Roseville Point Health & Wellness Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a grievance was resolved for one of four sampled residents (Resident 4), when Resident 4's reported missing clothes were not replaced since May 2026. This failure decreased the facility's potential to settle grievances in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents' (Resident 2 and Resident 4) were free from physical abuse and neglect when:1. Resident 1 physically grabbed Resident 2's arm and refused to release it; and,2. Resident 3 pushed Resident 4's arm, and Resident 4 was not assessed, monitored or that the physician was notified following the incident. These failures resulted in Resident 2 becoming agitated and placed Resident 4 at risk for an undetected injury or change in condition due to the facility's failure to assess, monitor, and notify the physician after a witnessed incident of resident to resident physical abuse.

Inspectors wroteBased on interviews and record review, the facility failed to exercise reasonable care to protect residents' personal property from loss for two of six sampled residents (Resident 1 and Resident 3) when staff did not properly inventory and safeguard Resident 1's hearing aids and Resident 3's clothing and toiletries. These failures contributed to the loss of Resident 1's hearing aids and the loss of Resident 3's clothing and toiletries and placed the residents' other property at risk for loss or theft.

Inspectors wroteBased on interviews and record review, the facility failed to protect one of seven sampled residents (Resident 2's) right to be free from physical and verbal abuse when Certified Nursing Assistant 1 (CNA 1) threw Resident 2 face down on her bed and called her a derogatory name. This failure had the potential to cause physical and mental harm to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate Gradual Dose Reduction (GDR) practices for a psychotropic medication (a drug prescribed to affect the mind, emotions or behavior) for one of 5 sampled residents (Resident 5) when Resident 5's dose of quetiapine (a psychotropic medication) was increased, and the GDR was documented as unsuccessful without any supporting clinical documentation to justify the dose increase. This failure resulted in the potential for unnecessary medication use and avoidable adverse effects for Resident 5. Clinical record review indicated that Resident 5 was admitted to the facility in December 2021 with diagnoses including dementia (memory loss condition), major depressive disorder (long term depression), and anxiety disorder (ongoing excessive worry or nervousness). [...]

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to implement pharmaceutical policies and procedures for a census of 87 when the refrigerator E-Kits (Emergency kits containing emergency medications for immediate use) had not been replaced within 72 hours after being used. This failure had the potential to result in emergency medications not being available when needed for the residents. During an inspection of the facility's medication room on 5/18/26 at 11:33 a.m., two emergency kits in the medication refrigerator were found to be previously opened and not replaced. A 3 ml (milliliter, unit of measure) glargine insulin pen (medication used to treat high blood sugar level) had been taken out of E-kit box #3116 on 4/3/26. A 3 ml glargine insulin pen had been taken out of E-kit box #2550 on 4/8/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon the Consultant Pharmacist (CP)'s recommendation for one of 5 sampled residents (Resident 5) when the facility did not address the need for a Gradual Dose Reduction (GDR) of quetiapine (a type of psychotropic medication). This failure resulted in the potential for unnecessary medication use and avoidable adverse effects for Resident 5. Clinical record review indicated that Resident 5 was admitted to the facility in December 2021 with diagnoses including dementia (memory loss condition), major depressive disorder (long term depression), and anxiety disorder (ongoing excessive worry or nervousness). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accurate and consistent medical record documentation for two of 27 sampled residents (Resident 26 and Resident 11) when: 1. A physician ordered wound care treatment for Resident 26 were not entered or documented on the Treatment Administration Records (TAR) and,2. Resident 11's Advance Health Care Directive (AHCD, a legal document that outlines your medical preferences) was incomplete; and, These failures increased the potential for miscommunication among staff that could lead to unmet needs for Resident 26 and Resident 11.

