Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Haven Nursing Home during CMS and state inspections, most recent first.
A resident who was dependent on staff for toileting and had multiple medical conditions was told by a CNA to have a bowel movement in bed instead of being assisted to the bathroom, contrary to the care plan and resident rights. This action was confirmed by the resident and an RN, and did not meet the facility's standards for dignity and respect.
A resident with moderate cognitive impairment and multiple medical conditions reported being slammed onto the toilet by a CNA, resulting in pain. Although the allegation was communicated among CNAs, there was uncertainty about whether it was promptly reported to nursing leadership, leading to a delay in the required abuse reporting process.
A resident with moderate cognitive impairment and significant care needs reported being slammed onto the toilet by a CNA, resulting in pain. The facility's investigation did not document follow-up on the staff member described by the resident, nor did it show that all required investigative steps were completed according to facility policy.
Multiple residents with varying levels of mobility and medical complexity were not safely transferred by staff, resulting in injuries and distress. Staff failed to consistently use gait belts as required by facility policy, instead relying on manual lifting techniques or improper use of transfer equipment. These actions led to incidents including bruising, pain, and a fall during a stand lift transfer.
The facility did not adequately address previously cited deficiencies related to F609 and F610 through its QAPI program, as the same violations were identified in consecutive surveys despite having a policy for identifying and correcting quality issues.
The facility failed to properly store and label medications, leading to several deficiencies. An LPN found a medication cup with pills not stored in their original packaging, involving a resident with multiple diagnoses. Additionally, an unlocked refrigerator contained insulin pens and other medications, raising concerns about drug diversion. A RN also failed to date an insulin pen after opening it, which is crucial for medication safety. These incidents highlight deficiencies in the facility's medication storage and administration processes.
A resident's prescribed Hydrocodone/Acetaminophen was missing and replaced with an unauthorized Acetaminophen 500 mg tablet. The facility's investigation was inadequate, as it did not involve all potential witnesses, and the established abuse prevention and investigation protocols were not fully followed.
A medication error occurred when a resident with multiple health conditions received the wrong medication due to a mix-up in appearance between acetaminophen and a prescribed narcotic. The facility's investigation was incomplete, as it did not include interviews with all relevant staff, particularly CNAs, and the policy on medication storage was inadequate.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
A resident with diagnoses including neurogenic bladder, pressure ulcer, diabetes mellitus, anxiety, and depression, and who was cognitively intact, was dependent on staff for toilet transfers and hygiene. The resident's care plan specified that staff should assist with toileting upon request and provide peri care every morning, evening, and as needed for incontinence. Despite these directives, the resident reported that a CNA instructed her to have a bowel movement in her bed if she needed to go immediately, rather than assisting her to the bathroom as required. This incident was confirmed by both the resident and a registered nurse, who expressed shock at the CNA's direction and reported the event to the Director of Nursing. The facility's policies and resident rights documents require staff to treat residents with dignity and respect, and to provide care that maintains or enhances quality of life. The CNA's actions did not align with these requirements, resulting in a failure to honor the resident's right to a dignified existence and self-determination.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The resident, who had diagnoses including respiratory failure, heart failure, and diabetes mellitus, and who required substantial assistance with toileting and transfers, reported that a CNA had slammed her down on the toilet, causing pain. The incident was reported by the resident to staff a few days after it occurred, and staff interviews revealed that the complaint was communicated among CNAs, but there was uncertainty about whether it was reported to a nurse immediately. The facility's policy required prompt reporting and investigation of abuse allegations, including documentation, assessment, and notification to appropriate authorities. Despite these requirements, the report indicates a delay in the reporting process, as staff were unsure if the complaint was escalated to nursing leadership in a timely manner. The Director of Nursing and Administrator both stated that staff are expected to report concerns to nurses and ensure they are heard, or to escalate to the DON if necessary. The deficiency was identified through review of clinical records, resident and staff interviews, and facility policy, showing a breakdown in the timely reporting of suspected abuse.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including respiratory failure, heart failure, and diabetes mellitus. The resident, who required substantial assistance with toileting and transfers, reported that a CNA slammed her down on the toilet, causing pain. The facility's documentation showed that while several residents were interviewed about staff treatment, there was no evidence that the specific description of the staff member provided by the resident was followed up on or investigated further. The facility's abuse prevention policy requires a designated management member to investigate all alleged incidents, collect supporting documents, review resident records, assess for injury, obtain witness statements, and preserve physical evidence. However, the investigation notes lacked documentation of these required steps, particularly regarding follow-up on the staff member described by the resident. The facility did not provide evidence that the investigation was comprehensive or that all protocols outlined in their policy were followed.
