Health inspection·August 5, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.During a review of Resident 1's Treatment Administration Record (TAR) for May 2024, the TAR indicated no documentation, as evidenced by the Licensed Nurse (LN) initials, that Resident 1's coccyx wound care was completed on 5/25/24 and 5/27/24.During a review of Resident 1's TAR for June 2024 indicated no documentation, as evidenced by the LN's initials, that Resident 1's coccyx wound care was completed as ordered on 6/2/24, 6/5/24, and 6/12/24.During a concurrent interview and record review on 8/5/25 at 11:06 a.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON confirmed there was no documentation Resident 1's coccyx wound care was completed on the above dates. The DON confirmed she would expect the nurses to complete the wound care and document their initials on the TAR.During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, effective date 11/14/23 indicated, Treatments administered will be documented in the resident medical record.2. During a review of Resident 1's clinical record, the record indicated a Weekly Skin/Wound Assessment was completed on 5/23/24 and 5/31/24. There was no documentation that a Weekly Skin/Wound Assessment was completed after 5/31/24.During a concurrent interview and record review on 8/5/25 at 11:06 a.m. with the DON, Resident 2's clinical record was reviewed. The DON confirmed a Weekly/Skin Wound Assessment was not completed the following weeks, 6/7/24, 6/14/24, 6/21/24, and 6/28/24. She also confirmed there was no documentation of the status of Resident 1's coccyx wound upon her discharge from the facility on 7/3/24. The DON confirmed she would expect the nurses to complete a Weekly Skin/Wound Assessment.During a review of the facility's P&P titled, Skin Integrity Management, effective date 11/14/23 indicated, A licensed nurse will complete the skin assessment weekly .License Nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis. 3. Resident 1's clinical record contained a physician's order, dated 5/23/25 for Assess for pain every shift and chart intensity of pain.During a review of Resident 1's Medication Administration Record (MAR) for May 2024, the MAR indicated no documentation, as evidenced by the LN initials, that Resident 1's pain was assessed on 5/27/24 day shift.During a review of Resident 1's MAR for June 2024, the MAR indicated no documentation, as evidenced by the LN initials, that Resident 1's pain was assessed on 6/6/24 evening shift, 6/7/24 day shift, Residents Affected - Few Page 1 of 2 056139 056139 08/05/2025 Roseville Point Health & Wellness Center 600 Sunrise Avenue Roseville, CA 95661

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 6/8/24 day shift and night shift, 6/21/24 night shift, 6/28/24 night shift and 6/29/24 night shift.During a concurrent interview and record review on 8/5/25 at 10:23 a.m. with the DON, Resident 1's clinical record was reviewed. The DON confirmed there was no documentation Resident 1's pain was assessed on the above dates and shifts. The DON confirmed she would expect the nurses to assess Resident 1's pain and document it on the MAR.During a review of the facility's P&P titled, Pain Management, effective 5/26/23 indicated, The Licensed Nurse will assess the resident for pain and document results on the MAR each shift. 4a. Resident 1's clinical record contained a physician's order, dated 6/5/24 for Norco (pain medication) one tablet by mouth every six hours for pain.During a review of Resident 1's MAR for June 2024, the MAR indicated no documentation, as evidenced by the LN initials, that Resident 1's Norco was given as ordered on 6/6/24 at 6 p.m., 6/9/24 at 12 a.m. and 6 a.m., and 6/22/24 at 6 a.m.During a concurrent interview and record review on 8/5/25 at 10:23 a.m. with the DON, Resident 1's clinical record was reviewed. The DON confirmed there was no documentation Resident 1's Norco was given as ordered on the above dates and times. The DON confirmed she would expect the nurses to administer the pain medication as ordered.During a review of the facility's P&P, Pain Management, effective 5/26/23 indicated, The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR).4b. Resident 1's clinical record contained a physician's order, dated 6/24/24 for Norco one tablet by mouth every four hours for severe pain.During a review of Resident 1's MAR for June 2024 indicated no documentation, as evidenced by the LN initials, that Resident 1's Norco was given as ordered on 6/29/24 at 2 a.m. and 6 a.m. and 6/30/24 at 2 a.m. and 6 a.m.During a concurrent interview and record review on 8/5/25 at 10:23 a.m. with the DON Resident 1's clinical record was reviewed. The DON confirmed there was no documentation Resident 1's Norco was given as ordered on the above dates and times. The DON confirmed she would expect the nurses to administer the pain medication as ordered.During a review of the facility's P&P titled, Pain Management, effective 5/26/23 indicated, The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR).5. During a review of Resident 1's Weights and Vitals Summary, indicated Resident 1's weight on 5/27/24 was 157.8 lbs. and her weight on 6/12/24 was 114.4 lbs., a weight loss of 43.4 lbs. in 16 days.During a review of Resident 1's hospital record, [NAME]/Sonoma Skilled Nursing Placement Referral, dated 5/21/25 indicated Resident 1's weight was 120 lbs.During a concurrent interview and record review on 8/5/25 at 9:09 a.m. with the DON, Resident 1's clinical record was reviewed. The DON confirmed there was no documentation that Resident 1's weight loss of 43.4 lbs. was evaluated by the IDT (Interdisciplinary Team). The DON concluded Resident 1's weight documented on 5/27/24 was possibly inaccurate due to Resident 1's weight was 120 lbs. on 5/21/25.During a review of the facility's P&P titled, Evaluation of Weight & Nutritional Status, revised 4/21/22 indicated, Any resident weight that varies from the previous reporting period by 5% in 30 days, 7 in 90 days, 10% in 180 days, will be evaluated by the IDT- Nutrition & Weight Variance Committee to determine the cause of weight loss/gain and the intervention(s) required. 056139 Page 2 of 2