Inspectors wroteBased on interviews and record review, the facility failed to follow professional standards of quality for four of the 27 sampled residents (Resident 26, Resident 52, Resident 32 and Resident 6 when:1. Staff did not accurately enter a physician's order for tracheal/oral suctioning into Resident 26's medical record;2. Resident 52's oxygen tubing was not changed as ordered by the physician; and3. Staff did not change the enteral feeding tubing for Residents 6 and 32 as ordered by the physician. These failures placed Resident 6, Resident 26, Resident 32, and Resident 52 at risk for infection and placed Resident 26 at additional risk for respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly for a census of 87 when Resident 55's opened inhaler (used to administer medication by breathing in) stored in the medication cart 1 was not dated when opened,This failure placed Resident 55 at risk of receiving ineffective, expired or outdated medication. During an inspection of medication cart 1 on 5/18/26 at 11:20 a.m., a box of budesonide and formoterol (a multidose inhaler containing two medications used to treat breathing issues) 80/4.5 mcg (microgram, unit of measure) was observed to be stored without an open date label. During an interview on 5/18/26 at 11:23 a.m. with Licensed Nurse (LN) 1, LN 1 stated there was no open date on the label to determine the product's expiration date. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to keep an effective infection prevention and control program for a census of 87 residents when: Licensed Nurse (LN) 5 entered a contact precaution room (Resident 6) without wearing the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments); and Respiratory Therapist (RT) did not change PPE after providing care between residents (Resident 6 and Resident 71). These failures increased the risk of infections and cross contamination for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment was maintained in working order when the arm rests of two wheelchairs (Resident 11 and Resident 35) out of 54 wheelchairs in use in the facility were in disrepair. This failure increased the potential for discomfort and skin tears to resident forearms. Resident 11 was admitted to the facility with diagnoses which included muscle weakness and difficulty in walking. During a review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 3/18/26, the MDS indicated Resident 11 was alert and oriented, able to make her needs known. During a review of Resident 11's care plan (CP) titled [Resident 11] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to]. DIFFICULTY IN WALKING. revised 2/14/26, the CP indicated independent with.wheelchair mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a functional, accessible communication system that allowed one of 27 sampled residents (Resident 28) to easily request staff assistance from his bedside when there was no call light or bell within reach. This failure increased the risk Resident 28 would not have to ability to call for help in an emergency or when needing assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from abuse when Activity Assistant (AA) 1 aggressively yelled at and grabbed Resident 1's shoulder. This failure had the potential to cause psychosocial harm to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control procedures for one of six sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2 provided care to Resident 1 without wearing the appropriate personal protective equipment (PPE- worn to protect against hazards like infections). This failure decreased the facility's potential to prevent the spread of infection among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from misappropriation of property and exploitation by a staff member that took money from Resident 1's personal bank accounts without consent. This failure resulted in financial loss totaling to $12,773 and emotional distress to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) was free from abuse, when Resident 3 touched Resident 2's groin area. This failure decreased the facility's potential to maintain Resident 2's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to report immediately to the Department an alleged incident of sexual abuse for one of six sampled residents (Resident 2), when the Department received the facility's report of alleged sexual abuse after two hours of occurrence. This failure had the potential to cause a delayed response by enforcement agencies to ensure Resident 2's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of six sampled residents (Resident 6), when the Housekeeper did not apply the required Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash and spray) while cleaning Resident 6's room. This failure had the potential to spread infection among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for a census of 79 when documents with resident's personal information were found outside the facility unsecured. This failure had the potential for unauthorized access to residents' personal and medical information.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 received care which met professional standards when there was no documentation:1. Resident 1 received wound treatments as ordered;2. Resident 1's coccyx wound was assessed; 3. Resident 1's pain was assessed every shift;4. Resident 1's pain medication was given as ordered; and 5. Resident 1's weight loss was assessed. These failures had the potential to result in unmet needs for Resident 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition and palliative care (care that provides symptom relief, comfort and support for someone with a serious illness).1. Resident 1's clinical record contained a physician's order, dated 5/24/24 for coccyx (buttock) wound treatment every day shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse, when Resident 2 punched Resident 1 ' s leg in the activity room. This failure decreased the facility ' s potential to maintain Resident 1 ' s highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected from verbal abuse and neglect when the resident was told, You will stay on the floor until the end of the f*cking shift and Certified Nursing Assistant (CNA) 1 placed a pillow under his head and placed a blanket on him and then left. This failure had the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) were free of accident hazards, when care provided was not consistent with care plan intervention and facility fall management policy. This failure resulted in delay of care for an unwitnessed fall of Resident 1, which potentially caused Resident 1's hip fracture, and had the potential for Resident 1 and Resident 2 to have repeat falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant 1 (CNA 1) hit Resident 1 on the back. This failure had the potential for Resident 1 to obtain physical injuries and have a negative impact on his psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that allegations of abuse were reported within the required timeframe for one of four sampled residents (Resident 2) when the allegations of abuse were not reported within two hours to the Department. This failure had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain privacy of communication for one of four sampled residents (Resident 1), when Resident 1 ' s mail was opened without consent by the Business Office Manager (BOM). This failure decreased the facility ' s potential to protect Resident 1 ' s communications privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 4, and Resident 5) participated in their care planning, when care conferences for Resident 1, Resident 4, and Resident 5 were not conducted quarterly as scheduled. This failure decreased the facility ' s potential to enable residents to exercise their right to participate in care plan meetings.

