Inspection Reports for Rose Haven Nursing Home
1500 N Franklyn Avenue, IA, 523011399
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 29, 2025 found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies related primarily to resident care issues, including medication administration, abuse and neglect investigations, and quality of care concerns. Several complaint investigations substantiated failures in timely abuse reporting, resident dignity and supervision, and medication management, with one instance of Immediate Jeopardy related to resident elopement in late 2023 that was promptly resolved. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent plans of correction accepted and the latest inspection indicating compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
45 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 29, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, certifying substantial compliance effective December 29, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance with health requirements.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 8
Date: Dec 8, 2025
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of complaints #2666162-C and #2689956-A between 12/8/25 and 12/11/25.
Complaint Details
Complaint #2666162-C resulted in deficiencies related to medication self-administration and abuse/neglect investigations. The facility failed to ensure residents were free from abuse and neglect, failed to report allegations timely, and failed to properly investigate and separate alleged perpetrators. No additional substantiated allegations of abuse were identified during the review.
Findings
The facility was found deficient in multiple areas including resident self-administration of medications, freedom from abuse and neglect, right to be free from chemical restraints, comprehensive care plans, and quality of care. Deficiencies were identified related to medication administration, abuse investigations, psychotropic drug monitoring, and documentation of assessments and follow-ups.
Deficiencies (8)
Failure to ensure resident #13 was clinically appropriate and safe to self-administer medications.
Failure to ensure resident #35 was free from physical abuse and neglect.
Failure to ensure resident #35 was free from chemical restraints without proper documentation and justification.
Failure to carry out gradual dose reduction or document contraindications for psychotropic medications for resident #35.
Failure to report allegations of abuse to the State Agency for resident #35 in a timely manner.
Failure to investigate and separate alleged perpetrator of abuse from resident #35.
Failure to ensure services met professional standards including timely insulin administration for resident #2.
Failure to ensure quality of care for resident #26 related to antifungal medication administration and infection assessment.
Report Facts
Census: 45
Deficiencies cited: 8
Medication orders: 1
Medication orders: 2
Blood sugar readings: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The document is a Plan of Correction submitted following an inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective April 4, 2025.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as an investigation of Facility Reported Incident #127069-I from March 4, 2025 to March 10, 2025, focusing on substantiated allegations of abuse and resident rights violations.
Complaint Details
The complaint investigation substantiated Facility Reported Incident #127069-I. Allegations included staff slamming residents down on toilets, failure to report and investigate abuse allegations timely, and unsafe resident transfers causing injuries. The facility failed to thoroughly investigate and report abuse allegations for Resident #2 and failed to prevent accidents for Residents #1, #2, and #5. Corrective actions and staff education were implemented.
Findings
The facility was found to have failed in treating residents with dignity and respect, timely reporting and investigating allegations of abuse, and ensuring safe transfers and supervision of residents. Deficiencies were substantiated related to resident rights, abuse reporting, and accident prevention, with corrective actions and education provided to staff.
Deficiencies (5)
Failure to treat one out of four residents reviewed in a dignified manner, violating resident rights.
Failure to report an allegation of abuse in a timely manner for one out of four residents reviewed.
Failure to thoroughly investigate an allegation of abuse for one out of four residents reviewed.
Failure to ensure residents received adequate supervision and assistance devices to prevent accidents for three out of four residents reviewed.
Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program addressing previously cited deficiencies.
Report Facts
Resident census: 49
Residents reviewed for abuse allegations: 4
Residents failed safe transfer: 3
Residents with documented abuse allegations: 2
Residents with accident hazards: 3
QAPI training frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurses Aid (CNA) | Involved in dignity violation with Resident #5 |
| Staff G | Registered Nurse (RN) | Reported Resident #5's complaint and education received |
| Staff N | Certified Nurses Aid (CNA) | Received abuse reporting education related to Resident #2 |
| Staff O | Certified Nurses Aid (CNA) | Involved in abuse allegation with Resident #2 |
| Staff C | Certified Nurses Aid (CNA) | Alleged to have caused bruising and improper gait belt use with Resident #1 |
| Staff P | Certified Nurses Aid (CNA) | Worked with Staff O during Resident #2 incident |
| Staff M | Certified Nurses Aid/Rehabilitation Aid | Pushed Resident #2 during transfer |
| Staff A | Certified Nurses Aid (CNA) | Reported on stand pivot transfer use for Resident #2 |
| Staff K | Licensed Practical Nurse (LPN) | Reported on gait belt use for Resident #1 |
| Staff I | Licensed Practical Nurse (LPN) | Observed bruising on Resident #1 |
| Administrator | Administrator | Oversaw corrective actions and education |
| Director of Nursing (DON) | Director of Nursing | Provided education and confirmed unacceptable practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on November 13, 2024, related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and plan of correction, the facility will be certified in compliance effective November 13, 2024.
