Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roseville Point Health & Wellness Center during CMS and state inspections, most recent first.
Failure to inventory and safeguard resident personal property resulted in lost hearing aids for one resident and missing clothing and toiletries for another. One resident’s hearing aids were documented in the admission summary and used during the MDS, but the inventory form was blank, while the other resident had no inventory form in the chart. Staff and the resident reported missing items, and facility interviews confirmed the inventory process was not completed as required.
Failure to Protect Resident from Physical and Verbal Abuse: A resident with lumbar spinal stenosis was found on a fall mat in her room, and a CNA assisting with repositioning allegedly grabbed the resident by the arm, threw her face-first onto the bed, then lifted and threw her onto the bed again while using a derogatory racial remark. A charge nurse stated this would be abuse, and the ADM confirmed residents have the right to be free from abuse.
An activity assistant became frustrated with a cognitively impaired resident with dementia and metabolic encephalopathy who repeatedly stood up, touched others, and shook a table during an activity. Despite multiple verbal prompts to sit, the assistant escalated to yelling in a powerful, aggressive manner, grabbed the resident’s shoulder, pulled the resident back into a wheelchair, and then aggressively wheeled the resident out of the activity room. Other residents and business office staff heard the shouting and observed the aggressive handling, and one manager stated that speaking or yelling aggressively at a resident is considered abuse under the facility’s abuse policy, which guarantees residents freedom from verbal, physical, and mental abuse.
A resident with a gastrostomy and laryngeal stenosis was on enhanced barrier precautions (EBP), as indicated by signage outside the room. During a bed-to-wheelchair transfer, two CNAs moved the resident without wearing gowns, despite the posted EBP requirements. Both CNAs later acknowledged they should have worn gowns, and an LN and the IP confirmed that proper PPE use, including gowns, was expected under EBP to minimize infection transmission. Facility policy stated that infection control procedures are intended to prevent and manage disease transmission and that staff are trained on these procedures.
A staff member exploited a resident with moderate cognitive impairment and major depressive disorder by taking her wallet and ATM card, then withdrawing over $12,000 from her bank accounts without consent. The resident, who trusted the staff member and provided her debit card and PIN, was unaware of the extent of the withdrawals until bank statements were reviewed. The incident caused significant emotional distress to the resident, who was observed crying and breaking down multiple times.
A resident with severe cognitive impairment and dementia was inappropriately touched in the groin area by another resident during a group activity. The incident was observed by an activity staff member, who intervened immediately. The facility's abuse prevention policy was not followed, resulting in a failure to protect the resident from abuse.
A resident with dementia was allegedly touched inappropriately by another resident with aphasia and hemiplegia during an activity. The staff member who witnessed the incident intervened but did not immediately report it to supervisors or authorities, resulting in the required abuse report being sent to the Department more than two hours after the event.
A housekeeper did not wear the required PPE, including a gown, while cleaning the room of a resident on Enhanced Barrier Precautions due to a stage 4 pressure ulcer. Despite clear signage and facility policy requiring gloves and gowns for environmental services staff in such cases, the housekeeper cleaned high-touch surfaces without proper protection, as confirmed by nursing and staff development personnel.
Boxes containing documents with residents' personal and medical information were found unattended and unsecured outside the facility on two carts. The DON confirmed the documents should have been secured and properly disposed of, in accordance with facility policies on confidentiality and PHI.
A resident with anxiety and no memory impairment was physically assaulted by another resident with dementia and memory impairment, who rammed his wheelchair into the first resident and punched him multiple times in the activity room. The incident was witnessed by staff, and the assaulted resident later reported feeling unsafe and fearful of returning to the activity room. Facility policy requires a safe environment free from physical abuse.
A resident with severe cognitive and physical impairments was found on the floor after a fall and was subjected to verbal abuse and neglect by a CNA, who used profane language, refused to assist the resident off the floor, and left after only providing a pillow and blanket. The incident was corroborated by another resident and confirmed through facility investigation and staff interviews.
Two residents identified as fall risks did not receive care consistent with their care plans and the facility's fall management policy. One resident with dementia experienced an unwitnessed fall that was not assessed or reported, leading to delayed care and a hip fracture diagnosis. Another resident with a history of pulmonary embolism had two falls, and required fall precautions such as a low bed and fall mat were not in place. Staff confirmed that fall protocols were not followed, and necessary documentation was missing.
A resident with severe dementia was reportedly slapped on the back by a CNA after knocking over a food tray, as witnessed by another CNA. The accused CNA claimed he only tapped the resident, but the witness described the action as a slap. No physical injuries were found, and the facility's leadership unsubstantiated the abuse allegation due to conflicting accounts and lack of additional witnesses.
A resident with bipolar disorder and intact cognition reported suspected staff abuse, but the facility did not submit the required SOC 341 report to authorities within the mandated two-hour timeframe. The delay in reporting was contrary to both regulatory and facility policy requirements.
A resident's privacy was compromised when the Business Office Manager opened a letter containing an EBT card without the resident's consent. Facility policy requires that personal mail be delivered unopened to residents, and staff interviews confirmed that mail should not be opened by personnel unless specifically requested by the resident.
The facility failed to conduct scheduled care conferences for three residents, all of whom had intact cognition and were capable of participating in their care planning. Despite being scheduled, the care conferences did not occur, and the residents were not involved in their care planning as required by the facility's policy.
A medication error rate of 9.09% was identified when a nurse crushed and administered medications to a resident without a physician's order. The resident, with depression and hypertension, received crushed carvedilol, lisinopril, and duloxetine, despite duloxetine's specifications against crushing. Facility policy requires a physician's order for crushing medications.
The facility failed to properly store medications, with expired sorbitol solution found in the storage room and various issues in medication carts, including an unbagged insulin pen, expired benzonatate, and loose pills. Additionally, medications lacked open dates, and a nasal spray had a torn label, making resident identification impossible. The DON confirmed that expired medications should not be stored and open dates are necessary.
The facility failed to ensure dietary staff demonstrated sufficient skills in using chemical sanitization test strips for a low temperature dishwasher and red bucket. A dietary aide did not follow the manufacturer's specifications, failing to blot the test strip before comparison and was unable to identify actions for incorrect sanitizing solution concentration. The Dietary Supervisor confirmed the expectation to follow instructions, and the facility's policy indicated re-education for staff unable to perform skills satisfactorily.
The facility failed to maintain food safety and sanitation standards, with uncovered and unlabeled food left on counters, personal items placed near food, expired tortillas in storage, and unclean air vents. Dietary staff confirmed these issues, acknowledging the need for proper labeling, dating, and cleanliness.
A resident with chronic respiratory failure and anxiety disorder was observed wearing soft mittens to prevent tracheostomy tube removal. The facility failed to obtain informed consent from the resident's representative for the use of these mittens, as required by their policy. Interviews confirmed the consent was incomplete and unsigned, potentially depriving the representative of decision-making regarding the resident's care.
A resident was transferred to a hospital without receiving a written bed hold agreement, as confirmed by a Licensed Nurse and the DON. The facility's policy requires notifying residents or their representatives in writing of the bed hold option during hospital transfers, which was not done in this case.
