Roseview Nursing and Rehabilitation Center

Inspectors wroteBased on record reviews and interviews the facility failed to notify 1 (#1) of 3 sample resident's RP (responsible party) of a change in a resident condition. The facility failed to notify resident #1's RP of new orders for medications including an antipsychotic was initiated without their knowledge.

Inspectors wroteBased on record reviews and interviews, the facility failed to monitor 1(#1) of 3 sample residents for possible adverse consequences reviewed for unnecessary medications. The facility failed to provide monitoring for behaviors and possible adverse consequences or side effects related to the use of the antipsychotic medications Seroquel and Risperdal for resident #1.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the residents' environment remained free of hazards for 1 (#1) of 4 sampled residents reviewed for facility transportation. The facility failed to:1. Ensure Resident #1 was properly secured with shoulder and lap belt in the facility van,2. Ensure Resident #1 was assessed following a fall on the van, and3. Ensure Resident #1's fall was promptly reported and documented.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the daily van safety checklist was accurately documented for 1 (#1) of 3 (#1, #2, #3) residents reviewed for transport.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#12 and #20) of 9 residents reviewed for accident hazards and supervision. The facility failed to ensure there were no medications at the bedside.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#7 and #9) out of 3 residents reviewed for respiratory services. The facility failed to ensure proper storage of respiratory equipment.

Inspectors wroteBased on record reviews, an observation and interview the facility failed to ensure 1 (#7) of 1 resident reviewed for food received a mechanically soft diet as ordered by physician. Review of facility Menu Matrix revealed mechanically soft diet was described as mostly for dysphagia; ground meats with soft foodsReview of Resident #7's face sheet revealed an admission date of 12/13/2025 with a diagnosis of dysphagia (oropharyngeal phase). Review of Resident #7's January 2026 physician orders revealed an order dated 09/13/2025 for a regular NSOT (no salt on tray) diet, mechanical soft texture, regular/thin consistency. Review of Resident #7's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 9 indicating moderately impaired cognition. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure 4 (#1, #2, #3, and #4) of 4 glucometers used in the facility were maintained in safe operating condition for residents with orders for blood glucose monitoring. S1 DON (Director of Nursing) reported the facility had 29 residents in the facility who required blood glucose monitoring with the facility's glucometer.

Inspectors wroteBased on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 3 (#30, #45, and #76) of 32 residents reviewed for Advance Directives.

Inspectors wroteBased on record review and interview the facility failed to inform the resident's responsible party/representative (RP) of a resident's change in condition for 1 (#35) of 2 residents (#10, #35) reviewed for falls. The facility failed to ensure the RP was notified of a resident's fall (#35).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 1 of 2 residents reviewed for hospitalization. The facility failed to notify the Office of the State Ombudsman of the emergency transfer and provide the resident and their RP (responsible party) written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for Resident #23.

Inspectors wroteBased on observations, interview and record review the facility failed to follow recognized infection control practices to prevent the development and transmission of infection for 1(#23) out of 2 (#23, #76) residents observed with an indwelling Foley catheter. The facility failed to ensure the Foley catheter collection bag did not touch the floor (#23).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident was free from neglect during ADL (activities of daily living) care. The facility failed to ensure S4 CNA (Certified Nursing Assistant) asked for assistance for a two person assist before providing incontinence care which resulted in a fall with injuries for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for neglect. The deficient practice resulted in an immediate jeopardy for Resident #1 on 07/25/2025 at approximately 10:30 a.m. when Resident #1 fell out of the right side of the bed during incontinent care when S4 CNA (Certified Nursing Assistant) failed to ensure a two person assist was used during incontinent care to prevent Resident #1 from falling out of the bed. S4 CNA did not ask for assistance before providing ADL care and Resident #1 fell from the bed resulting in multiple injuries. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow a resident's plan of care for 1 (#1) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record reviews, interviews, and video footage the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one (Resident #1) of three (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review, interview, and facility camera footage, the provider failed to ensure services were provided to meet professional standards of quality by failing to complete a full head to toe assessment with vital signs after a resident fall prior to being moved from the floor to a wheelchair for one (Resident #1) of three (#1, #2, #3) residents reviewed for falls.

Inspectors wroteBased on record reviews, observations and interviews the facility failed to provide necessary care and services in accordance to the professional standards of practice and the resident's plan of care for 2 (#39, #90) of 2 (#39, #90) residents reviewed for respiratory care.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care by not developing a care plan within 48 hours of admission for 1 (#201) of 1 (#201) resident baseline care plan reviewed for dialysis and nutrition.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a resident's person centered plan of care was reviewed and revised to include approaches and interventions to address the resident's need for O2 (Oxygen) for 1 (#90) of 23 sampled resident's care plans reviewed.