Rose Villa Health Care Center

Inspectors wroteBased on record review and interview, the facility staff failed to document the accurate intake and output (I&O) for one of three sampled residents (Resident 1), who was admitted to the facility with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) . This deficient practice resulted in the inability of the facility to accurately gauge the amount urine output and quality of urine for Resident 1 and had the potential for urinary inconsistencies to be unrecognized.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of three sampled residents (Resident 2), who was continent of bowel and bladder functions, that he was not made to wear an adult brief (diaper) and not asked to urinate in it. This deficient practice resulted in Resident 2's inability to use the restroom and feeling like a child when made to wear diapers. This deficient practice had the potential for Resident 1's ability to use the restroom to diminish over time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed by the physician and not left unattended on the bedside table of one of three sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving his prescribed medication and had the potential for the unattended medication to be taken and/or ingested by other residents causing unnecessary medication administration and/or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented the medication administration for one of three sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving medication as prescribed to him, but his clinical records indicating it was. This deficient practice had the potential to negatively impact Resident 4's health, mismanagement of his medication regimen and result in non-continuity of care.

Inspectors wroteDuring interview and record review, the facility failed to ensure two of three sampled residents (Resident's 1 and 2), who were assessed at a high fall risk, and had previous falls, and were cognitively (the ability to think and reason) impaired, were capable of following Care Plan interventions which included using the call light for assistance. The facility failed to investigate and review causal factors per Resident 2's Care Plan interventions after Resident 2 fell on [DATE]. These deficient practices resulted in Resident's 1 and 2 getting up unassisted without the knowledge of staff resulting in Resident 1 falling on 10/28/2025, and Resident 2 falling 11/22/2025. These failures increased the risk of future falls, potential injuries, and unnecessary hospitalizations for Resident's 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVNs) 2 and 3 administered 9 a.m. medications in a timely manner, for one of three sampled residents (Resident 4). These deficient practices resulted in Resident 4 not receiving his scheduled 9 a.m. medications on time on 11/15/2025 and 11/16/2025. These deficient practices had the potential of causing increased risk of harm to Resident 4 due to potential underdosing or overdosing, which could lead to unstable blood pressure, heart complications, and unnecessary discomfort.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure four out of five sampled residents' (Resident 14 and Resident 21, Resdent 28 amd 12)'s Minimum Data Set ([MDS], a resident assessment tool) was coded appropriately when: a. Resident 14's MDS was not coded correctly in the bladder and bowel portion. b. Resident 21's MDS was not coded correctly in the active diagnosis portion. c. Resident 28's MDS was not coded correctly to reflect Resident 28 had Bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and chair sensor alarm( a safety device a pressure sensitive pad use to detect when a resident leaves their bed). d. Resident 12's MDS was not coded correctly to reflect a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a care plan for two of three sampled residents (Resident 28 and Resident 29) when : a. Resident 28 had an order for a bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and a chair sensor alarm (a safety device a pressure sensitive pad used to detect when a resident tries to get up from the chair) b. Resident 29 refusing to get out of bed and attend activities for three days .

