St Rose Care Center

Based on staff interview, the facility failed to ensure 1 of 1 culinary services supervisor (#2) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure the facility had qualified dietary management to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors.Findings include:During an interview on the afternoon of 03/31/26, the culinary services supervisor (#2) stated she is currently enrolled in a certified dietary manager course but has not completed it.The facility failed to ensure the culinary services supervisor (#2) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, review of facility policy, and staff interview, the facility failed to discard spoiled and expired food in 1 of 1 kitchen. Failure to discard spoiled and expired food may affect the quality of the food and may result in foodborne illness to residents, staff, and visitors.Findings include:Review of the facility policy titled Food Storage - Perishable occurred on 04/01/26. This policy, dated August 2019, stated, . Sanitary procedures will be maintained in perishable food storage to keep foods safe, wholesome and appetizing; and to prevent contamination.Observation of the main kitchen occurred on 03/30/26 at 11:05 a.m. and showed the following:* One unopened packaged head of lettuce with visible browning and moisture* One container of cottage cheese with an expiration date of 03/10/26* One snack Jello with an expiration date of 01/26/26* Butter scotch baking chips with an expiration date of May 2025During an interview on 03/30/26 at 11:30 a.m., the culinary services supervisor (#2) confirmed she expected staff to discard the expired and spoiled food items.

Based on observation, review of facility policy, and staff interview, the facility failed to implement standard infection control practices for 1 of 9 sampled residents (Resident #3) observed during cares and 1 of 1 laundry room observed. Failure to practice infection control standards related to hand hygiene, and handling/transporting of soiled linen has the potential to spread infection throughout the facility. Findings include: Review of facility policy titled Hand Hygiene occurred on 04/01/26. This policy, dated September 2023, stated, . Times to Perform Hand Hygiene are, but not limited to: . After contact with a resident's . body fluids or excretions . After removing gloves . Review of facility policy titled Linen and Laundry occurred on 04/01/26. This policy, dated 05/15/24, stated, .Clean linen must always be kept separate from contaminated linen. A functional barrier must separate soiled and clean area. - Observation on 03/30/26 at 1:59 p.m. showed Resident #3 in bed. Two certified nurse aides (CNA) (#3 and #4) applied gowns, gloves, and masks, and entered Resident #3's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #2 and #13). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.Findings include:The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness .- Review of Resident #2's medical record occurred on all days of survey.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure compliance with provider orders for 1 of 1 sampled resident (Resident #33), observed with medications at the bedside. Failure to follow physician orders may result in medication errors and place the resident and/or others at risk for harm.Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 04/01/26. This policy, dated 04/10/25, stated, . The nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. If it is determined a resident cannot safely self-administer medications, the nursing associates will administer the medication. Review of Resident #33's medical record occurred on all days of survey. A Self-Administration of Medication assessment, dated 11/25/25, stated, . Does the resident want to self-administer medications . No. A physician's order, dated 11/25/24, stated, Medications: May give Whole, observe her take.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure accurate medication labeling to facilitate precautions and safe administration for 1 of 1 sampled resident (Resident #42) receiving intravenous (IV) medication. Failure to include the infusion rate and specific administration route on the medication label may result in inaccurate medication administration and placed the resident at risk for adverse outcomes. Findings include: Review of facility the policy titled Infusion Therapy Medication Administration occurred on 04/01/26. This undated policy stated, . Regulate flow of medication infusion as prescribed. Review of the pharmaceutical professional reference [NAME], Rocephin occurred 03/31/26. This reference stated, . Intravenous injection . For i.v. injection, Rocephin 1 g [gram] in 10 ml [milliliter], of sterile water for injections. The intravenous administration should be given over 2-4 minutes.Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 1 sampled residents (Resident #22) who received insulin in a public area and in 1 of 1 activity room. Failure to administer insulin in a private area, to address the resident with their preferred name, and remove incontinence pads from chairs in the activity room, does not preserve the resident's personal dignity and has the potential to affect the resident's psychosocial well-being. Findings include: Review of the facility policy titled Resident Rights and Notifications of Resident Rights occurred on 03/20/25. This policy, revised 01/16/24, stated, Resident Rights include . Respect and Dignity . Privacy and Confidentiality . Review of the facility policy titled, Administering Medications occurred on 03/20/25. This policy, revised 2020, stated, . Do not administer . injections in public . - Observation on 03/18/25 at 3:39 p.m. showed a certified nurse aide (CNA) (#3) entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate medication labeling for 1 of 1 sampled resident (Resident #20) receiving medications through a gastrostomy tube (G-tube). Failure to ensure medication labels matched physician orders may result in administration via incorrect route. Findings include: Review of the facility policy titled Administering Medications occurred on 03/19/25. This policy, dated 2020, stated, . To ensure safe administration of resident's medication as indicated and ordered by the provider . To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient identification for administration . Administer medications following the 6 rights of medication administration: . Right Route . Review of Resident #20's medical record occurred on all days of survey. The medical record identified Resident #20 as NPO (nothing by mouth) and medications administered per a G-tube. Physician's orders for Tylenol, Baclofen (a muscle relaxer), Warfarin (a blood thinner),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 5 sampled residents (Resident #28) and 1 supplemental resident (Resident #2) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 03/19/25. This policy, revised September 2023, stated, . All associates will be trained and competent . proper hand hygiene practices. Hand hygiene. After removing gloves. Before and after direct resident care . - Observation on 03/18/25 at 3:28 p.m. showed a certified nurse aide (CNA) (#3) assisted Resident #28 with perineal cares. The CNA (#3) applied gloves, performed perineal cares and without removing the gloves, the CNA brushed food crumbs from the bed linen, lifted the resident's legs on to the bed, and lowered the bed. The CNA (#3) failed to remove the soiled gloves and perform hand hygiene after performing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of dietary department manager employment histories and staff interview, the facility failed to employ a full-time qualified dietary manager to carry out the functions of food and nutrition services. Failure to ensure qualified staff have the appropriate competencies and skill sets to carry out the functions of the food and nutrition services has the potential to result in foodborne illness and/or adverse consequences to residents, staff, and visitors. Findings include: During an interview on 02/20/24 at 11:45 a.m., a licensed registered dietician (LRD) (#2) stated she is employed at the facility on a part-time basis (approximately 16 hours per week), oversees the kitchen, food, and nutrition services, and the facility has not had a dietary manager for a while. Review of the dietary department manager employment histories identified the facility employed three individuals as DMs over the past year. The individuals failed to complete the required training and certification during their employment. The facility failed to ensure a full-time dietary manager with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident representative for 1 of 1 sampled resident (Resident #16) reviewed for elopement. Failure to notify the resident representative of the elopements does not allow the representative to be fully informed of the resident's current status. Findings include: Review of the facility policy titled Change in Condition occurred on 02/22/24. This undated policy stated, . When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Review of Resident #16's medical record occurred all days of survey. The record identified the resident triggered the wanderguard system by exiting a facility door (elopement) seven times between November 2023-February 2024. The record lacked evidence the facility notified the resident representative on 11/27/23, 12/14/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 3 sampled residents (Resident #12, #14 and #17) reviewed for antiplatelet (medicine that stops blood cells from sticking together and forming a blood clot) use. Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, page N-8, states, . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period . - Review of Resident #12, #14, and #17's medical record occurred on all days of survey and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide oral hygiene for 1 of 7 sampled residents (Resident #15) dependent on staff for assistance with oral cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased gum problems, decline in oral intake, and a decreased quality of life. Findings include: Review of the facility policy and procedure titled Activities of Daily Living (ADL) occurred on 02/22/24. This undated policy stated, . Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . During an interview on 02/20/24 at 12:06 p.m., Resident #15 reported staff do not brush her dentures and observation showed a pink substance between the resident's bottom teeth. Review of Resident #15's medical record occurred on all days of survey. The current care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.