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 Goldwater Care Roseville during CMS and state inspections, most recent first.
A facility failed to provide a working call system or accessible alternative for all residents after the electronic call system became inoperable. One resident with significant cardiac and mobility issues was admitted without a functioning call light and experienced chest pain for over two hours without staff response, ultimately requiring emergency services. Other residents also lacked access to call lights or bells, and staff were unaware or did not provide alternatives, resulting in unmet care needs and delayed assistance.
Surveyors found that several resident bathrooms and the main dining room vent were not properly cleaned or maintained, with issues such as debris, stained caulking, missing paint, and damaged walls. Residents expressed dissatisfaction with the cleanliness, and staff interviews revealed confusion over cleaning responsibilities. The DON confirmed all residents use the affected dining area, and the Administrator acknowledged the need for repairs.
The facility did not provide required QAPI training to all staff, as confirmed by review of in-service schedules and staff training records, and verified by the DON. This deficiency potentially affected all 40 residents in the facility.
A review of facility records and staff interviews revealed that employees did not receive required training on the Compliance and Ethics Program. The in-service schedule and assessment tools omitted this training, and the DON confirmed that staff had not been trained, affecting all residents in the facility.
The facility did not maintain a working nurse call system in resident bathrooms, leaving several residents—many with significant mobility issues and fall risks—unable to summon assistance during toileting. Residents and staff reported the system had been non-functional for months, leading to delays in care, increased anxiety, and, in one case, a fall with injury. Despite repeated complaints to administration, the deficiency persisted, and alternative measures such as bells were inadequate.
The facility did not maintain a working bathroom nurse call light system, as documented in multiple concern forms and resident council minutes over several months. Observations confirmed that call buttons in several bathrooms failed to activate lights or audible alerts, and both residents and staff reported the system had been down for an extended period. The Maintenance Director and Administrator acknowledged the system's ongoing failure and the lack of available parts for repair, with no clear timeline for replacement.
The facility did not assess the risk of entrapment from side rails for five residents, despite their use for mobility assistance. Observations showed side rails in various positions, and interviews confirmed their use. The administrator acknowledged the lack of documentation for entrapment assessments, indicating a failure to follow policy and ensure resident safety.
A facility failed to conduct a required Level II PASRR evaluation for a resident with suspected schizophrenia, major depression, and anxiety. The resident's PASRR Level I Form indicated the need for a face-to-face Level II evaluation, as required by Federal law, but the medical record lacked documentation of this evaluation. The Regional Operation Manager confirmed the oversight.
A facility failed to assess a resident for the removal of an indwelling urinary catheter after returning from hospitalization. The resident, who was usually continent and used the bathroom with assistance before hospitalization, returned with a catheter but was not consulted about its removal. The DON stated that staff should obtain orders for removal if a catheter was not present before hospitalization, which was not done in this case.
A facility failed to weigh a resident weekly as recommended by a dietitian after a significant weight loss. The resident's weight dropped from 237 to 222 pounds, prompting a recommendation for weekly weights, which was not documented in the medical record after the initial weight loss.
A resident was prescribed Seroquel for mood disorder related to Vascular Dementia without documented behaviors justifying its use. Despite the facility's policy requiring psychotropic drugs only when necessary, the resident showed no aggressive behaviors, and the DON was unsure of antipsychotic regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with Chronic Viral Hepatitis C, as required by their infection control policy. Observations showed no EBP signs or PPE in the resident's room, and the resident confirmed staff only wore gloves during care. Staff interviews revealed a lack of adherence to EBP protocol, despite acknowledging the resident's condition warranted such precautions.
A resident reported verbal and physical abuse by CNAs, including being called 'crazy' and experiencing pain during a transfer. The incidents were reported to the DON, but the facility failed to report the allegations to the State Agency as required by their policy.
A facility failed to investigate allegations of abuse involving a resident and CNAs. The resident reported incidents of verbal and physical mistreatment, which were communicated to the DON but not investigated or reported to the Administrator. Interviews confirmed the interactions, but no immediate action was taken, resulting in a deficiency.
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. Multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director, were observed with unrestrained hair while engaged in various kitchen activities. This non-compliance with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions for residents with indwelling urinary catheters, leading to potential spread of MDROs. Staff were observed providing care without necessary PPE, and appropriate signage was not posted, despite documented orders and policies.