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (the effort to ensure that [antibiotics - medicines that fight bacterial infections in people and animals] are used only when necessary and appropriate) for two of four sampled residents (Resident 148 and Resident 14) as evidenced by: A. Failing to identify the indication of use and assess Infection Surveillance (an active reassessment of an antimicrobial prescription 48-72 hours after first administration) of Zosyn (a prescription drug that's used to treat or prevent certain infections intravenously) for Resident 148. B. Failing to implement Infection Surviellance of daptomycin (medication used to treat infection) for Resident 14. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a policy for use of, sensor alarm pads (a device that alerts staff when a resident moves or leaves their bed or chair) and to ensure consistent monitoring of the use of the sensor alarm pads for the bed and chair, for one of three sampled residents (Resident 26) while the sensor alarm pads were utilized. This deficient practice had the potential to place Resident 26 at risk for decline in physical functioning, reduced mobility, and loss of dignity due to the unmonitored use of sensor alarm pads.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 12) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program (a structured approach to help individuals regain or improve control over their bowel and bladder functions), to regain the resident's normal bowel and bladder function as much as possible. This failure had a potential to result in Resident 12's inability to regain control of bowel and bladder function and can lead to a loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 17) received multivitamins with minerals in accordance with physician orders during medication administration. This deficient practice had the potential to result in weakness and fatigue due to low levels of vitamins and minerals for Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) for one of four sampled residents (Resident 12) was indicated for a specific, diagnosed condition as documented in the medical evaluation and record. This deficient practice had the potential to place Resident 12 at risk for significant adverse events (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of an unnecessary psychotropic drug (a medication that affects brain activities associated with mental processes and behavior), which could result in impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 11's multivitamin liquid bottle indicated a manufacturer expiration date in accordance with manufacturer's specifications and facility's policy and procedures (P&P) titled, Medication Storage dated 2012 and Medication Ordering and Receiving from Pharmacy Provider, Medications Brought to Care Center by Resident or Family Member, dated 2012 in one of one inspected medication room (Station 1 Medication Room). This deficient practice had the potential to result in Resident 11 receiving multivitamin liquid that had become expired, ineffective, or toxic due to improper labeling and/or storage possibly leading to adverse effects from the multivitamin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate medical diagnosis was documented for one of three sampled residents (Resident 21), by failing to ensure Resident 21's diagnoses of adjustment disorder with depressed mood a specific type of adjustment disorder where the dominant symptoms are those associated with depression, such as low mood, tearfulness, and feelings of hopelessness, in response to a stressful event or life change was reflected. This deficient practice had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of resident receiving care in the facility.

Inspectors wroteBased on observation. interview and record review, the facility failed to implement infection control measures by failing to ensure: A. Resident 148's visitor was wearing Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while the visitor (Vistor 1) was assisting the resident. B. To place Resident 148 in Contact Isolation (a preauction that is used for patients with diseases caused by bacteria and viruses that are spread through direct and indirect contact) due to possible clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection while waiting for lab result. This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 20, 30, and Resident 43). The facility failed to ensure that Resident's 11, 20, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as indicated in the residents' care plans. This deficient practice had the potential for Resident's 11, 20, 30 and Resident 43 to have an avoidable decline in range of motion and mobility. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for four of 12 sampled residents (Resident's 11, 12, 30, and Resident 43). The facility failed to ensure that Residents 11, 12, 30 and Resident 43 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident's 11, 12, 30 and Resident 43 to have an avoidable decline in range of motion and mobility.

Inspectors wroteBased on interview and record review, the facility failed to communicate the following consultant pharmacist's recommendations in the Medication Regimen Review ([MRR] a thorough evaluation of the medication list of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for two of twelve residents (Resident 20 and 13). The facility failed to: a. Attempt the gradual dose reduction (GDR), of Resident 20's Escitalopram (medication for depression), and b. Gradually discontinue Resident 13's Pantoprazole (medication that reduces acid in the stomach. These deficient practices had the potential to result in Resident 20 and 13's continued use of unnecessary medications which leads to adverse drug reactions and negative health outcomes for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses acted upon the Pharmacists' Consultation Report by notifying Resident 20's physician about the pharmacist recommendation to attempt a gradual dose reduction of Escitalopram Oxalate (medication used to treat depression [a constant feeling of sadness and loss of interest, which stops a person from doing normal activities]) 5 milligrams ([mg] a unit of measure of weight) give one tablet by mouth (PO) one time a day for depression manifested by verbalization of feeling depressed. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 20 and had the potential to place other residents who were receiving antidepressant (medication used to treat depression) medications at risk for use of unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for one out of four sampled residents (Resident 35) as indicated in the facility's policy and procedure (P&P). 2. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic) medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of twelve sampled residents (Resident 5 and Resident 20). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure monitoring of the medication refrigerator temperature on 4/5/2024 was done per the facility's policy and procedure (P&P) titled, Storage of Medication. This deficient practice had the potential for exposure of the medication to extreme temperatures potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call lights for two out of four residents sampled (Residents 8 and 155) were within reach. The deficient practice had the potential to result in delayed care and services that promote the residents' well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled residents (Resident 37's) 7-day-bed-hold (a guaranteed reservation for residents that are transferred out emergently) was honored, by admitting a new resident to Resident 37's bed. This deficient practice violates Resident 37's right to come back to his guaranteed bed and is against the facility's policy and procedure for bed hold.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 3 failed to check for gastrostomy tube ([G-tube] a surgical opening made into the stomach to provide nutritional support) placement (the correct positioning or location of something) and patency (being open) per the physician's orders, prior to administering medications for one of one sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for peritonitis (inflammation, swelling of the lining of the belly or abdomen), pain, and unnecessary hospitalization from administering medications into a G-tube which may have been dislodged.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide quality of care and services in accordance with professional standards of practice for one of three residents (Resident 8) when: 1. The facility failed to ensure the physician and the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) were notified immediately, as indicated in the nutrition care plan, after Resident 8 was identified with severe weight loss on 2/5/2024 and 4/5/2024. a. On 2/5/2024, Resident 8 was identified to have a 9.73 % weight loss and the physician and RD were notified of the weight loss on 2/8/2024, three days later. b. On 4/5/2024, Resident 8 was identified to have 7.7 % weight loss and the physician and RD were notified of the weight loss on 4/6/2024, a day after the weight loss was identified. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the enteral (method of supplying nutrients directly into the gastrointestinal tract) feeding administration set, and piston syringe were signed and dated per facility's policy and procedure, to prevent complications of gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) for one of one sampled residents (Resident 1). This failure had the potential for Resident 1 getting infections due to the enteral feeding set being used beyond it's use-by date.

