Rose Glen Manor

The facility failed to administer medications in accordance with physician orders, specifically involving the administration of discontinued morphine concentrate to Resident #5 on 06/14/25. Additionally, a medication error involving an allergy medication was observed for Resident #7 during a medication pass on 08/19/25, resulting in a medication error rate of 4.2%.

The facility failed to administer medications as ordered for two residents. Specifically, a medication aide administered morphine concentrate to Resident #5 on 06/14/25 after the medication had been discontinued by the provider. Additionally, an error involving an allergy medication was observed during a medication pass on 08/19/25.

The facility failed to administer medications as ordered for 4 out of 6 sampled residents. Specifically, scheduled medications including pain medication, eye drops, and blood pressure/angina medication were either not administered or were unavailable for administration.

The facility failed to administer medications as ordered for several residents. Specifically, one resident received a discontinued iron supplement, and multiple residents did not receive prescribed fast-acting insulin, cholesterol medication, or other essential medications such as blood pressure and thyroid treatments.

The facility failed to administer medications in accordance with physician orders. Specifically, multiple residents were observed receiving discontinued medications or missing prescribed medications, including insulin, iron supplements, and various other treatments as ordered.

The facility failed to ensure that 2 of 6 sampled staff members were tested for tuberculosis disease in compliance with required control measures upon employment. Specifically, personnel records for two staff members lacked documentation of the required second-step TB skin test per facility policy.