Roseville Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of four sampled residents (Resident 4) when facility staff witnessed Resident 1 hit Resident 4. This failure resulted in Resident 4 to verbalize sadness and not be free from abuse and potential harm.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of abuse for one of four sampled residents (Resident 1) when Resident 1 reported to nursing staff that she was injured by facility staff during patient care. This failure had placed Resident 1 and other residents in the facility at risk for potential physical abuse and/or psychosocial harm. Resident 1 was admitted to the facility October 2025 with multiple diagnoses which included muscle weakness and abnormalities of gait (manner of walking and limb movement) and mobility. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/5/25, indicated Resident 1 had moderate memory impairment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision to protect two residents (Resident 1 and Resident 2) from abuse when Resident 1 and Resident 2 had a physical altercation. This failure had the potential to result in physical injury or emotional distress for both Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper dishwashing process and sanitary conditions were maintained in the dietetic services when: 1. Two serving metal pans with debris particles stacked together were found stored in a clean and ready-to-use storage area. 2. Dietary Aide (DA) 1 was not able to verbalize and/or demonstrate: -The practice of measuring the water temperatures for the automated dishwashing and -The knowledge of the temperatures and sanitation concentrations for the manual dishwashing by 3-compartment sink procedure. 3. The wash and rinse temperatures log and instructions of the dishwashing machine did not match the manufacturer's guidance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of 52 sampled residents (Resident 170 and Resident 15) when: 1. Resident 170's LAL (low air loss, designed to prevent and treat pressure ulcers by reducing and redistributing pressure on the body) mattress was not followed as ordered; and 2. Resident 15's blood pressure medication was not administered as ordered. These failures increased the potential for Resident 170 to develop new pressure ulcers and for Resident 15 to experience complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures to meet the needs of each resident and ensure that these procedures were consistent with standards of practice, when: 1. A medication for Resident 76 was not administered as prescribed by physician; 2. A prescribed medication was not available at the time of administration for Resident 529; 3. Resident 731 did not receive prescribed ointment treatment for multiple days; 4. Resident 68 received medication beyond the expiration date; 5. A loose unidentified medication was stored in the drawer with controlled substances, and 6. A loose pink pill was observed on the floor in hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) and recipes (a set of instructions for preparing a particular dish, including a list of the ingredients required) were followed for the therapeutic diets during the lunch meal distribution on 6/25/25 when: 1. Resident 14 with low fat and low cholesterol diet (a diet designed to lower elevated levels of cholesterol and other fats in the blood to reduce the risk of heart disease) received tartar sauce (a cold sauce, typically eaten with fish, consisting of mayonnaise) instead of a lemon slice for the lunch. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures to prevent the introduction and spread of infections to residents, when: 1. The nursing staff did not implement EBP (enhanced barrier precautions) for Resident 731; 2. The housekeeping staff did not wear appropriate PPE (personal protective equipment) while cleaning inside a room on EBP; 3. Resident 25's nebulizer mask (a face mask that fits over the nose and mouth to deliver medication into the lungs) was not stored properly; and 4. Treatment Nurse provided care to an open wound and did not wear adequate PPE per EBP standards. These failures had the potential to spread infections among residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the laundry was maintained in a sanitary manner and in good repair when the contaminated linen area was found dirty, and a window screen was damaged. This failure had the potential to result in the facility not providing safe and sanitary handling of laundry items used by residents for a census of 175.

Inspectors wroteBased on interview and record review the facility failed to ensure that two of 52 sampled residents (Resident 82 and Resident 9) were free from unnecessary drugs including chemical restraints when medications were administered without specific target behaviors and diagnoses to support indication for use of these drugs. This failure resulted in the administration of medications without adequate indication for use.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessments were completed for two of 52 sampled residents (Resident 170 and Resident 176) when: 1. Resident 170's Minimum Data Set (MDS- a federally mandated resident assessment tool) did not indicate the correct number of pressure ulcer or pressure injury (PU or PI) present on admission; and, 2. Resident 176's MDS did not reflect the resident's status at the time of discharge from the facility. These failures increased the potential for Resident 170 not to receive consistent care and for Resident 176 not to receive referral for necessary services in the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of 52 sampled residents (Resident 160) from further injury when they did not implement specified interventions from the care plan to prevent skin tears. This failure resulted in Resident 160 sustaining additional skin tears to her left leg.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for one of 52 sampled residents (Resident 731), when the facility did not follow a physician order for straight catheterization (a thin, flexible tube is inserted into the urethra to drain urine and removed immediately) when the resident complained of inability to urinate and inserted a Foley catheter (a flexible plastic tube inserted into the bladder) to provide continuous urinary drainage. This failure had the potential to result in urinary tract infection.