Inspectors wroteBased on observation, interview, and record review, the facility had a 9.09 % error rate when three medication errors out of 33 opportunities were observed during a medication pass for one of seven residents (Resident 2). This failure decreased the facility's potential to administer residents' medications according to prescriber's orders and manufacturer's specifications. Findings A review of an admission record indicated, Resident 2 was admitted to the facility in June 2024 with diagnoses including depression and hypertension (HTN-high blood pressure). During an observation on 10/7/24 at 8:23 a.m., Licensed Nurse 4 (LN 4) was observed preparing medications for Resident 2. LN 4 crushed all medications, mixed it with apple sauce and spoon fed it to Resident 2. During an interview on 10/7/24 at 08:26 a.m. with LN 4, LN 4 stated there was no order to crush Resident 2's medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly for a census of 80. This failure increased the residents' risk of infection and receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff demonstrated sufficient skills during red bucket and low temperature dishwasher test strip testing for a census of 80. This failure decreased the facility's ability to carry out the functions of the food and nutrition services safely and effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner and air vents were sanitarily maintained for a census of 80, when: 1. A big container pan of cooked brussels sprout was uncovered and left exposed to contaminants on top of the stove burner; 2. A square-shaped stainless steel container with corn and sliced bell pepper was left on a counter corner undated and unlabeled; 3. A rectangle-shaped stainless steel container with cooked carrots was left uncovered, unlabeled, and undated in the counter corner; 4. Personal cell phone and water jug were placed next to the uncovered and unlabeled food; 5. Three packs of corn tortilla wrap was found expired in the dry storage area; and 6. The air vents horizontal slats in the dry storage area had whitish substance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for one of 24 sampled residents (Resident 34), when Resident 34's representative did not sign a consent for the use of bilateral mittens. This failure had the potential to deprive the representative from making decisions regarding Resident 34's care.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold agreement for one of 24 sampled residents (Resident 40) or his representative before and upon transfer to hospital. This failure had the potential for Resident 40 or his representative to be unaware of their right to return to the facility after hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of 24 sampled residents (Resident 27), when Resident 27's prior level of function (PLOF) on admission was inaccurately coded. This failure increased Resident 27's risk for inadequate care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise and review a person-centered comprehensive care plan for two of 24 sampled residents (Resident 2 and Resident 44), when: 1. Resident 2 had recurrent falls; and, 2. Resident 44's tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and facilitate breathing) was removed. This failure decreased the facility's potential to maintain the residents' psychosocial, physical, and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for two of 24 sampled residents (Resident 9 and Resident 45) when: 1. The tube feeding (TF, a tube inserted to the stomach to provide nutrition, fluid and medicine to people who are unable to eat or drink safely by mouth) was left connected to Resident 9 after its completion and the residual volume was not properly documented in the Medication Administration Record (MAR) to show it had been monitored as ordered; and, 2. An empty container of a TF was left hanging for more than 24 hours for Resident 45. These failures decreased the facility's potential to safely follow the physician's order to meet residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing assistance to two of 24 sampled residents (Resident 9 and Resident 40) when: 1. Resident 9's left hand carrot and right hand foam roll splints were not placed as ordered; and 2. Resident 40's bilateral resting hand splints were not applied consistently as per plan of care. These failures decreased the facility's potential to help maintain range of motion (ROM) and prevent further contracture (a stiffening/shortening at any joint, that reduces the joint's ROM) for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and facilitate breathing) care risk and benefit assessment, care plan and physician's order were placed for one of 24 sampled residents (Resident 15), when Resident 15 was allowed to perform his own tracheostomy gauze change, suction, and inner cannula insertion. This failure decreased the facility's ability to provide proper tracheostomy care to maintain a patent airway and to prevent infection for Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for a census of 80, when: 1. Licensed Nurse 4 (LN 4) did not perform hand hygiene during medication pass; 2. Resident 44's breath activated call cord disposable mouthpiece was not changed and had a large, brown substance in the end of it; 3. One container of food sitting on shelf labeled yogurt dated 10/6/24 was found inside Resident 17's room; and, 4. Resident 17's and Resident 44's privacy curtains were dirty, stained, and in disrepair. These failures had the potential to expose residents to infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted on a daily basis at the beginning of each shift for a census of 80, when staffing information was not posted for five consecutive days including weekend and at the beginning of weekdays' morning shifts. This failure decreased the facility's potential to post staffing information on a daily basis for residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted quarterly (every 3 months) for one of three sampled residents (Resident 1). This failure resulted in violating the rights of Resident 1 to participate in choosing treatment options and making decisions regarding their plan of care.

