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Operation Guardians Reports

Roseville Pointe Health & Wellness Center - Roseville


The walls, floors, and resident equipment in this facility are heavily soiled and in need of deep cleaning. The facility lacks proper lighting, making it difficult for residents to eat in their rooms. The facility is cold and the residents’ blankets are thin and inadequate.

One resident developed a stage three pressure ulcer on her buttocks, but the chart did not contain a comprehensive care plan to treat it, nor was one ever administered. Another resident wandered from the facility into the streets and was found only after a concerned citizen contacted the police. The facility was aware of this resident’s tendency to wander, but failed to take proactive measures to prevent it.

One resident had been referred for a psychologic evaluation over a year prior to the inspection, but the charts reflected that she had yet to be evaluated. One resident’s chart contained no evidence of having undergone a physical exam in over 15 months. Another resident, whose chart reflected that he had never been diagnosed with Parkinson’s disease, was being administered Parkinson’s medication. One patient chart indicated that Haldol, a powerful antipsychotic medication, was administered whenever the patient became agitated or yelled.