Inspectors wroteFindings: A review of Resident 732's admission Record indicated the facility admitted the resident recently after hospitalization for lung infection. Resident 732's multiple diagnoses included muscle weakness and unsteadiness on feet. A review of the 'Order Summary Report' contained a physician's order dated 6/8/25 indicating that Resident 732 had capacity to make healthcare decisions. A review of Resident 732's care plan titled Malnutrition: Resident is at risk for malnutritioninitiated on 6/8/25, indicated resident's goal was to maintain adequate nutritional status as evidenced by stable weight. The care plan interventions indicated, Assist with meals/fluids as needed, encourage adequate nutrition and hydration, encourage position [sic] of choice of meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety for one of 52 sampled residents (Resident 100) with gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) when the facility did not follow the physician's order to keep Resident 100's head of bed (HOB) elevated at 30 degrees during tube feeding. This failure increased the risk for Resident 100 to experience aspiration (inhaling liquid, vomit or saliva) and develop pneumonia or lung infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 52 sampled residents (Resident 82) was provided with respiratory care when Resident 82 was not provided with a functioning continuous positive airway pressure (CPAP, a breathing machine designed to increase air pressure, keeping the airway open when the person breaths in) machine. This failure had the potential to result in Resident 82 experiencing respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one of 52 residents (Resident 15) when doses of Resident 15's PRN (as needed) pain medications were given without indication. This failure had the potential to increase Resident 15's risk of exposure to side effects and dependence to pain medication.

Inspectors wrote2. During a review of Resident 579's admission records, the records indicated Resident 579 was admitted in June 2025 with diagnoses that included end stage renal disease and dependence on renal dialysis. Resident 579's MDS indicated Resident 579 had intact cognition. During a review of Resident 579's care plan, initiated 6/7/25, the care plan indicated, Dialysis: Resident Requires Hemodialysis .and has an AV Fistula (shunt) (left arm) .Avoid taking blood pressure .on the AV site extremity . During a review of Resident 579's physician order, dated 6/12/25, the order indicated, Avoid taking BP [blood pressure] on Left Arm . During a review Resident 579's Weights and Vitals Summary, the summary indicated blood pressures were taken on Resident 579's left arm twice on 6/9/25 and once on 6/19/25. During a concurrent interview and review on 6/27/25 at 8:56 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice, to prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of five sampled residents (Resident 1) when: 1) Daily skin checks were not documented, 2) Bowel and bladder care were not provided at regular intervals. These failures resulted in Resident 1 developing Stage 2 pressure ulcers (partial-thickness loss of skin, presenting as a shallow open sore or wound) on Resident 1's left and right buttocks.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 3) in a census of 179 was seen by their physician as required. This failure had the potential for a delay in services and treatment of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of four sampled residents (Resident 1) when Resident 1 received Isavuconazonium Sulfate Capsule (an antifungal medication- used to treat lung infections) every eight hours when the physician's order from the hopsital was to receive the medication one time per day. This failure resulted in Resident 1 receiving 32 extra doses of medication, which increased the potential for adverse systemic effects and jeopardized Resident 1's health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards for one of three sampled residents (Resident 1) with an indwelling urinary catheter (a thin tube that is inserted into the bladder, held in place by a soft balloon, and used to drain urine) when: 1. There was no active physician order for an indwelling urinary catheter nor was the presence of the catheter included in the plan of care or weekly summary notes. 2. There was no documented evidence of care and management of the urinary catheter and drainage bag according to professional standards. 3. Resident 1's urine collection bag was observed lying on the floor with no privacy cover. [...]

