which was several days after admission, and was subsequently identified as a Stage 2 pressure wound. Staff acknowledged that the wound was not captured in the initial assessment and was not treated in a timely manner.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for a resident diagnosed with heart failure and chronic obstructive pulmonary disease. The resident was admitted to the facility with a physician's order for a BiPAP machine, which is a non-invasive ventilation therapy used to treat sleep apnea and other breathing disorders. However, the resident was mistakenly provided with a CPAP machine instead of the ordered BiPAP machine. This error was discovered after a public complaint was received by the State Survey agency, indicating that the resident had been using the wrong equipment since admission. Observations and interviews confirmed that the resident had been using a CPAP machine instead of the prescribed BiPAP machine. The resident's oxygen saturation levels were notably low when using the CPAP, but improved significantly when switched to a nasal cannula. Staff interviews revealed that the respiratory company delivered the incorrect machine, leading to the resident receiving inappropriate respiratory care. The resident, who was cognitively intact, also confirmed the use of the wrong machine upon readmission from the hospital.
Lack of Documentation for Antibiotic Use in Residents
Penalty
Summary
The facility failed to provide adequate documentation for the indication of use of medications for two residents, leading to a deficiency in ensuring that each resident's drug regimen was free from unnecessary drugs. Resident 6, admitted with diagnoses including heart failure and shortness of breath, was prescribed multiple antibiotics such as Doxycycline Hyclate, Augmentin, and Linezolid over a period of time. However, there was no documentation in the resident's clinical record indicating the specific reasons for these antibiotics, which is a requirement for ensuring appropriate medication use. During an interview, the Director of Nursing Services (DNS) acknowledged the expectation for diagnoses to be documented for antibiotic use. Similarly, Resident 131, who was admitted with severe pressure wounds, was administered Cephalexin as indicated in the August 2024 Medication Administration Record (MAR). However, there was no documented indication of use for this antibiotic. The DNS confirmed the absence of a documented indication for the Cephalexin. These oversights in documentation placed the residents at risk for receiving unnecessary medications, as there was no clear justification for the antibiotic treatments provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roseburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Umpqua Valley Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
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