A facility failed to ensure an accurate MDS assessment for a resident with lung cancer requiring ventilator support. The resident's prior level of function was inaccurately coded as independent, despite using a mechanical lift. The MDS Coordinator confirmed the error, and the DON acknowledged the lack of a specific MDS policy.
The facility failed to update care plans for two residents, one with recurrent falls and another with a removed tracheostomy. Despite hospitalization and reminders, care plans were not revised, leading to outdated interventions. Staff acknowledged the oversight, which contradicted facility policy requiring updates for changes in condition.
The facility failed to meet professional standards for two residents by not properly managing tube feeding protocols. A resident's tube feeding was left connected after completion, and residual volumes were not documented as ordered. Another resident had an empty tube feeding container left hanging for over 24 hours, contrary to guidelines. Staff confirmed these practices, which did not align with physician orders or facility policies.
Two residents in the facility were not provided with the necessary restorative nursing assistance to maintain their range of motion. One resident, with cerebral infarction and hand contractures, was not wearing the prescribed splints, while another resident with a traumatic brain injury was not consistently using the ordered hand splints. Staff confirmed the lack of adherence to the care plans, which were designed to prevent further contracture progression.
A resident with acute and chronic respiratory failure was allowed to perform his own tracheostomy care without a risk and benefit assessment, care plan, or physician's order. The facility's policies on care planning and physician's orders were not followed, as confirmed by the MDS Coordinator and RT Director.
A LTC facility failed to implement proper infection control practices, including a nurse not performing hand hygiene during medication pass, a resident's unclean call cord mouthpiece, expired food in a resident's room, and dirty privacy curtains. These deficiencies were contrary to the facility's infection prevention policies.
The facility did not post nurse staffing information daily at the beginning of each shift for a census of 80 residents. Observations showed that staffing data was not posted for five consecutive days, and when posted, it was after the morning shift had started. The DON confirmed that postings should occur before the shift begins, as per the facility's policy.
A resident with quadriplegia and full mental capacity did not receive quarterly care conferences, violating their rights to participate in care planning. The facility missed conferences in January and March, as confirmed by the ADM and DON. The resident reported not being updated on their care since the last conference in October.
A resident's medical records request was delayed due to the absence of a designated medical records person, resulting in the facility failing to provide the records within the required two working days. The request, initially received on 7/31/24, was not addressed until 8/15/24, contrary to the facility's policy.
A resident with major depressive disorder and lymphedema, capable of making healthcare decisions, had a documented preference for female CNAs for personal care. Despite this, a male CNA attended to her, causing discomfort. The CNA was unaware of her preference, and the ADON confirmed that care plan preferences should be honored. The facility's policy requires person-centered care, but this was not implemented, leading to a deficiency.
The facility failed to treat residents with dignity and respect as staff were overheard speaking in a foreign language throughout the facility. Multiple staff members and residents confirmed that this behavior occurred frequently in hallways and at the nurses' station, making residents feel uncomfortable and insecure. Despite being raised in Resident Council meetings, the issue remained unaddressed by the administration.
A facility failed to inform a resident's responsible party about a new medication order for ivermectin, as required by its policy. The resident, diagnosed with a neurocognitive disorder, lacked the capacity to make healthcare decisions. Licensed Nurse 1 forgot to notify the RP, and the Director of Nursing confirmed the absence of documentation. This oversight had the potential to disregard the resident and her RP's right to be informed of her treatment.
A resident with hypertension and end-stage renal disease did not have their blood pressure checked before receiving BP medication, contrary to physician orders. The resident reported this issue had occurred multiple times. The facility's records confirmed that BP medication was administered despite systolic BP readings being below the threshold set by the physician.
A medication cart was left unlocked and unattended by a nurse while at the nursing station, with multiple residents and staff present in the hallway. The DON confirmed that the expectation is for medication carts to be locked. Facility policy states that medications should be stored securely and only accessible to authorized personnel.
A facility failed to separate two residents after an altercation, resulting in one resident sustaining bruises. Despite witnessing the incident, an LPN did not follow the facility's policy to separate the residents and did not report the incident to the Nurse Supervisor or DON. The residents, both with dementia, remained in the same room, leading to further harm.
A deficiency occurred when an LPN failed to immediately notify the NP and RPs after witnessing an altercation between two residents, one with severe memory problems and the other with moderate memory issues. This led to delayed assessments and diagnostic testing for injuries. The NP was not informed of the incident until the following day, and the DON confirmed that the LPN did not follow professional standards or facility policy, which requires immediate notification of changes in a resident's condition.
A resident with neurocognitive disorder slapped another resident with dementia, and the incident was not reported to authorities within the required timeframe. Despite being witnessed by an LPN, the report to the CDPH, Ombudsman, and police was delayed. The facility's policy mandates reporting within two hours for incidents resulting in serious injury, which was not followed.
A licensed nurse failed to document and assess two residents after witnessing an altercation where one resident slapped another. The nurse did not conduct or document assessments or initiate care plans for the residents involved, despite facility policy requiring such actions. The incident involved residents with dementia, resulting in one resident sustaining bruises, which were later documented by other staff.
An LPN in an LTC facility failed to document an altercation between two residents and did not notify their responsible parties in a timely manner. This incident involved a resident with severe memory problems and another with moderate memory issues. The LPN witnessed the altercation but did not record the details in the medical records or inform the Nurse Supervisor, Director of Nursing, or Nurse Practitioner promptly, leading to delayed assessments and distress for one resident's responsible party.
A licensed nurse in the facility failed to follow abuse prevention policies by closing a resident in her room to monitor her whereabouts, resulting in the resident being isolated. The resident, with a history of wandering and moderate cognitive impairment, confirmed she would not leave the room if the door was closed. The nurse was terminated for this violation.
The facility failed to document the administration of permethrin cream for a resident with scabies and two roommates treated prophylactically. The Infection Preventionist Nurse confirmed the medication was given, but it was not recorded in the MAR, and the Director of Nursing verified no electronic orders were present.
The facility failed to follow its abuse prevention policy when a CNA continued to provide care after allegedly tying a resident's hand to the bed. The incident was reported three hours later, and the CNA was not suspended until four hours after the shift ended, potentially risking further harm to other residents.
The facility failed to develop and implement a comprehensive care plan for a resident with a deep tissue injury pressure ulcer (DTI-PU). Despite the resident's high risk for pressure ulcers and severe cognitive impairment, the facility did not create a care plan or document regular turning and incontinent care, leading to the development of a pressure ulcer.
A resident with severe cognitive impairment and high risk for pressure ulcers developed a deep tissue injury pressure sore due to the facility's failure to follow preventive measures and create a care plan. The resident was not turned every two hours or provided with appropriate incontinent care, leading to significant skin breakdown.