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records for 1 of 4 sampled residents (Resident 1) within two working days as required per the facility's policy. This failure resulted in the delay of the release of Resident 1's medical records.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one resident (Resident 1) of two sampled residents when Resident 1's preference for personal care needs was not provided by a female staff member. This failure resulted in Resident 1 not getting person-centered care and feeling uncomfortable during perineal care.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of seven sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) were treated with dignity and respect when staff were overheard speaking in a foreign language throughout the facility. This failure resulted in residents feeling insecure and wondering if they were being talked about by staff.

Inspectors wroteBased on interview and record review the facility failed to implement its own policy and procedure for one of 4 sampled residents (Resident 4) when Resident 4's Responsible Party (RP) was not informed of a new medication order due to a change in condition. This failure had the potential to result in disregarding Resident 4 and her RP's right to be informed of her treatment.

Inspectors wroteBased on interview and record review the facility failed to provide services which meet professional standards of quality for one of 4 sampled residents (Resident 3) when Resident 3's Blood Pressure (BP, the force of blood pushing against the walls of the arteries as the heart pumps blood in the body) was not checked against physician orders before administering his BP medication. This failure had the potential to affect Resident 3's health by receiving BP medication that is not in accordance with the physician's order.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were kept locked or under the direct observation of authorized staff for a census of 91. This failure had the potential for unauthorized staff or residents to access drugs and biologicals.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety for two residents (Resident 1 and Resident 2) after Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face and did not separate Resident 1 and Resident 2 into different rooms. This failure resulted in Resident 1 obtaining a 4.5 centimeter (cm, a unit of measure) by 3.5 cm bruise along the right cheek and jaw due to continued exposure to the perpetrator.

Inspectors wroteBased on interview and record review the Licensed Nurse 1 (LN 1) failed to immediately notify the Nurse Practitioner (NP) and Responsible Parties (RP) for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face. These failures resulted in delayed assessments and diagnostic testing for injury, and distress to Resident 1's RP when he discovered Resident 1's injuries without having been notified by facility staff.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of abuse within the regulatory timeframe for two residents (Resident 1 and Resident 2) when Resident 1 slapped Resident 2 on the face. This failure resulted in Licensed Nurse 1 (LN 1) not reporting a known issue.

Inspectors wroteBased on interview and record review, the Licensed Nurse 1 (LN 1) failed to provide care per professional standards for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face and: 1. Did not assess both of the residents after the witnessed altercation; and, 2. Did not initiate a care plan for each of the residents after the witnessed altercation. These failures decreased the facility's potential to provide nursing care which encompassed the nursing practice.

Inspectors wroteBased on interview and record review, the Licensed Nurse 1 (LN 1) failed to accurately document on medical charts for two residents (Resident 1 and Resident 2) of two sampled residents when LN 1 witnessed Resident 1 slap Resident 2 in the face and: 1. Did not document the details of the altercation in either of the residents' medical records; and, 2. Did not document the time at which both of the residents' Responsible Parties (RP) were notified. These failures resulted in delayed assessments and diagnostic testing for injury, and distress to Resident 1's RP when he discovered Resident 1's injuries without having been notified by facility staff.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility failed to follow their policy and procedure to prevent abuse for one of three sampled residents (Resident 1) when Resident 1 was closed in her room by Licensed Nurse 1 (LN 1). This failure resulted in Resident 1 to be isolated and had the potential for further abuse or injury while closed up in her room.