Failure to Ensure Safe Resident Transfers and Proper Use of Gait Belts
Penalty
Summary
The facility failed to ensure safe transfer practices for multiple residents, resulting in improper use of gait belts and manual handling that led to resident injury and distress. One resident, with diagnoses including pulmonary hypertension and hyperthyroidism, was assessed as independent with transfers and ambulation but required some assistance with toileting. Despite this, a CNA gripped the resident's arm with excessive force during a transfer, causing a visible bruise. Staff interviews confirmed that gait belts were not consistently used as required by facility policy, and manual lifting techniques were employed instead. Another resident, with respiratory failure, heart failure, and diabetes, required substantial assistance for toileting and transfers. This resident reported being handled roughly during a transfer, resulting in pain. Staff interviews revealed inconsistent use of gait belts during stand pivot transfers, with some staff admitting they did not always use the gait belt as directed by policy. The care plan specified one-person assistance with a walker for transfers, but staff actions did not consistently align with these instructions. A third resident, dependent on staff for all transfers and requiring a stand lift, experienced a fall during a transfer when two CNAs were using the stand lift. The resident became unresponsive and fell through the lift, with staff attempting to lower her to the floor. Staff interviews indicated uncertainty about proper strap placement and use of the stand lift. Facility policy required the use of gait belts for hands-on assistance and specified correct use of the stand lift, but these protocols were not consistently followed, leading to unsafe transfer events.
Failure to Address Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to address previously cited deficiencies related to F609 and F610 in its Quality Assessment and Performance Improvement (QAPI) program. Despite having a QAPI policy that outlines the process for identifying and correcting quality deficiencies, including developing and implementing corrective actions and monitoring their effectiveness, the same violations were identified in consecutive surveys. The facility's records and staff interviews confirmed that these deficiencies had not been adequately addressed through the QAPI process, as the same issues were cited in both the prior and current surveys.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications, leading to several deficiencies. In one instance, a Licensed Practical Nurse (LPN) discovered a medication cup containing pills with the first name of a resident, indicating that the medications were not stored in their original packaging as required. This incident involved a resident with multiple diagnoses, including cancer, diabetes, and dementia, who was prescribed various medications for pain management and other conditions. The medications found in the cup were from the evening medication pass, and the issue was reported to the charge nurse and the Director of Nursing (DON). Another deficiency was observed when a refrigerator in the nurse's area was found unlocked, containing a box with several insulin pens and other medications. The DON expected the refrigerator to be locked, but a staff member admitted to forgetting to lock it after accessing it. This oversight raised concerns about the potential for drug diversion, particularly for insulin and Lorazepam stored in the refrigerator. The facility's policy on medication storage did not adequately address the storage of prescription medications, contributing to this deficiency. Additionally, a Registered Nurse (RN) failed to date an insulin pen after opening it, which is a critical step to ensure the medication's efficacy and safety. The insulin pen was used for a resident with type 2 diabetes, and the RN acknowledged the oversight, stating she would have discarded the undated pen if she had noticed. The Assistant Director of Nursing (ADON) confirmed that insulin pens must be marked with the date they are opened, and any undated pens should be discarded immediately. This failure to date the insulin pen was identified as a deficiency in the facility's medication administration process.
Failure to Investigate Missing Narcotic Medication
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures following the identification of a missing narcotic medication for a resident. The resident, who had a history of cancer, diabetes mellitus, and dementia, was prescribed various medications, including Hydrocodone/Acetaminophen for pain management. On a particular day, it was discovered that the resident's scheduled Hydrocodone/Acetaminophen was missing from the medication cup, and instead, an unauthorized Acetaminophen 500 mg tablet was present. This discrepancy was noted by a staff member who reported the issue, highlighting the similarity in appearance between the two medications. The investigation into the missing medication was insufficient, as it did not involve interviews with all potential witnesses. The previous administrator conducted an investigation but only spoke with the nurses and not the Certified Nursing Assistants (CNAs) who were on duty at the time. This lack of thorough investigation was confirmed by the current administrator, who acknowledged that the medication carts were always located at the nurse station, suggesting that other staff might have observed something related to the missing narcotic medication. The facility's policy on abuse prevention, identification, investigation, and reporting was not fully implemented. The policy mandates the protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, and misappropriation of property. However, the investigation into the missing medication did not follow these protocols, as it failed to gather comprehensive witness statements and did not preserve potential physical evidence. This oversight in following the established procedures contributed to the deficiency identified in the report.
Incomplete Investigation of Medication Error
Penalty
Summary
The facility failed to conduct a thorough investigation into a medication error involving a resident with multiple health conditions, including cancer, diabetes, and dementia. The resident's care plan required pain management, including prescribed narcotics. However, a medication cup found in the medication cart contained an incorrect medication, acetaminophen 500 mg, instead of the prescribed Hydrocodone/Acetaminophen 10-325 mg. The error was discovered by staff members who noted the similarity in appearance between the two medications. Despite this discovery, the facility's investigation was incomplete, as it did not include interviews with all relevant staff members, particularly the Certified Nurses Aides (CNAs) who were on duty at the time of the incident. The facility's policy on medication storage, dated May 1, 2022, did not adequately address the storage of prescription medications other than controlled substances. The investigation conducted by the previous administrator was limited to discussions with nurses and did not involve CNAs, who might have had relevant observations. The resident involved could not recall the incident due to the time elapsed. This lack of comprehensive investigation and policy oversight contributed to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marengo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Of Amana | 7.8 mi | — | 0 | 0 |
| Highland Ridge Care Center, Llc | 8.8 mi | — | 11 | 0 |
| Belle Plaine Specialty Care | 13.7 mi | — | 1 | 0 |
| Keystone Nursing Care Center Inc | 16.8 mi | — | 4 | 0 |
| The Gardens Of Cedar Rapids | 18.6 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.