Inspectors wroteBased on interview and record review the facility failed to ensure: 1. The primary care physician visited Resident 37 to assess and continue admission orders from the hospital and complete a history and physical (H&P) making sure the facility provided the care needed during the stay in the facility for one of one sampled resident (Resident 37). 2. Ensure Resident 29's physician conducted a monthly visit for the month of 3/2024. This deficient practice has the potential to not provide Resident's 37 and 29 the appropriate medical interventions during their facility stay and had the potential to have issues or concerns missed which they may have wanted to discuss with their physician.

Inspectors wroteBasedoninterviewandrecordreviewthefacilityfailedtoensurethecomputedtomographyscan([CT]imagingteststodetectinternalinjuriesanddisease withintravenouscontrast(toadministermaterialsdirectlytothepersonsveintoenhancetheimagesofthetest, orderedon3/14/2024, toruleoutClostridioidesdifficile(germthatcausesinfectionofthecolon / Colitisrelapsediagnosiswithdiarrhea(loosewaterystools foroneofoneresident(Resident48) wascompleted ThedeficientpracticehadthepotentialtoresultinanundiagnosedproblemwhichcouldhaveplacedResident48 athigherriskforphysicaldecline Findings DuringareviewofResident48'sAdmissionRecord dated4/6/2024, theadmissionrecordindicatedResident48 wasadmitted tothefacilityon3/1/2024 withdiagnosesincludinginfectiousgastroenteritis(aninflammation[responsetoinjurycausingredness swelling pain lossoffunctionandheat]oftheliningofthestomachandintestines [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 8 received the ordered Consistent Carbohydrate Diet (CCHO, diet with the same amount of carbohydrates [sugars], main nutrients in our diet, every day), regular texture, thin liquids consistency, fortified (extra nutrients added), with chopped meat, on 4/7/2024. This deficient practice placed Resident 8 at higher risk for continued severe weight loss (weight loss greater than 5 percent in one month and greater than 7.5 percent in three months) and at higher risk for malnutrition (body does not get enough nutrients).

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to ensure the facility's administrator attended the monthly meetings. This deficient practice has a potential for the QAA committee not to identify and not to respond to systemic problems to improve services for the residents.

Inspectors wroteBased on interview and record review the facility failed to offer the influenza (Flu-an infection of the nose, throat and lungs, which are part of the respiratory system) vaccine and pneumococcal vaccine (vaccine that helps prevent pneumonia, an infection that inflames the air sacs in one or both lungs) to two of six sampled residents (Resident 1 and Resident 104). This failure had the potential to result in Residents 1 and 104 acquiring and transmitting the flu and pneumonia to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure that Resident 104 received the covid-19 (an disease caused by a virus, which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination. This deficient practice placed Resident 104 at risk of acquiring serious infections such as pneumonia and covid-19 that could result in serious symptoms.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure a baseline care plan for one of three sampled residents (Resident 1). Resident 1 did not have a baseline care plan that identified that Resident 1 refused and Resident 1 ' s family member (FM) refused to attend the Integrated Discharge Disciplinary Team (IDT the Residents health care team made up of various specialties). This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to her needs.