Failure to Inventory and Safeguard Resident Personal Property
Penalty
Summary
The facility failed to exercise reasonable care to protect residents’ personal property from loss for two sampled residents when staff did not properly inventory and safeguard a resident’s hearing aids and another resident’s clothing and toiletries. Resident 1 was admitted with cellulitis and had hearing aids listed in the admission summary and used during the MDS assessment, but the Personal Effects Inventory Form was undated and did not inventory the hearing aids at admission or at any point during the stay. Resident 3 was admitted with acute kidney failure and did not have a Personal Effects Inventory Form in the medical record. During interview, Resident 3 reported that pants and toiletries such as shampoo had gone missing since admission and that the items were never inventoried or reimbursed. Staff interviews confirmed that the inventory sheet should have been completed on admission and could be updated later, but Resident 1’s discharge inventory sheet was blank and staff were responsible for tracking belongings. The Administrator stated the facility would try to reimburse residents for lost items listed on the inventory sheet, and CNA 3 reported that Resident 3’s missing pants were searched for in the room and laundry room but were not found. The facility policy required a CNA or designee to complete a personal property inventory on admission, place it in the medical record, and provide a copy to the resident or representative.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect one of seven sampled residents from physical and verbal abuse when a CNA threw the resident face down onto the bed and used a derogatory racial remark. Resident 2 was admitted in December 2025 with diagnoses that included spinal stenosis in the lumbar region. The incident was reviewed in an IDT note dated 5/6/26, which stated that a witness CNA reported finding the resident lying face down on the fall mattress in her room and that another CNA came to assist. According to the witness CNA, the assisting CNA grabbed the resident by the arm and said, "Come here you old Chinese lady," then threw the resident face-first sideways onto the bed. The CNA then picked the resident up by the back of the collar and pants and threw her onto the bed again, positioning her on the bed. During interviews, a charge nurse stated that throwing a resident face down on the bed and making derogatory comments would be considered abuse, and the administrator confirmed that residents have the right to be free from abuse. The facility policy stated that it does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.
Abusive Verbal and Physical Interaction by Activity Staff Toward Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a resident from abuse when an activity assistant (AA 1) yelled at and physically grabbed the resident (Resident 1) during an activity. Resident 1 had been admitted with dementia with agitation and metabolic encephalopathy, and an MDS dated 3/11/26 documented a BIMS score of 0/15, indicating severe cognitive impairment. According to the interim DON, Resident 1 was confused and, on 4/3/26, was in the activity room repeatedly standing up and touching other residents. IDON 1 stated that AA 1 used a powerful voice to tell Resident 1 to stop and grabbed the resident’s shoulder to assist him back into his wheelchair. Other witnesses corroborated that AA 1 escalated to yelling and physically handling Resident 1. One resident reported that Resident 1 kept standing up, holding onto the table and causing it to shake, and that when Resident 1 was about to grab another resident, AA 1 yelled at him, grabbed his shoulder, and pulled him back into his wheelchair. Another resident stated that Resident 1 was being difficult, would not sit down, and that after repeatedly asking him to sit, AA 1 became frustrated, began yelling, and placed Resident 1 back into his wheelchair. The business office manager heard shouting from the activity room, recalled AA 1 yelling phrases such as “Stop this” and “Don’t do that,” and then observed AA 1 aggressively wheeling Resident 1 out of the room while appearing visibly frustrated. A second business office manager stated that AA 1 was speaking aggressively to a resident, later identified as Resident 1, and indicated that talking or yelling aggressively at a resident was considered a form of abuse. The facility’s operational manual on reporting abuse stated that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices when staff did not follow enhanced barrier precautions (EBP) for a resident on transmission-based precautions. The resident was admitted in March 2024 with diagnoses including a gastrostomy and stenosis of the larynx. On 3/4/26 at 10:34 a.m., an observation showed a sign outside the resident’s room indicating the resident was on EBP. During this time, CNA 1 and CNA 2 transferred the resident from bed to wheelchair without wearing gowns, despite the posted EBP sign. In subsequent interviews, CNA 1 and CNA 2 confirmed they were not wearing gowns during the transfer. CNA 1 stated she was aware the resident was on EBP and that she should have worn a gown, and CNA 2 stated he should have been wearing a gown because it could spread an infection to other residents. LN 1 confirmed the resident was on EBP and stated CNAs should have been wearing proper PPE to minimize the risk of passing infection to other residents. The Infection Preventionist also confirmed the expectation that staff follow the precaution signs and wear appropriate PPE, including gowns, under EBP. Review of the facility’s infection control policy, dated 1/12/12, indicated the facility’s infection control policies and procedures are intended to help prevent and manage transmission of diseases and infections and that staff are trained on these policies upon hire and periodically thereafter.
Failure to Protect Resident from Financial Exploitation by Staff
Penalty
Summary
A staff member at the facility failed to protect a resident with moderate cognitive impairment and a history of major depressive disorder from misappropriation of property and exploitation. The resident, who was admitted with diagnoses including major depressive disorder, adult failure to thrive, and economic difficulties, reported that a staff member took her wallet and ATM card, and subsequently withdrew money from her personal bank accounts without her consent. The resident and her cousin both reported the missing wallet and alleged that the staff member had borrowed money and failed to return it. Bank statements reviewed by facility staff and the resident's cousin showed multiple unauthorized withdrawals over several months, totaling $12,773, with the staff member's name appearing on the transactions. Interviews with the resident, her cousin, and facility staff confirmed that the staff member had access to the resident's bank accounts and had transferred money to her own account. The resident consistently stated that she trusted the staff member, provided her with the debit card and PIN, and was unaware of the extent of the withdrawals. The resident experienced significant emotional distress upon learning of the financial exploitation, as evidenced by multiple episodes of crying and emotional breakdowns documented in psychosocial notes and observed by staff. Facility policy explicitly prohibits exploitation, misappropriation of resident property, and financial abuse, defining these as the deliberate or wrongful use of a resident's belongings or money without consent. Despite these policies, the staff member was able to access and withdraw funds from the resident's accounts over an extended period, resulting in substantial financial loss and emotional harm to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and dementia was touched in the groin area by another resident during a facility activity. The incident was witnessed by an Activity Assistant, who observed one resident using his left hand to touch the lap near the groin area of the other resident. The staff member immediately intervened and separated the two residents. The resident who was touched had a history of cognitive communication deficit and dementia, with a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment. The resident who initiated the contact had diagnoses of aphasia and hemiplegia, but was assessed as having intact cognition. The facility's policy prohibits any form of resident abuse, neglect, or mistreatment, but this policy was not upheld in this instance.
Delayed Reporting of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged incident of sexual abuse involving a resident with cognitive communication deficit and dementia. The incident occurred when an activity assistant observed another resident, who has aphasia and hemiplegia, touching the first resident's lap near the groin area during a group activity. The activity assistant intervened by stopping the behavior and separating the residents but did not notify her supervisor or report the incident to the appropriate agencies at that time. Documentation shows that the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was not faxed to the Department until the following day, more than two hours after the incident occurred. The facility's policy requires immediate reporting of all allegations of abuse as mandated by law and regulation. The delay in reporting was confirmed through interviews and review of the facility's fax log and policy documents.