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse to the Department on a timely manner for one of four sampled residents (Resident 1) when the Department received the report of alleged abuse the day after the incident occurred. This failure resulted in a delay in the abuse investigation and decreased the facility's potential to protect the resident from harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the protection of residents' personal information for census of 179, when tray tickets were thrown into the trash and outside dumpsters. This failure had the potential to place resident personal information at risk for misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately maintain pharmacy services for 3 out of a census of 185 when: 1. An injectable Emergency medication box with a fill date of 2/29/24 was found to be opened and unsealed without proper documentation and not replaced within 72 hours; 2. An Emergency medication E-kit (a box with a supply of medications that may be used for residents when pharmacy services are not available) in the refrigerator was accessed and used without proper documentation when one used lorazepam (a medication used to treat mood disorders) injectable medication was not documented; 3. Prescription medication for 3 residents (Resident 97, Resident 114, and Resident 7) were not available at the time of administration; and, 4. A dose of lacosamide (a medication given for seizures) was given and not signed on out by the LN (Licensed Nurse). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled, when: 1. A partially used Multi dose inhaler was found without an open date label in a medication cart; 2. Two partially used glucose test strips containers without an open date label were found in two medication carts; 3. An intravenous IV antibiotic bag was found on one of the medication carts in the narcotic binder, accessible to residents and unauthorized individuals; 4. A medication cart was left unlocked with one of the drawers open, with four medication blister packs on top accessible to residents and unauthorized individuals; 5. The medication refrigerator was left unlocked with an unlocked medications box inside for controlled medications; and, 6. Five loose pills were found in three medication carts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conserve the nutritive value and flavor of pureed foods for 17 out of 179 residents (Resident 1, Resident 2, Resident 17, Resident 26, Resident 30, Resident 37, Resident 52, Resident 56, Resident 69, Resident 74, Resident 86, Resident 133, Resident 470, Resident 570, Resident 571, Resident 572, and Resident 573) when the recipes were not followed. This failure had the potential for malnutrition, weight loss, slow wound recovery, and vulnerability to diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 179 residents who received facility prepared foods when: 1. Milk and eggs were stored only 1.5 above floor level; 2. Opened food items were not sealed in the dry storage area; 3. Food products were not labeled to ensure food safety; 4. Kitchen floors contained build-up of black grime, broken tile, and walls with chipped paint; 5. Unsafe kitchenware stored and available for use; 6. Emergency food was not monitored to ensure safety; and, 7. Resident refrigerator log in C3 showed two days of recordings above safe food storage range without corrective actions. These failures had the potential to lead to contamination and/or food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective infection control program when: 1. Certified Nurse Assistant 3 (CNA 3) did not wear the proper Personal Protective Equipment (PPE) while giving care to Resident 12 who was on Enhanced Barrier Precautions (EBP) and did not perform hand hygiene in between tasks of providing care and collecting garbage; and, 2. Licensed Nurse 2 (LN 2) did not disinfect the glucometer (a device used to measure blood sugar) according to manufacturer's recommendation during a medication pass observation. These failures increased the risk of spreading infection at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its own policy for medication self-administration for one of 36 sampled residents (Resident 422) when the facility did not obtain a physician's order for Resident 422 to self-administer medications. This failure had the potential to result in an unsafe medication self-administration.

Inspectors wroteBased on interview and record review the facility failed to ensure a Significant Change of Status Assessment (SCSA) was completed within 14 days after discharging from Hospice Care (end of life care) for one of 36 sampled residents (Resident 97). This failure decreased the facility's potential of providing appropriate care and services to Resident 97 based on his current status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess three of 36 sampled residents (Resident 101, Resident 88, and Resident 143), when: 1. Resident 101's Minimum Data Set (MDS; an assessment tool) indicated restorative nursing program (RNA; a program to maintain a person's highest level of physical, mental, and psychosocial function) was not performed; 2. Resident 88's MDS assessment did not reflect continuous oxygen use; and, 3. Resident 143's MDS wound assessment was coded inaccurately. These failures decreased the facility's potential to identify residents' care needs accurately.