Inspectors wroteBased on interview and record review, the facility failed to readmit one out of two sampled residents (Resident 1) from the General Acute Care Hospital 1 (GACH1) after the resident was cleared by GACH 1 to return to the facility on 9/14/2022. This deficient practice resulted in denial of Resident 1 ' s right to return to the facility where she lived.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Do a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [medications that act on the mind] medication after three months of starting on the psychotropic medication, unless clinically contraindicated) for two of three residents (Resident 16 and Resident 36). This deficient practice resulted in Resident 16 receiving Escitalopram (brand name Lexapro, a medication to treat depression), and Resident 36 receiving Aripiprazole (brand name Abilify, a medication to treat depression) and Fluoxetine (brand name Prozac, an antidepressant medication that works in the brain) without clinical justification for use. 2. Ensure a proper physician consultation evaluation for Aripiprazole for one of three residents (Resident 36). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate space for therapy in the rehabilitation gym as evidenced by multiple binders, cardboard boxes, plastic containers, a laptop, bags, a water bottle, and office supplies were placed on the therapy mat (an adjustable padded surface used for therapy treatment) that is used for residents during therapy. This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to routinely clean and remove lint from the dryer. This deficient practice had the potential to cause a fire and/or injury to all residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents (Resident 12) was not provided grooming of fingernails. This deficient practice had the potential to result in Resident 12 being predisposes to microorganisms that can cause infection and a decrease self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for activities for one of 40 sampled residents (Resident 12). This deficient practice had the potential to negatively impact the resident's physical, cognitive and emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion (ROM, full movement potential of a joint) and/or mobility for one of 12 sampled residents (Resident 6). The facility failed to ensure that Resident 6 received Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) treatment five times a week as ordered. This deficient practice had the potential for Resident 6 to have an avoidable decline in range of motion and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify physician orders for an accurate dose of MiraLAX AX (medication used to treat occasional constipation) for one of three residents (Resident 38). This deficient practice had the potential to result in Resident 38 having unintended complications related to bowel patterns that can lead to constipation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer two medications necessary to treat Resident 12's anemia. The deficient practice had the potential to result in a delay of alleviating of or worsening of Resident 12's anemia. 2. Replace inhalation (INH) solution medication in the Emergency Kit ([E-kit] medications needed immediately) in a timely manner, taken for Resident 202 for Nurses Station (Station 1). The deficient practice had the potential to result in a delay in administration of necessary emergency medication for the residents. 3. Properly document resident names on E-kit slips at one of two Nurses Stations (Station 1). The deficient practice had the potential to result in unclear communication which could have led to issues with follow-up evaluations and treatment.

Inspectors wroteBased on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation in the Medication Regime Review (MRR), (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the physician for one of five residents (Resident 16) for unnecessary medications. This deficient practice resulted in a recommended gradual dose reduction not performed for Resident 16, with a potential for adverse drug reaction for the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure one of seven residents (Resident 16), who had a physicans order for insulin (used to control the level of the sugar-glucose in the blood) according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) was free from significant medication error when insulin was potentially omitted. This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar), or hypoglycemia (abnormal low blood sugar) which untreated can lead to complications, such as eye, kidney, or heart disease, nerve damage, loss of consciousness and even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper temperature controls for medications requiring storage in the medication room. This deficient practice had the potential of medication exposure to extreme temperatures in the medication storage room in station 1, potentially leading to loss of strength of the medications, causing residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired food was not stored in the kitchen and accessible to be used in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps, and diarrhea including decrease in food flavoring and taste.

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy (PT) and occupational therapy (OT) evaluations as ordered for one of 12 sampled residents (Resident 6). This deficient practice had the potential to prevent Resident 6 from maximizing her functional mobility (the way in which one moves in the environment to complete everyday tasks), joint range of motion (ROM, full movement potential of a joint), and activities of daily living (ADL, basic activities such as eating, dressing, toileting) while residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship by failing to: 1). Ensure Resident 46 was prescribed an antibiotic drug without meeting the criteria, after being screened for a urinary tract infection UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), and failing to provide a McGeer's criteria surveillance list. 2). Provide a McGeer's criteria surveillance documentation for (Resident 198). Resident 198 was prescribed antibiotic drug without following McGeer's surveillance. These deficient practices had the potential to result in antibiotic resistance (not effective to treat infection) due to unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) was administered timely (within admission)) to one of one resident (Resident 36). This deficient practice placed Resident 36 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. [...]