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 4
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of a facility reported incident #118701-1 from October 21 to October 24, 2024.
Complaint Details
Facility Reported Incident #118701-1 was substantiated. The investigation was triggered by allegations of abuse, neglect, and misappropriation of resident property related to missing narcotic medication for Resident #24.
Findings
The facility was found to have failed to follow abuse policies and procedures after identifying a missing narcotic medication for one resident. The investigation revealed failures in medication storage, labeling, and handling, including unlocked medication refrigerators and missing locked storage for insulin pens. Staff failed to properly investigate and report incidents, and medication administration errors were identified. The facility provided education and corrective actions, and deficiencies were corrected by November 2024.
Deficiencies (4)
Facility failed to follow abuse policy and procedures after identifying a missing narcotic medication for Resident #24.
Facility failed to thoroughly investigate medications found in a medication cup that lacked a prescribed narcotic for Resident #24.
Facility failed to store medication in locked compartments and failed to keep one out of three refrigerators locked.
Facility failed to label and store drugs and biologicals in accordance with professional principles and regulations.
Report Facts
Census: 47
Medication errors: 1
Number of refrigerators: 3
Number of CNA's worked: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse (LPN) | Reported medication cup failed to include scheduled medication; was suspended during investigation. |
| Staff F | Licensed Practical Nurse (LPN) | Reported medication cup discrepancy and provided statement regarding medication pass. |
| Staff C | Registered Nurse (RN) | Investigated medication cup discrepancy and provided statement; notified Director of Nursing. |
| Staff E | Certified Nurses Aid (CNA) | Reported concerns about Staff J and interactions with Administrator and DON. |
| Staff D | Certified Nurses Aid (CNA) | Reported Administrator and DON failed to ask about incidents related to Staff J. |
| Staff H | Previous Administrator | Reported investigation of medication cup and facility practices. |
| Administrator | Administrator | Confirmed medication cart location; responsible for ensuring proper investigation of abuse allegations. |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation and re-education of staff; responsible for medication storage and abuse prevention policies. |
| Staff I | Registered Nurse (RN) | Observed insulin administration and medication storage practices. |
| Staff B | Licensed Practical Nurse (LPN) | Demonstrated locking medication refrigerator and assisted resident. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
The inspection was conducted as a result of the investigation of Complaint #115345-C and a Facility Self-Reported Incident #116559-I from November 1 to November 7, 2023.
Complaint Details
Complaint #115345-C was substantiated. Facility Self-Reported Incident #116559-I was substantiated. Immediate Jeopardy began October 30, 2023 and was removed October 31, 2023 after corrective actions.
Findings
The facility failed to provide adequate supervision to prevent hazards during a temporary disabling of a door alarm, resulting in a confused resident exiting the building unattended in cold weather, which constituted Immediate Jeopardy. The Immediate Jeopardy was removed after corrective actions including resident assessment, reactivation of the door alarm, policy updates, and staff education.
Deficiencies (1)
Failure to provide adequate supervision and maintain door alarms to prevent resident elopement, resulting in Immediate Jeopardy when a confused resident exited the building unattended.
Report Facts
Resident census: 44
Temperature: 36
Wind gusts: 24
Wind chill: 27
Resident BIMS score: 7
Duration alarm disabled: 150
Confused residents: 26
Mobile confused residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Maintenance Supervisor | Turned off the door alarm and failed to notify nursing staff; last saw contractors before leaving for lunch. |
| Staff F | Business Office Manager | Reported the alarm was disabled and summoned Maintenance Supervisor to reactivate it. |
| Staff G | Certified Nursing Assistant (CNA) | Responded to alarm and assisted in bringing resident back inside. |
| Staff D | Licensed Practical Nurse (LPN) | Reported unaware of alarm being disabled and completed follow-up training. |
| Staff A | Night Cook | Observed resident in dining room before elopement and was unaware alarm was off. |
| Staff B | Activity Assistant | Noted resident missing from dining room and unaware alarm was disabled. |
| Director of Nursing (DON) | Director of Nursing | Assessed resident after elopement and confirmed alarm was off; stated expectations for door alarms. |
| Administrator | Administrator | Stated expectation that doors not be unattended if alarms disabled and to do resident counts if elopement occurs. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for Rose Haven Nursing Home.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective September 29, 2023. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 8
Date: Aug 30, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of multiple substantiated complaints between 8/27/23 and 8/30/23.