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards of practice for 3 of 6 sampled residents (Resident 1, Resident 2 and Resident 3) when permethrin cream (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) was not accurately documented in their Medication Administration Record (MAR). These failures had the potential for the 3 Residents to not receive proper treatment and/or prophylactic treatment for scabies.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow their own policy and procedure for prevention of further abuse, when the facility allowed Certified Nursing Assistant 1 (CNA1) to continue to provide resident care after the Respiratory Therapist (RT) allegedly witnessed CNA1 tie Resident 1's hand to the side of the bed. This failure could have potentially resulted in physical and/or psychological harm to other residents of the facility, for a census of 87.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records were accurate and complete for two sampled residents (Resident 1 and Resident 3) for a census of 83 residents when licensed nurses (LNs) failed to document administration of medications in the Medication Administration Record (MARs) as per the facility's policy and procedure guidelines. These failures had the potential to negatively impact the management of these resident's medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Licensed Nurse (LN) 1 walked out of Resident 1's room, while in the middle of providing care. This failure resulted in Resident 1 to feel fearful of staff.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a deep tissue injury pressure ulcer (DTI-PU, a purple or maroon area of discolored intact skin due to pressure) for one of five sampled residents, Resident 4. This failure prevented Resident 4 from receiving the care she needed to prevent the development of a pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures to prevent a pressure sore from developing for one of five sampled residents (Resident 4) when, the resident developed a deep tissue injury pressure sore (DTI-PU- a purple or maroon area of discolored intact skin with underlying tissue damage due to pressure or shearing). This deficient practice caused the development of a deep tissue injury pressure sore to Resident 4's left and right buttocks, coccyx area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a decrease in range of motion (ROM) for one of five sampled residents (Resident 1) when Resident 1's plan of care for the use of a wheelchair leg rest was not consistently implemented and Resident 1's order for a reevaluation after 90 days was not timely done. This failure resulted in Resident 1experiencing a decline of negative 15 degrees (unit of measurement) in her left ankle range of motion (AROM) dorsiflexion (backward bending and contracting of the foot).

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was made aware of his right to return to the facility when Resident 1 was transferred emergently to an acute care hospital and the facility did not provide a written bed-hold notice (holding or reserving a resident's bed during the resident's absence from the facility). This failure placed Resident 1 and his representative at risk for not understanding his rights to return to the facility.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to provide the requested medical records for one of three sampled residents (Resident 1) within the two working days required per the facility's policy. This failure violated Resident 1's rights to allow her family to have a copy of her medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two incidents of allegations of abuse were reported and investigated as required by the regulations for one of three sampled residents (Resident 1). This failure resulted in a delay in the abuse investigation process and decreased the facility's ability to protect residents from physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety was maintained for one of three sampled residents (Resident 1) when Resident 1 was involved in two alleged incidents of altercation with Resident 2. This failure had the potential to result in injury and negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control for one resident (Resident 1) of four sampled residents when a Certified Nurse Assistant (CNA) did not wear an N-95 respirator (a protective device designed to efficiently filtrate infectious airborne particles) and faceshield while providing care to a resident diagnosed with COVID-19 (an infectious virus that can cause respiratory illness and is spread by small liquid particles emitted by the mouth). The CNA also did not perform hand hygiene after providing care to Resident 1 and prior to exiting the resident's room. This failure decreased the facility's potential to prevent the spread of infection among a census of 88 residents.