Failure to Follow Enhanced Barrier Precautions During Environmental Cleaning
Penalty
Summary
A housekeeper failed to follow required infection control practices while cleaning the room of a resident who was admitted with a stage 4 pressure ulcer to the sacrum. The resident had been placed on Enhanced Barrier Precautions (EBP) due to the presence of a chronic wound, as indicated by a physician order and signage outside the room. During an observation, the housekeeper was seen cleaning the resident's room without wearing the appropriate personal protective equipment (PPE), specifically a gown, despite being aware of the EBP status. Interviews with a licensed nurse and the Director of Staff Development confirmed that the housekeeper did not adhere to the facility's policy, which requires environmental services personnel to use gloves and gowns when cleaning and disinfecting the environment around residents on EBP. The facility's policy, revised in October 2024, specifically states that gown and gloves must be used when cleaning high-touch surfaces in the rooms of residents on EBP, such as those with chronic wounds.
Unsecured Resident Records Found Outside Facility
Penalty
Summary
During an observation by the facility's back patio, boxes containing documents with residents' personal information were found unattended and unsecured on top of two carts. This was confirmed during a concurrent observation and interview with the DON, who acknowledged that the documents belonged to residents and should have been secured, shredded, and properly disposed of. A review of the facility's policies indicated requirements to protect confidential clinical information and residents' rights regarding protected health information (PHI). The documents were left outside the facility, creating the potential for unauthorized access to residents' personal and medical information.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the leg in the activity room. According to progress notes and staff interviews, one resident, who had no memory impairment and was admitted with anxiety, was sitting in the activity room when another resident, diagnosed with dementia and depression and exhibiting significant memory impairment, rammed his wheelchair into the first resident's wheelchair and proceeded to punch him in the leg multiple times. The incident was witnessed by the activities assistant, who also reported that the aggressive resident attempted to hit her as well. Following the altercation, the assaulted resident expressed feeling unsafe and scared to return to the activity room when the other resident was present. Documentation from the social services director confirmed the resident's fear and reluctance to participate in activities due to the incident. The facility's abuse prevention policy defines physical abuse as including hitting and punching and requires the administrator or designee to provide a safe environment for residents. The failure to prevent this incident decreased the potential for the resident to maintain his highest practicable physical, mental, and psychosocial well-being.
Resident Subjected to Verbal Abuse and Neglect After Fall
Penalty
Summary
A resident with significant cognitive and physical impairments, including aphasia, memory problems, and dependence on staff for daily activities, was found on the floor after a fall. The resident was unable to explain why he was on the floor and called out for help. A Certified Nursing Assistant (CNA) who was not assigned to the resident entered the room, used profane and demeaning language, and told the resident he would remain on the floor until the end of the shift. The CNA placed a pillow and blanket under the resident and then left, rather than assisting him off the floor or ensuring his immediate safety and comfort. The incident was witnessed and corroborated by the resident's roommate, who reported hearing the CNA use inappropriate language and dismiss the resident's needs. The CNA herself admitted to using profanity in the presence of residents and staff, citing frustration as the reason for her behavior. Facility records and interviews confirmed that the CNA's actions were verbally abusive and neglectful, as she failed to provide appropriate care and respect for the resident's dignity following his fall. The facility's investigation substantiated the allegations of verbal abuse and neglect, with both the resident and his roommate providing consistent accounts of the CNA's conduct. The facility's policy requires staff to treat residents with dignity and respect at all times, and prohibits demeaning practices. The CNA's actions directly violated these standards, resulting in a failure to protect the resident from abuse and neglect.
Failure to Implement Fall Prevention Protocols and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of four sampled residents. For one resident with dementia, the care plan identified a risk for falls and required adherence to the facility's fall protocol. However, the fall risk evaluation was incomplete and lacked a score, and after an unwitnessed fall in the hallway, the resident was assisted back to a wheelchair without assessment or physician notification. There was no documentation of the fall, no post-fall assessment, and no follow-up, despite the resident later experiencing acute hip pain and being diagnosed with a femoral neck fracture. Staff interviews confirmed the fall was not reported or documented, and the Director of Nursing acknowledged that facility protocol was not followed, resulting in delayed care and increased risk for repeat falls. For another resident admitted with a history of pulmonary embolism, the care plan also identified a fall risk and called for fall precautions. Despite this, the resident experienced two falls—one in the bathroom and another from bed. When observed, the resident's bed was not in the lowest position and a fall mat was not in place, contrary to required precautions. The facility was unable to provide documentation of fall risk precautions for this resident, and staff confirmed that fall precautions were not implemented as required, increasing the risk of injury. The facility's fall management policy required specific interventions and documentation, which were not followed in these cases.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was reported to have hit a resident with dementia on the back after the resident knocked over a food tray. The resident, who had a history of unspecified dementia and a BIMS score of 0 indicating severe cognitive impairment and inability to express ideas or wants, was involved in an incident during dinner time. According to another CNA, the staff member became upset and slapped the resident on the back multiple times. The accused CNA stated he only tapped the resident on the shoulder to redirect him, but the witness differentiated between a tap and a slap, describing the action as a side-to-side motion consistent with slapping. The incident was documented in the resident's progress notes, and an assessment found no physical injuries such as redness or bruising. The facility's administrator and director of nursing ultimately unsubstantiated the abuse allegation, citing a lack of witnesses and conflicting accounts. The facility's abuse prevention policy prohibits any form of resident abuse, neglect, or mistreatment, and the expectation is for staff to ensure resident safety and follow established protocols.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe. A resident with a diagnosis of bipolar disorder and a perfect score on the Brief Interview for Mental Status (BIMS) reported suspected staff-to-resident abuse to the Social Services Director. The notification from the resident was documented at 6 p.m., but the written SOC 341 report was not faxed to the Department until the following day at 4:28 p.m., exceeding the mandated two-hour reporting window. Additionally, the initial document presented by the Administrator lacked the resident's name or any identifying information. During interviews and policy review, the Administrator acknowledged the regulatory requirement to report allegations of abuse within two hours if there is serious bodily injury, and within 24 hours if there is no injury, as outlined in the state operations manual. The facility's own policy also required notification of outside agencies within two hours for all allegations of abuse. The delay in reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.
Resident Mail Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy of communication for a resident when the Business Office Manager (BOM) opened a letter addressed to the resident without the resident's consent. The letter contained an electronic benefit transfer (EBT) card. According to interviews, the BOM acknowledged opening the mail and stated that, typically, mail addressed to residents, including EBT cards, should be delivered directly to them by staff such as the Activities Director and not opened by the BOM. The Administrator confirmed that business office personnel should not have opened the resident's mail without consent, as this action infringed on the resident's privacy rights. A review of the facility's policy indicated that residents are allowed to send and receive personal mail unopened, and staff are not to open mail unless requested by the resident.
