Rose Vista Assisted Living

The facility failed to provide sufficient preparation and orientation to residents to ensure a safe and orderly discharge. This includes failure to properly explain the necessity of discharge and provide required documentation such as the resident's current assessment, care plan, and medication lists to the resident or their legal representative.

The facility failed to discharge a resident after providing a discharge notice dated 04/10/24 and failed to notify the local County Department of Social Services (DSS) that appropriate placement had not been found. This occurred for a resident with dementia whose care needs had changed to a level requiring a Special Care Unit (SCU).

The facility failed to provide a safe and clean environment free of hazards related to bed bugs. Specifically, the facility did not maintain the premises in an uncluttered, clean, and orderly manner as required by the housekeeping regulations.

The facility failed to provide a safe and clean environment free of hazards related to bed bugs. Inspections and invoices revealed bed bug activity in multiple resident rooms, including beds, walls, and furniture.

The facility failed to ensure health care referral and follow-up for 3 of 5 residents sampled. Specifically, the facility failed to refer two residents with thick toenails for podiatry and failed to notify the primary care provider of a resident experiencing episodes of low oxygen levels and seizures.

The facility failed to ensure that exit doors accessible to residents are equipped with functioning sounding devices. Specifically, three out of six sampled exit doors did not have working alarms or were not properly secured, which led to a resident with dementia wandering from the facility unnoticed.

The facility failed to ensure that exit doors accessible to residents are equipped with functioning sounding devices. Specifically, three out of six sampled exit doors did not have working alarms or were not properly secured, which led to a resident with dementia wandering from the facility undetected.

The facility failed to equip the front door and the smoking area exit doors with sounding devices that activate when opened. This lack of monitoring resulted in a resident known to be a wanderer exiting the facility without staff knowledge. Documentation also showed previous incidents where the resident wandered near a highway and a trash area without alarms sounding.