Inspectors wroteBased on interviews, clinical record review, and facility policy and procedure, the facility failed to keep Resident 1's medical records in accordance with accepted professional standards and practices. The facility must maintain medical records on each resident that are complete and accurately documented. This failure resulted in an inaccurate and incomplete medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was treated with dignity and respect when Licensed Nurse (LN) 1 was heard yelling at Resident 1 saying, What do you think the diet shot is going to do for you? Do you really think the diet shot is going to help you lose weight? No diet shot is going to keep you from lifting your arm to your mouth eating big bags of food. This failure resulted in Resident 1 to have felt awful and defeated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly apply side rails [bed rails] for 3 of 5 sampled residents (Resident 1, Resident 4, and Resident 5), when risk for entrapment (a position or situation from which it is difficult to escape) assessments were not completed prior to use of side rails. This failure had the potential to result in injury and entrapment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement contact precautions for 2 residents (Resident 1 and Resident 2) for a census of 76 when staff were observed preforming tracheostomy care ( a procedure to remove excess secretions from an opening in the throat) in the resident's room without maintaining contact precautions (procedures used to prevent the spread of infection including performing hand hygiene before entering and exiting a room, and wearing a gown and gloves while in a resident room). This failure increased the potential for the spread of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure the conservative use of antipsychotic medications for three residents (Resident 29, Resident 9, and Resident 69) of 33 sampled residents when: 1. Resident 29 did not have an informed consent for the use of quetiapine fumarate; 2. Resident 9 did not have a signed informed consent nor was there a consent form for the current dosage of quetiapine fumarate being administered; and, 3. Resident 69 did not have an informed consent for the use of ziprasidone. This failure decreased the facility's potential to ensure residents or their responsible person(s) were fully informed of the risks, benefits, and alternative treatment options prior to the use of an antipsychotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment for a census of 85 residents when: 1. A vinyl floor plank near nurse's station was observed damaged and partially unglued from the floor; 2. Resident 343's left bed rail was reported malfunctioning and rotating off the locked position; 3. Resident 52's room air vent was observed covered with black dust specks; and, 4. Resident 343's and Resident 1's windows were observed to be dirty and covered in dust. This failure resulted in the residents living in an uncomfortable environment and had the potential to cause fall-related injuries to staff, residents, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to provide care and services to prevent the development of pressure ulcers (PU; a breakdown of the skin and potential layers of fat and muscle beneath) for 5 of 32 sampled residents, (Resident 13, Resident 23, Resident 47, Resident 63, and Resident 66) when pressure ulcers increased in size and/or developed after admission while in the care of the facility staff. This failure resulted in the development of avoidable pressure ulcers which jeopardized the health and safety of residents and had the potential to cause infection, physical and mental anguish, and possible death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications and biologicals were labeled as discontinued, dated, and securely stored for destruction for a census of 85. This failure had the potential to encourage diversion of medications and compromise the health and safety of staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment accurately reflected current care and services staff could provide to residents. This failure decreased the potential for the facility to ensure safe and knowledgeable care based on resident diagnoses.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' personal and nutritional information when the residents' dietary meal tickets were disposed together with the food scraps in the regular garbage. This failure had the potential for residents personal health information to be accessible to those who were not involved in the residents' care, for residents receiving food prepared by the kitchen for a facility census of 85.

Inspectors wroteBased on interview and record review the facility failed to conduct in-service training to staff in the safe operation and care of equipment used to provide care for the residents. This failure had the potential to cause inadequate and inaccurate care and possible injury to the residents for a facility census of 85.

Inspectors wroteBased on interview and record review, the facility failed to discuss and provide information on advanced directives for one resident (Resident 55) of 33 sampled residents. This failure had the potential to cause Resident 55's values and desires related to end-of-life care not to be honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive assessment and complete a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) when one resident (Resident 63) of 33 sampled residents developed a stage 4 (deep wound reaching the muscles, ligaments, and bones) pressure ulcer (PU) to the left ear. This failure decreased the facility's potential to develop a personalized plan of care to prevent a further decline in Resident 63's health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was conducted for one resident (Resident 29) of 33 sampled residents. This failure decreased the facility's potential to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered baseline care plan was completed and signed by the resident or responsible party within 48 hours of admission for one resident (Resident 69) of 33 sampled residents. This failure decreased the facility's potential to ensure residents and their responsible persons were aware of the plan of care being provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of quality for three residents (Resident 56, Resident 25, and Resident 64) of 33 sampled residents when: 1. Resident 56's tube feed (TF) was left to continuously operate when the feed bottle was empty; 2. Resident 64's gastrostomy tube was discontinued 29 days late and was not documented in the medical chart; and, 3. Resident 25's hospice order was discontinued 22 days late. This failure had the potential to compromise residents' care and cause health complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure employee performance evaluations were completed annually for 2 of 5 sampled employees, Certified Nurse Assistant (CNA, [CNA1 and CNA2]). This failure increased the potential for CNAs to provide inadequate care and for residents to receive poor quality of care.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist drug recommendations in a timely manner for two residents (Resident 9 and Resident 2). This failure decreased the facility's potential to provide immediate action to protect residents and prevent an occurrence of adverse drug events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for the use of psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) for one of 33 sampled residents (Resident 69). This failure had the potential to result in unnecessary prolonged use of psychotropic medication which may cause adverse consequences and a decline in Resident 69's health status.

Inspectors wroteBased on interview and record review, the facility failed to administer significant medications as ordered by the physician for two residents (Resident 40 and Resident 9) out of 33 sampled residents. This failure decreased the facility's potential to ensure residents are able attain or maintain their highest practicable physical, mental, and psychosocial well-being.