Failure to Conduct Scheduled Care Conferences
Penalty
Summary
The facility failed to ensure that three residents participated in their care planning as required. Resident 1, who was admitted with quadriplegia and had full cognitive capacity, did not have his care conference on the scheduled date. The Director of Nursing confirmed that the care conference was not conducted as planned. Similarly, Resident 4, also with quadriplegia and intact cognition, did not have a care conference in December as scheduled, and the Social Services Director did not communicate with him about it. Resident 5, diagnosed with multiple sclerosis and with intact cognition, also missed her scheduled care conference in December. The facility's policy requires that residents and their representatives be notified and involved in care planning meetings, which should be documented. However, the Director of Nursing confirmed that no Interdisciplinary Team notes were found for the scheduled care conferences of Residents 4 and 5, indicating that these meetings did not occur. This lack of adherence to the facility's policy resulted in the residents not being able to participate in their care planning as intended.
Medication Error Due to Improper Administration
Penalty
Summary
The facility was found to have a medication error rate of 9.09% during a medication pass, exceeding the acceptable threshold of 5%. This error rate was observed when three medication errors occurred out of 33 opportunities. Specifically, a licensed nurse crushed and administered medications to a resident without a physician's order to do so. The resident, who was admitted with diagnoses of depression and hypertension, was given crushed medications mixed with applesauce, despite the absence of an order permitting this method of administration. The medications involved included carvedilol, lisinopril, and duloxetine. Notably, duloxetine's manufacturer's specifications explicitly state that the medication should not be crushed or mixed with food or liquids. The facility's policy also requires a physician's order for medications to be crushed. Interviews with the nurse practitioner and the director of nursing confirmed that an order was necessary for crushing medications, and the facility's pharmacist had previously noted the need to add a 'do not crush' instruction for duloxetine in the medication regimen review.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications, which was observed during a survey. In the medication storage room, 10 bottles of sorbitol solution were found with an expiration date of the previous month. A licensed nurse acknowledged that expired medications should not be stored in the medication room. Additionally, in a skilled nursing medication cart, a used insulin pen was stored without a plastic bag, a medication card of benzonatate pills was found expired, and six loose pills were discovered in the drawer. The nurse confirmed these issues, stating that the insulin pen should have been bagged to prevent cross-contamination, the expired benzonatate should have been discarded, and loose pills should not be present in the cart. Further observations in another medication cart revealed an opened bottle of simethicone tablets, an unwrapped inhaler, and a bottle of atropine sulfate eye drops, all without open dates. A bottle of lansoprazole powder was expired, and a vial of nasal spray had a torn prescription label, making it impossible to identify the resident it belonged to. The nurse confirmed the lack of open dates and the presence of expired medications and loose pills. The Director of Nursing stated that expired medications should not be stored and that medications needed open dates. The facility's policy indicated that outdated or deteriorated medications should be immediately removed from stock.
Deficiency in Dietary Staff's Use of Sanitization Test Strips
Penalty
Summary
The facility failed to ensure that dietary staff demonstrated sufficient skills in using chemical sanitization test strips for a low temperature dishwasher and red bucket, affecting the food and nutrition services for a census of 80. During an observation, a dietary aide (DA) did not follow the manufacturer's specifications for using chlorine test strips, as she did not blot the test strip on a tissue paper before comparing it against the test strip kit. This was confirmed during an interview with the DA, who acknowledged not following the manufacturer's instructions. Additionally, the DA was unable to identify the appropriate actions to take when the sanitizing solution did not meet the target concentration. The Dietary Supervisor (DS) confirmed that the DA was expected to follow the manufacturer's specifications. The manufacturer's instructions specified that the test strip should be dipped, removed quickly, blotted immediately with a paper towel, and compared to the color chart at once. The facility's policy indicated that re-education would be provided to employees unable to satisfactorily perform their skills.
Food Safety and Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to ensure that food was prepared and stored in a safe and sanitary manner, as observed during a survey. A large container of cooked Brussels sprouts was left uncovered on a stove burner, and containers of corn with sliced bell pepper and cooked carrots were found undated and unlabeled on a counter. Additionally, personal items such as a cell phone and water jug were placed next to the uncovered food. These actions were confirmed by the Dietary staff, who acknowledged that food should have been covered, dated, and labeled, and personal belongings should not be placed near food. Further observations revealed expired food items and unsanitary conditions in the dry storage area. Three packs of corn tortillas were found to be expired, and the air vents in the storage area had a whitish substance on the slats. The Dietary Supervisor confirmed these findings and stated that the expired tortillas should have been discarded and the air vents cleaned. The facility's policies on food storage and maintenance were reviewed, indicating that food should be labeled and dated, and maintenance should ensure cleanliness and safety.
Failure to Obtain Informed Consent for Restraint Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bilateral mittens for a resident, identified as Resident 34, who was admitted with chronic respiratory failure and anxiety disorder. During an observation and interview, it was noted that the resident was wearing soft mittens to prevent him from pulling out his tracheostomy tube. The order for the mittens was documented in the resident's Order Summary Report, but the informed consent was incomplete and unsigned by the resident's representative. Interviews with Licensed Nurse 2 and the Director of Nursing confirmed that the informed consent for the use of mittens was not completed, lacking the prescriber's name, the representative's name, and a signature. The facility's policy on restraints requires that informed consent be obtained before any restraint is used, and if the resident lacks decision-making capacity, consent should be obtained from the surrogate. This oversight had the potential to deprive the resident's representative of making informed decisions regarding the resident's care.
Failure to Provide Bed Hold Agreement Notification
Penalty
Summary
The facility failed to provide a written bed hold agreement to a resident or their representative before and upon transfer to a hospital. This deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated the resident was admitted to the hospital for further evaluation due to low oxygen saturation. The Licensed Nurse confirmed that there was no copy of the completed bed hold policy agreement signed by the resident or their representative. During an interview with the Director of Nursing, it was confirmed that if the bed hold policy agreement was not available, then the resident or their representative did not receive a notice and were not informed of the transfer. The facility's policy and procedure require that the resident and/or representative be notified in writing of the bed hold option whenever the resident is transferred to an acute care hospital. This oversight had the potential to leave the resident or their representative unaware of their right to return to the facility after hospitalization.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident 27. This resident was admitted with diagnoses including lung cancer, which required dependence on a ventilator. The comprehensive MDS assessment inaccurately coded Resident 27's prior level of function (PLOF) as independent with indoor/outdoor mobility and transfers, despite the use of a mechanical lift. During a review, the MDS Coordinator confirmed the inaccuracy and acknowledged the need for modification. The Director of Nursing (DON) stated that the facility lacked a specific MDS policy and expected staff to accurately complete MDS assessments to provide appropriate care. This inaccuracy in coding increased the risk of inadequate care planning for Resident 27.
Failure to Update Care Plans for Residents with Changed Conditions
Penalty
Summary
The facility failed to revise and review comprehensive care plans for two residents, leading to deficiencies in their care. Resident 2, who had a history of Parkinson's disease and recurrent falls, was hospitalized due to falls but did not have their fall care plan updated with new interventions to prevent further incidents. The Minimum Data Set Coordinator confirmed that the care plan was not reviewed or revised as required, which was a lapse in maintaining the resident's safety and well-being. Similarly, Resident 44, diagnosed with quadriplegia, had their tracheostomy removed, but the care plan was not updated to reflect this significant change. Despite the resident's mental capacity and repeated reminders to staff, the care plan still included outdated tracheostomy care interventions. The Licensed Nurse and Director of Nursing acknowledged that the care plan should have been revised to ensure appropriate care. The facility's policy mandates that care plans be updated with any change of condition, which was not adhered to in these cases.