Complaint Details
The visit included investigation of substantiated complaints #113148-C, #113279-C, #113516-C, #113520-C, #114186-C, and #115061-C.
Findings
The facility was found deficient in multiple areas including resident rights, privacy, dignity, care planning, safe environment, quality of care, infection prevention, and staffing. Several residents were observed to have unmet needs related to privacy, dignity, and care interventions. The facility failed to provide timely interventions, proper care plan updates, and adequate infection control staffing.
Deficiencies (8)
Facility failed to provide privacy during personal cares and dignity bag covering for resident with indwelling catheter.
Facility failed to promote resident self-determination and choice, including scheduling and activities.
Facility failed to maintain a safe, clean, comfortable, and homelike environment, including missing personal items and dignity covers for catheter bags.
Facility failed to provide timely interventions and care plan revisions after incidents and hospitalizations.
Facility failed to ensure quality of care, including failure to implement interventions after resident suicide threats.
Facility failed to ensure continence care and proper catheter care, including dignity bag placement.
Facility failed to employ a full-time Director of Nursing as required.
Facility failed to employ an Infection Preventionist with required qualifications and training.
Report Facts
Resident census: 45
Number of substantiated complaints: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to resident privacy and dignity. |
| Staff F | Registered Nurse (RN) | Named in findings related to resident care and dignity. |
| Staff G | Activity Assistant | Named in findings related to resident privacy. |
| Staff H | Licensed Practical Nurse (LPN) | Named in findings related to resident privacy. |
| Administrator | Named in findings related to staff expectations and facility management. | |
| Assistant Director of Nursing | Director of Nursing | Named in plan of correction as appointed on 9/27/23. |
| Staff K | Assistant Director of Nursing/Infection Control Preventionist | Named in plan of correction as hired and trained. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The document is a plan of correction submitted by the facility following a prior inspection to address cited deficiencies and achieve compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective June 5, 2023. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: May 4, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of multiple complaints (#107412-C, #107585-C, #109587-C, #110537-C, and #111982-C) were conducted by the Department of Inspection and Appeals from May 4, 2023 to May 11, 2023.
Complaint Details
Complaints #110537-C and #111982-C were substantiated. The complaint investigation revealed ongoing issues with Staff B's attitude, including yelling at residents, rude behavior, and poor communication, as documented through resident council meeting minutes and staff interviews.
Findings
The facility was found to be in compliance with CDC recommended COVID-19 practices. However, deficiencies were identified related to resident council meetings and staff response to resident grievances, specifically concerning Staff B's attitude and behavior towards residents.
Deficiencies (1)
The facility failed to consider the views of the Resident Council and act promptly upon grievances concerning staff attitude and treatment issues, specifically related to Staff B's behavior.
Report Facts
Total Residents: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurses Assistant (CNA) | Named in multiple findings related to poor attitude, yelling at residents, and inadequate response to resident grievances |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction, the facility will be certified in compliance effective July 19, 2022.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
Date: Jul 6, 2022
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from June 26, 2022 to July 6, 2022 to assess compliance with federal regulations.
Findings
The facility was found to have multiple deficiencies including failure to respond to resident grievances, failure to ensure resident code status documentation was current, inadequate bowel movement management, unsafe oxygen tank handling, failure to provide recommended nutritional supplements, lack of non-pharmacological interventions prior to PRN anti-anxiety medication administration, and food safety violations during meal assistance.
Deficiencies (7)
Failure to consider views of Resident Council and respond promptly to grievances regarding staff treatment.
Failure to ensure resident code status documentation was current and accurately reflected orders.
Failure to carry out assessments and interventions for residents without bowel movements for more than 4 days.
Failure to properly secure oxygen tanks during transport and respond timely to alarms.
Failure to provide recommended nutritional supplements and document provision.
Failure to provide three non-pharmacological interventions prior to administering PRN anti-anxiety medications and failure to discontinue PRN orders after 14 days without renewal.
Failure to ensure staff used proper food safety practices when assisting residents with eating.
Report Facts
Census: 42
Deficiencies cited: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective March 18, 2022.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Mar 18, 2022
Visit Reason
The inspection was conducted as part of the investigation of Complaints #100467 and #102484, along with a Facility Self-Reported Incident #102785. Both complaints were substantiated.
Complaint Details
Investigation of Complaints #100467 and #102484, both substantiated. Facility Self-Reported Incident #102785 also related.
Findings
The facility failed to meet professional standards of quality by not following physician's orders for one resident (Resident #1) related to blood pressure medication and assessments. The facility also failed to ensure comprehensive assessments and proper documentation upon the resident's return from the hospital emergency room.
