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Inspection visit

complaint

ROSE GARDENLicense 4058022852 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

The facility did not have a doctor's order for a gait belt for R1. LPA interviewed witnesses 1 & 2 (W1)(W2) which revealed while at the facility visiting R1, R1 raised up R1's arms and witnesses noticed a gait belt wrapped around R1's waist and tied to the back of the reclining chair R1 was sitting in. W2 stated they had never been told about a change in condition or the use of a gait belt for R1. Several texts messages were sent back and fourth between Administrator and R1's family regarding the incident. Based on the evidence this allegation is Substantiated at this time. On the allegation: Licensee does not ensure enough staffing to meet the needs of residents. LPA interviewed Licensee/Administrator regarding the staffing needed for R1. R1 had a recent change in condition and sun downing was becoming an issue for R1. The change in condition was reported to R1's physician and Administrator is getting an up to date LIC 602A physicians report for the change, and will update the appraisal needs and services plan accordingly. Administrator stated R1 does need additional staffing during sun downing from 3pm-7pm or 4pm-8pm. Administrator plans to do a two day rate increase for the change in condition and to provide a staffing 1 on 1 to R1 during sun dowing to keep R1 safe. Administrator said the facility has hired 3 new staff in February 2025 but all 3 staff are no longer working, the administrator is currently hiring for caregivers and hired 2 new caregivers yesterday, once trained the staff will be added to the schedules. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator/Licensee.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87411(a)Type B

    (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, the facility will need additional staffing to take care of R1 due to change in condition and meeting R1's needs which posses a potential Health, Safety and Personnel rights risk to residents in care.

  • 87608(a)(1)Type A

    (a)...(1)Postural supports shall be limited to appliances...soft ties, used to achieve proper body position and balance,..or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirment was not met as evidenced by: Based on interviews the Licensee did not comply with the regualtion above Administrator used a gait belt to tie a resident to reclining chair which poses an immediate Health, Safety and Personal rights risk to reisdnets in care.

  • 87205(b)Type B

    (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, the Incorporation is not in good standing with the Secretary of the State and needs immediate attention which posses a potential personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the June 11, 2025 inspection of ROSE GARDEN?

This was a complaint inspection of ROSE GARDEN on June 11, 2025. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to ROSE GARDEN on June 11, 2025?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to m..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.