Failure to Adhere to Tube Feeding Protocols
Penalty
Summary
The facility failed to provide services meeting professional standards of quality for two residents. For Resident 9, who was admitted with dysphagia, the tube feeding was left connected after completion, and the residual volume was not documented in the Medication Administration Record (MAR) as ordered. Licensed Nurse 8 confirmed the practice of leaving the tube connected until the next feeding, and the Director of Nursing acknowledged the incomplete documentation and incorrect practice, which should have included checking and documenting the residual volume to follow the physician's order. For Resident 45, who was admitted with traumatic brain injury, persistent vegetative state, and quadriplegia, an empty container of tube feeding was left hanging for more than 24 hours. Licensed Nurse 3 confirmed the container's date and stated it should be changed every 24 hours to prevent infection risk. The Director of Staff Development and the Director of Nursing both stated that the tube feeding containers and tubing should be changed every 24 hours, in accordance with the manufacturer's guidelines and facility policy.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to provide restorative nursing assistance to two residents, leading to deficiencies in maintaining and improving their range of motion (ROM). Resident 9, who was admitted with cerebral infarction and bilateral hand contractures, was observed without the prescribed carrot and foam roll splints on multiple occasions. Despite the order for daily application of these splints to minimize contracture risk, both the Restorative Nurse Assistant and a Licensed Nurse confirmed that Resident 9 was not wearing the splints as required. Similarly, Resident 40, admitted with a traumatic brain injury and limited ROM in the upper limbs, was not consistently wearing the ordered bilateral resting hand splints with finger separators. Observations and interviews revealed that the splints were not applied as per the care plan, which was intended to prevent further contracture progression. The Director of Nursing acknowledged that both residents should have been assisted and monitored to ensure adherence to their care plans, as outlined in the facility's contracture-prevention policy.
Failure to Ensure Proper Tracheostomy Care
Penalty
Summary
The facility failed to ensure proper tracheostomy care for a resident, identified as Resident 15, who was allowed to perform his own tracheostomy gauze change, suction, and inner cannula insertion without a risk and benefit assessment, care plan, or physician's order in place. Resident 15 had diagnoses of acute and chronic respiratory failure with hypoxia and was tracheostomy dependent. During observations and interviews, it was confirmed that Resident 15 had all the necessary supplies at his bedside and was independently managing his tracheostomy care. The Minimum Data Set Coordinator and the Respiratory Therapy Director both confirmed that there was no documentation of a risk and benefit assessment, care plan, or physician's order to ensure Resident 15's capability to safely perform his own tracheostomy care. The facility's policies on comprehensive person-centered care planning and physician's orders were not followed, as they require a clear and complete description of the physician's plan of care and documentation in the resident's medical record.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices during a medication pass when a licensed nurse did not perform hand hygiene. The nurse entered a resident's room, checked the resident's blood pressure, and then prepared medication without sanitizing hands after removing gloves. This was contrary to the facility's infection prevention and control program, which mandates hand hygiene upon entering and leaving a room and before and after medication preparation. Another deficiency was observed with Resident 44, who had a breath-activated call cord disposable mouthpiece that was not changed and had a large brown substance in it. The resident, diagnosed with quadriplegia, indicated that the mouthpiece was not replaced regularly. Staff confirmed the presence of the substance and acknowledged the risk of infection, including pneumonia, due to the unclean mouthpiece. The facility's policy requires regular replacement of such equipment to prevent infection. Additionally, a container of yogurt dated beyond its safe consumption date was found in Resident 17's room, posing a risk of foodborne illness. The facility's policy requires perishable food items to be discarded if not consumed within two hours. Furthermore, the privacy curtains in the rooms of Residents 17 and 44 were found to be dirty and stained, which could contribute to infection control issues. The facility's policy emphasizes maintaining a clean and sanitary environment for residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift for a census of 80 residents. Observations and interviews revealed that staffing information was not posted for five consecutive days, including weekends and weekday morning shifts. On 10/7/24, the staffing information displayed was outdated, showing data from 10/2/24. On 10/8/24, the staffing information was observed to be posted after the morning shift had already started, as confirmed by Licensed Nurse 2 and the Staffing Coordinator. The Director of Nursing acknowledged that the staffing information should be posted before the start of the morning shift, as per the facility's policy from 2018, which mandates daily postings at the beginning of each shift.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for a resident, resulting in a violation of the resident's rights to participate in their care planning. The resident, who was admitted in 2022 with quadriplegia, had a full mental capacity to make decisions as indicated by a perfect score on the Brief Interview for Mental Status. Despite this, the resident did not have care conferences in January and March of 2024, as confirmed by both the Administrator and the Director of Nursing. The resident expressed that they and their spouse were not kept informed about their care situation, with the last care conference before June 2024 occurring in October 2023.
Delay in Providing Resident's Medical Records
Penalty
Summary
The facility failed to provide the requested medical records for a resident within the required two working days, as per the facility's policy. The resident, who was admitted in 2023 with a diagnosis of respiratory failure, had their medical records requested on 7/30/24. However, due to the absence of a designated medical records person at the time, the request was overlooked. The Director of Nursing (DON) confirmed that the policy was not followed, and the initial request was missed. The Medical Records (MR) staff acknowledged that the request was not found until 8/13/24 and was not sent until 8/15/24, despite being received on 7/31/24. The facility's policy, titled 'Resident Access to PHI,' mandates that medical records be provided within two working days of a written request. The DON verified that the records should have been sent by 8/2/24, but as of 8/15/24, the records had not been sent to the requesting party.
Failure to Implement Resident's Care Plan Preference
Penalty
Summary
The facility failed to implement a care plan for a resident who had expressed a preference for personal care to be provided by female staff members. The resident, who had been diagnosed with major depressive disorder and lymphedema, was capable of making healthcare decisions and had a care plan initiated that specified her preference for female CNAs for personal care needs, including changing and showers. Despite this documented preference, the resident was attended to by a male CNA, which made her feel uncomfortable during perineal care. Interviews conducted during the investigation revealed that the male CNA was not informed of the resident's preference for female staff. The Assistant Director of Nursing confirmed that resident preferences indicated in the care plan should be honored. The facility's policy on comprehensive person-centered care planning, revised in 2018, mandates that the facility provide care that meets the health, safety, psychosocial, behavioral, and environmental needs of the resident to maintain their highest well-being. However, the failure to communicate and implement the resident's care plan preference resulted in a deficiency in providing person-centered care.