Inspectors wrote4. A record review of Resident 525's admission record indicated Resident 525 was admitted in early May 2024 for aftercare following right hip replacement surgery. A review of Resident 525's OSR for active orders as of 5/9/2024, indicated Resident 525 was prescribed, [Oxycodone] Oral Tablet 5 MG [milligram a unit of measure] .Give 3 tablet by mouth every 4 hours as needed for severe pain . start date 5/2/2024 . An interview on 5/8/24 at 4:07 p.m., LN 12 stated when giving a resident a controlled drug (drugs that can cause physical and mental dependence), nurses are expected to document the time and how many tablets/pills given to the resident on the controlled drug record form as well as document in the resident's electronic health record (EHR). LN 12 added the EHR will indicate the accurate time when the controlled drug was administered to the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper care and services to one of 36 sampled residents (Resident 420) when Resident 420's order for enteral feeding (a method of providing nutrient directly to the stomach or small bowel using a tube) did not include the kind of feeding formula to be infused, its duration, and the mechanism of administration. This failure had the potential to cause an error during administration of the feeding.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was less than 5% when a medication was not available for one resident, an extended release medication was crushed, and a chewable aspirin was given and not the delayed release medication. This failure resulted in 3 errors out of 28 opportunities during an observation of medication administration, which resulted in an error rate of 10.71 % for the faclility.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the residents' protected health information (PHI, such as individuals' health, treatment and payment information) visible and accessible to the public when the Kiosk/computer located between resident's room and storage room was left unattended and the computer screen showed information for the census of 179 residents. This failure had the potential for the public to access unauthorized residents' PHI and cause a breach of confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2's) safety when, the resident's bed locks were not completely secured in place. This failure had the potential to contribute to Resident 2's fall and placed the resident at a greater risk for avoidable accidents.

Inspectors wroteBased on interview and record review, the facility failed to manage one of three sampled residents (Resident 1's) pain timely when staff had incongruent (inconsistent) communication regarding the resident's complaint of pain. This failure resulted in Resident 1 having uncontrolled pain and a hospital transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of hazards when one of five sampled residents, (Resident 1)'s, bed malfunctioned and the head of bed dropped suddenly. This failure resulted in Resident 1 experiencing neck pain.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when the resident specific health condition and the pertinent care needs and services were not identified and addressed. This failure placed the resident at risk for unmet care needs and resulted in lack of coordination of Resident 1's care with the agency responsible for the protection and advocacy for residents living with developmental disability (DD).

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain evidence of the results of any grievances for all residents in a census of 139 when: No record of grievances nor resolutions were retained by facility. This failure had the potential to violate the residents rights to file grievance and have it resolved.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. Kitchen staff unable to explain the manual three-part sink dish washing steps; 2. Dusty fan by window with sill that had build-up of gray/black particles, leaving black smudge on finger when wiped; 3. Screen for kitchen window found with gap, allowing pest entry; 4. Dented cans found in canned good section for use. Food not properly cooled; 5. Floor under shelves in dry food storage with grayish, black build-up and was rough to touch; 6. Kitchen floor found with broken tiles; 7. Dishwasher not found with air gap; 8. Food not properly cooled. These failures had the potential to increase the risk of food borne illness for 139 residents receiving food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly in order to prevent the harborage of pests when the dumpster lid was left open. This failure increased the risk of an unsanitary environment due to the potential for flies and rodents on facility grounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for residents, staff, and the public, when carpet throughout the facility was damaged. This failure had the potential to cause fall related injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in accordance with their policy and federal laws when: 1. An unlocked and unmonitored refrigerator, which contained an expired biological product, was found in a conference room; and 2. A drawer used to store controlled medications for disposition did not have a lock that sufficiently secured the drawer to prevent diversion. These failures had the potential for residents to have received a biological product that was less potent and increased the risk of unauthorized people having access to controlled medications with a high probability for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for Dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) for one resident (Resident 117), that was person-centered and supportive of Resident 117's needs. The facility failed to develop care plan interventions to reduce Resident 117's confusion, which had the potential to cause the resident anxiety and an inability to achieve her highest level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two residents (Resident 34 and Resident 144) in a census of 139 when: 1. Resident 34's prescription for lorazepam (a medication used to treat an active seizure) was expired and available for use in the medication refrigerator; and, 2. Resident 144 did not receive his morning dose of finasteride (a medication used to treat urinary retention) due to the medication not being available. These failures had the potential to result in Resident 34 receiving a medication that was no longer effective at treating his seizures, and Resident 144 experiencing discomfort.