Deficiencies (2)
Facility failed to follow physician's orders for Resident #1 regarding blood pressure medication and monitoring.
Facility failed to ensure comprehensive assessments and proper documentation for Resident #1 upon return from hospital emergency room.
Report Facts
Census: 38
Sample size: 8
Correction date: Mar 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to administer medication and document assessments for Resident #1 |
| Staff A | Registered Nurse | Received verbal order to transfer Resident #1 to hospital |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 17, 2021
Visit Reason
The onsite revisit was conducted from June 15, 2021 to June 17, 2021 to verify compliance and certification status of the facility.
Findings
The facility was certified in compliance effective May 26, 2021. The plan of correction was not effectuated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
A complaint investigation was conducted on June 14-15, 2021 to determine the validity of Complaint #97704.
Complaint Details
Complaint #97704 was investigated and found not substantiated.
Findings
The complaint investigation found that Complaint #97704 was not substantiated.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: May 3, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #95689 and a Facility Self-Reported Incident #96001 from 5/3/21 through 5/6/21. Both the complaint and incident were substantiated.
Complaint Details
Complaint #95689 and Facility Self-Reported Incident #96001 were investigated and both substantiated.
Findings
The facility failed to respond adequately to resident grievances regarding food temperature and variety, failed to provide a safe environment preventing falls, did not ensure proper dialysis assessments, and failed to serve food at proper temperatures. Deficiencies were identified related to resident group participation, accident hazards, dialysis care, and food service.
Deficiencies (4)
Failure to consider views of Resident Council and respond to grievances about food temperature and variety.
Failure to provide adequate supervision and accident prevention devices leading to resident falls.
Failure to consistently complete full nursing assessments and monitoring before and after dialysis treatments.
Failure to ensure food was served at proper temperatures and with adequate variety.
Report Facts
Resident census: 44
Resident Council meeting attendance: 11
Food temperature measurements: 124
Food temperature measurements: 120
Food temperature measurements: 118
Food temperature minimum standard: 140
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Feb 8, 2021
Visit Reason
The investigation was conducted in response to Complaint #94838 and Mandatory #90161 regarding allegations of abuse and failure to report such allegations promptly.
Complaint Details
Complaint #94838 was not substantiated. The deficiency relates to Mandatory #90161 regarding reporting of alleged violations. The allegation involved Resident #2 and staff failed to report the abuse allegation timely.
Findings
The facility failed to ensure that all alleged abuse violations were reported immediately and within the required timeframe of 2 hours after the allegation. Staff misunderstood reporting requirements, leading to delayed reporting of an incident involving Resident #2.
Deficiencies (1)
Failure to report all alleged abuse violations immediately and within 2 hours after the allegation was made.
Report Facts
Census: 40
Correction Date: Feb 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jalissa Winn | Administrator | Named as the administrator responsible for re-education and policy enforcement |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #91586 were conducted by the Department of Inspections and Appeals from 9/28/20 to 10/1/20.
Complaint Details
Complaint #91586 was unsubstantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91586 was unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Feb 5, 2020
Visit Reason
The inspection was conducted as an investigation of a Facility Self-Reported Incident #87002 which was substantiated, concerning a resident fall with injury.
Complaint Details
The visit was complaint-related, investigating a substantiated Facility Self-Reported Incident #87002 involving a fall with injury to Resident #1.
Findings
The facility failed to appropriately supervise one resident (Resident #1) to prevent a fall resulting in a fractured right humerus. The resident was ambulating with limited assistance but was assisted by a float staff member who did not use a gait belt as required. The facility corrected the deficient practice prior to the survey by educating staff and agency personnel on gait belt use.
Deficiencies (1)
Failure to ensure adequate supervision and use of assistive devices to prevent a fall resulting in injury to Resident #1.
Report Facts
Resident census: 54
Date of fall incident: Oct 23, 2019
Number of deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse's Aide (CNA) | Agency staff who failed to use a gait belt and was disciplined following the fall incident. |
| Staff A | Licensed Practical Nurse (LPN) | Found Resident #1 after the fall and issued a warning to Staff B. |
| Staff D | Director of Nursing (DON) | Conducted the investigation of the fall incident. |
| Staff E | Certified Nurse's Aide (CNA) | Reported observations about the resident's condition and gait belt use. |
Report
Dec 11, 2025
Report
Dec 11, 2025
Report
Mar 10, 2025
Report
Oct 24, 2024
Report
Oct 24, 2024
Report
Nov 7, 2023
Report
Aug 30, 2023
Report
Aug 30, 2023
Report
May 11, 2023
Report
May 11, 2023
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