Staff Language Use Affects Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as staff were overheard speaking in a foreign language throughout the facility. This behavior was observed by multiple staff members, including a Respiratory Therapist, Housekeeper, Certified Nursing Assistants, a Licensed Nurse, and the Activities Director, who all confirmed that staff frequently spoke in a foreign language in the hallways, at the nurses' station, and around residents. The issue was raised in Resident Council meetings, indicating that it was a persistent concern among residents. Four residents, who had no memory impairments, expressed feeling uncomfortable, insecure, and like outsiders due to the staff's behavior. They reported that the issue had been discussed extensively in Resident Council meetings, but no action had been taken by the administration. The Infection Preventionist acknowledged the problem, stating that the expectation was for staff to speak English in work areas to prevent residents from feeling that they were being talked about. The Administrator also agreed that staff should not speak loudly in a foreign language around residents, as it was their home.
Failure to Inform Responsible Party of New Medication Order
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informing the responsible party (RP) of a resident about a new medication order. This deficiency was identified for one of the four sampled residents, who was diagnosed with a neurocognitive disorder with Lewy bodies and lacked the capacity to make her own healthcare decisions. The facility's policy required that the family or RP be informed of any changes in the resident's condition. However, when a new order for ivermectin was prescribed for scabies prophylaxis, the RP was not notified. The deficiency was confirmed through interviews and record reviews. Licensed Nurse 1 admitted to forgetting to inform the RP about the new medication order. The Director of Nursing also acknowledged the absence of documentation indicating that the RP was informed before the medication was administered. The facility's policy, revised in 2015, clearly stated that licensed nurses must notify the family or surrogate decision-makers of any changes in the resident's condition as soon as possible and document the time of contact. This oversight had the potential to disregard the resident and her RP's right to be informed of her treatment.
Failure to Check Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for a resident when the resident's blood pressure (BP) was not checked against physician orders before administering BP medication. The resident, who was admitted with diagnoses including hypertension and end-stage renal disease on dialysis, reported that nurses did not check his BP before giving his BP medications, which had occurred five times. This oversight had the potential to affect the resident's health by administering BP medication not in accordance with the physician's order. A review of the resident's Order Summary Report indicated that the resident had three different BP medications ordered, all with parameters to hold the medication if the systolic BP was less than 130. However, the Medication Administration Record showed that on two occasions, the resident received nifedipine 30 mg despite having systolic BP readings below 130. The Director of Nursing confirmed that the medication was administered without checking the BP and acknowledged that the medication should have been held according to the doctor's order.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were kept locked or under the direct observation of authorized staff, which had the potential for unauthorized access by staff or residents. During an observation and interview, a Licensed Nurse left a medication cart unlocked and unattended while at the nursing station on the telephone. At that time, multiple residents and other staff were present in the hallway. The Licensed Nurse acknowledged that the medication cart should have been locked. The Director of Nursing confirmed that the expectation is for the medication cart to be locked. A review of the facility's policy on medication storage indicated that medications and biologicals should be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The policy also stated that medication rooms, carts, and supplies should be locked or attended by authorized personnel.
Failure to Separate Residents After Altercation
Penalty
Summary
The facility failed to ensure the safety of two residents after an altercation occurred between them. Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face but did not separate the two residents into different rooms, as required by the facility's policy. This inaction led to Resident 1 sustaining a bruise on the right cheek and jaw due to continued exposure to the perpetrator. Resident 1 was admitted with diagnoses including neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, and had a severe memory problem. Resident 2 was admitted with dementia with other behavioral disturbances and had a moderate memory problem. On the evening of the incident, Resident 1 became aggressive and combative, leading to the altercation with Resident 2. Despite the altercation being witnessed by LN 1, the residents were not separated, and the incident was not reported to the Nurse Supervisor or the Director of Nursing. The facility's policy requires immediate separation of residents involved in altercations to ensure safety, but this was not followed. Interviews with staff revealed that LN 1 did not inform the Nurse Supervisor or the Director of Nursing about the incident, and the residents remained in the same room. The failure to separate the residents and report the incident promptly resulted in Resident 1 sustaining multiple bruises, which were later documented by other nursing staff.
Failure to Notify NP and RPs After Resident Altercation
Penalty
Summary
The report details a deficiency involving the failure of a Licensed Nurse (LN 1) to immediately notify the Nurse Practitioner (NP) and Responsible Parties (RP) for two residents after witnessing an altercation. Resident 1, who has a neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, slapped Resident 2, who has dementia with other behavioral disturbances. This incident was not promptly communicated to the NP or the RPs, leading to delayed assessments and diagnostic testing for potential injuries. Resident 1 was admitted to the facility with severe memory problems, while Resident 2 had moderate memory issues. On the morning following the altercation, another nurse (LN 2) noticed bruises on Resident 1 and notified the NP, who ordered an x-ray and cold compress. However, the NP's progress note indicated that there was no documentation on how Resident 1 acquired the bruises, and the NP was not informed of the altercation until the following day. The NP stated that had she been informed earlier, she would have evaluated both residents immediately. The Director of Nursing (DON) confirmed that LN 1 did not adhere to professional standards by failing to notify the NP or on-call physician and the RPs of both residents promptly. The facility's policy requires immediate notification of changes in a resident's condition, including incidents involving altercations. The failure to follow this policy resulted in distress for Resident 1's RP, who discovered the injuries without prior notification from the facility staff.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse within the regulatory timeframe involving two residents. Resident 1, who has a neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, slapped Resident 2, who has dementia with other behavioral disturbances, on the face. This incident was documented by Licensed Nurse 1 (LN 1) in Resident 1's progress note, indicating that the altercation had occurred twice. Despite being aware of the incident, LN 1 did not report it to the California Department of Public Health (CDPH) and other authorities within the required timeframe. The incident was witnessed by LN 1, who intervened by separating the residents and redirecting them to their beds. However, the report to the CDPH, the Ombudsman, and the police department was not made until several days later, as confirmed by the Director of Nursing (DON). The facility's policy requires that any known instances of physical abuse be reported to the proper authorities within two hours if it results in serious bodily injury, which was not adhered to in this case. The facility's training records show that LN 1 attended sessions on abuse prevention and reporting, indicating that they were aware of the procedures. Despite this, the incident was not reported promptly, leading to a deficiency in the facility's compliance with state and federal regulations. The delay in reporting was acknowledged by the DON, who confirmed that LN 1 was the only witness to the incident and should have reported it earlier.
Failure to Document and Assess After Resident Altercation
Penalty
Summary
The report identifies a deficiency in the care provided by a licensed nurse (LN 1) at a nursing facility, where LN 1 failed to adhere to professional standards following an altercation between two residents. LN 1 witnessed Resident 1 slap Resident 2 but did not conduct or document an assessment of either resident after the incident. Additionally, LN 1 did not initiate a care plan for either resident following the altercation, which is a requirement according to the facility's policy and procedure for changes in condition. Resident 1, who has a diagnosis of neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, was involved in the altercation with Resident 2, who has dementia with other behavioral disturbances. The incident resulted in Resident 1 sustaining bruises on the face and body, which were later documented by other nursing staff. However, there was no initial documentation by LN 1 regarding the altercation or the resulting injuries, which was confirmed by the Nurse Supervisor and other staff members during interviews. The facility's policy requires that any change in a resident's condition, such as an altercation, be documented promptly, and a care plan be updated to reflect the resident's current status. The Director of Nursing (DON) confirmed that LN 1 did not meet these professional standards, as there was no documentation of the altercation or assessments in the residents' charts, nor was there an immediate update to their care plans following the incident.
Failure to Document and Notify After Resident Altercation
Penalty
Summary
The report identifies a deficiency in the documentation and notification process following an altercation between two residents in a long-term care facility. Licensed Nurse 1 (LN 1) witnessed Resident 1 slap Resident 2 but failed to document the details of the incident in the medical records of both residents. Additionally, LN 1 did not record the time at which the responsible parties (RPs) of both residents were notified, leading to a delay in assessments and diagnostic testing for injuries. Resident 1, who has a diagnosis of neurocognitive disorder with Lewy Bodies and dementia with psychotic disturbance, was admitted to the facility with severe memory problems. Resident 2, diagnosed with dementia with other behavioral disturbances, was admitted with moderate memory issues. The altercation occurred on the evening of 5/2/24, but LN 1 did not document the incident in the residents' charts, nor did she notify the Nurse Supervisor (NS), Director of Nursing (DON), or Nurse Practitioner (NP) in a timely manner. The NP was only informed of Resident 1's bruises the following morning, which delayed the necessary medical evaluations. The facility's policy requires that any change in a resident's condition, including incidents, be reported and documented promptly. LN 1's failure to adhere to these standards resulted in distress for Resident 1's RP, who discovered the injuries during a video call without prior notification from the facility. The DON confirmed that LN 1 did not meet professional standards by failing to notify the NP or on-call physician and the RPs of both residents as soon as the residents' safety was ensured.
Failure to Prevent Abuse and Isolation of Resident
Penalty
Summary
The facility failed to follow their policy and procedure to prevent abuse for one of three sampled residents when a licensed nurse closed a resident in her room. This action resulted in the resident being isolated, which had the potential for further abuse or injury. The resident, who was admitted with Alzheimer's disease, hypertension, and unspecified dementia, was described as usually able to make herself understood and understand others, with a moderate cognitive impairment. The resident had a history of wandering, and the licensed nurse closed the door to her room to monitor her whereabouts, which was against the facility's policy on abuse prevention. Interviews with staff members and a review of facility documents revealed that the licensed nurse had a practice of closing doors and isolating residents. Two CNAs confirmed that the nurse would close the door and curtains to monitor residents' whereabouts. The facility's policy clearly stated that residents have the right to be free from involuntary seclusion and isolation. The licensed nurse was terminated for violating this policy. The resident confirmed during an interview that she would not leave the room if the door was closed, indicating that the action effectively isolated her against her will.
Failure to Document Administration of Permethrin Cream
Penalty
Summary
The facility failed to provide services according to professional standards of practice for three residents when permethrin cream, used to treat scabies, was not accurately documented in their Medication Administration Record (MAR). Resident 1, who tested positive for scabies, and his two roommates, who were treated prophylactically, did not have proper documentation of the administration of permethrin cream. The Infection Preventionist Nurse confirmed that the medication was administered but not recorded in the MAR, and the Director of Nursing verified that there were no electronic orders for the medication in the residents' records. Resident 1 was readmitted to the facility with multiple diagnoses, including scabies, and tested positive for the condition. Resident 2 and Resident 3, who were roommates of Resident 1, were treated prophylactically with permethrin cream. However, there was no documented evidence in their clinical records or MARs that the medication was given. The facility's policy requires that medication orders be received by a licensed nurse prior to administration and that the administration be documented in the MAR, which was not followed in this case.
Failure to Follow Abuse Prevention Policy
Penalty
Summary
The facility failed to follow its own policy and procedure for the prevention of further abuse when it allowed a Certified Nursing Assistant (CNA) to continue providing resident care after an alleged abuse incident. The incident involved a Respiratory Therapist (RT) witnessing the CNA tying a resident's hand to the side of the bed using a sheet. The resident had a laceration on her nose and a swollen lip. Despite the facility's policy requiring immediate suspension and removal of the staff member from the premises upon an allegation of abuse, the CNA was allowed to work an additional three hours before being suspended. The Director of Nursing (DON) confirmed that the alleged abuse was not reported to the nurse until the end of the night shift, approximately three hours after the incident occurred. The DON acknowledged that the CNA should have been suspended and sent home immediately when the situation was first reported. The CNA confirmed that he completed his full shift and was not suspended until approximately four hours after the shift had ended. This failure to promptly remove the CNA from resident care could have potentially resulted in further harm to other residents in the facility, which had a census of 87 residents at the time.
Failure to Develop and Implement Care Plan for Resident with Pressure Ulcer
Penalty
Summary
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). Resident 4, who was admitted with severe cognitive impairment and high risk for pressure ulcers, developed a pressure ulcer during her stay. The clinical records indicated that Resident 4 was dependent on staff for mobility and had a high Braden Scale score, indicating a high risk for pressure ulcers. Despite these indicators, the facility did not create a care plan or document regular turning and incontinent care for Resident 4, leading to the development of a pressure ulcer on her coccyx and buttocks. Interviews with the Assistant Director of Nursing (ADON) and Licensed Nurse 4 (LN 4) confirmed that there was no care plan created for Resident 4's DTI-PU and no documentation of the required two-hourly turning and incontinent care. The ADON and LN 4 acknowledged that the care plan should have been initiated as soon as the wound was identified, and the staff should have been monitoring and documenting the resident's care to prevent skin breakdown. The facility's policy on Comprehensive Person-Centered Care Planning, which mandates addressing resident-specific health and safety concerns to prevent decline or injury, was not followed in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to follow their policy and procedures to prevent a pressure sore from developing for Resident 4, who was admitted with severe cognitive impairment and high risk for pressure ulcers. Despite being dependent on staff for mobility and being incontinent, there was no documentation that Resident 4 was turned every two hours or received appropriate incontinent care. The resident developed a deep tissue injury pressure sore on the left and right buttocks and coccyx area, which was identified by a licensed nurse on 12/15/23. The wound was later confirmed to be a deep tissue pressure injury with significant necrotic tissue. The Assistant Director of Nursing (ADON) and Licensed Nurse 4 (LN 4) both acknowledged that Resident 4 was at high risk for pressure sores and should have been turned every two hours. However, there was no documentation to confirm that these preventive measures were taken. Additionally, no care plan was created for Resident 4's pressure sore, which was against the facility's policy. The facility's policy on skin integrity management required the identification, evaluation, and intervention to prevent and heal pressure ulcers, but these steps were not followed in Resident 4's case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 687 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roseville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Ridge Healthcare Center | 0.3 mi | ★★★★★ | 20 | 0 |
| Roseville Care Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Pine Creek Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Citrus Heights Post Acute | 4.9 mi | ★★★★★ | 13 | 0 |
| Fair Oaks Healthcare Center | 5.6 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Roseville Point Health & Wellness Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.