The facility failed to provide the required minimum of twelve hours of CNA training over a twelve-month period, affecting all 43 residents. The ADON could not find training records for the past year, except for those from January 2024 forward, which did not meet the twelve-hour requirement, nor did they include dementia care and abuse prevention training.
The facility failed to perform a PASARR level I re-screening for a resident with Bipolar Disorder, Depression, and PTSD. The initial screening was conducted and valid for 90 days, but no subsequent screenings were found in the resident's medical record.
The facility failed to update the care plans for three residents, leading to deficiencies in their care. One resident's care plan did not reflect contact isolation precautions for VRE, another's did not address significant edema, and a third's was not updated to reflect the resolution of a pressure ulcer. These deficiencies were confirmed by facility staff and indicate non-compliance with the facility's care planning policy.
The facility failed to implement fall prevention interventions for three residents. One resident's call light was out of reach, another's chair alarm was non-functional, and a third resident experienced a fall due to inadequate staff assistance during a transfer. These deficiencies highlight lapses in adhering to fall prevention policies.
The facility failed to secure an indwelling urinary catheter for a resident with Neuromuscular Dysfunction of the Bladder. CNAs and the DON confirmed the absence of a securement device, which is against the facility's policy.
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The diagnosis was documented, but the care plan did not address this condition, as confirmed by the Care Plan Coordinator.
The facility failed to ensure a physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for a resident. The resident had a PRN order for Haldol IM for Anxiety Disorder, but the required physician evaluation and documentation were missing since November 2023, as verified by the Care Plan Coordinator.
The facility failed to implement physician orders for a resident with Type 2 Diabetes Mellitus, as no Hemoglobin A1C tests were documented since the resident's admission. The DON confirmed the oversight and acknowledged the missed monitoring.
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. Several residents reported not receiving account balance statements for months, and the Administrator in Training confirmed that no financial statements had been issued since the previous year, affecting all 43 residents.
The facility failed to ensure survey results from the past three years were available for review. Several residents were unaware of where to access these results. A binder near the entrance contained outdated information, and the Administrator in Training confirmed it had not been kept current.
Failure to Provide Accessible Call System During Outage
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to all residents, particularly in bathrooms and bathing areas, after the electronic call system became inoperable. This failure was observed through multiple interviews, record reviews, and direct observations, revealing that several residents, including those with significant medical needs, were left without a functioning call light or an alternative means to summon assistance. One resident, who was admitted with diagnoses including Atrial Fibrillation, repeated falls, heart failure, and morbid obesity, was placed in a bed without a working call system and was not provided with a bell or any alternative device to call for help. The resident experienced chest pain and shortness of breath for over two hours without staff response, ultimately requiring emergency services for a new onset of atrial fibrillation. Other residents were also found to be without working call lights or bells, and staff interviews confirmed that some residents had never been provided with a bell. Residents reported having to rely on roommates or yelling for help, and in some cases, staff were unaware of the inoperability of the call lights. Documentation showed that the facility's call light system had been out of service for an extended period, and there was no documented plan to ensure all residents had access to an alternative call system. The facility's own policy required that all residents have access to a call system at all times, and that defects be promptly reported and addressed, but these procedures were not followed. The lack of a functioning call system affected all 40 residents in the facility, with specific incidents of delayed care and unaddressed needs, including a resident who was left in soiled clothing for hours and another who was unable to call for help during a medical emergency. Staff interviews revealed confusion and lack of communication regarding the status of the call system and the provision of alternative devices. Maintenance records did not reflect timely reporting or repair of the call system failures, and care plans were not updated to reflect the need for increased supervision or alternative call systems during the outage.
Removal Plan
- All resident care plans were updated to ensure residents receive frequent rounding to ensure needs are met and bells are within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.
- All staff were in-serviced on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly.
- V2 was educated on the facility's Comprehensive Care Plan policy, including developing a comprehensive care plan after completion of the comprehensive assessment that includes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.
- V6 (Maintenance Director) was educated to document when call lights were out of service, when repairs were made, and to keep a service repair/work order binder to document when call lights are out of service and when repairs are made.
- All resident bathrooms were provided with hand bells.
- Daily audits were completed to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue.
- All staff were re-in serviced on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.
- The new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.
Failure to Maintain Clean and Safe Resident and Common Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment for its residents. During a facility tour, multiple resident bathrooms were found with significant maintenance and cleanliness issues, including cove base pulled away from the wall, missing chunks of drywall with debris on the floor, stained caulking around toilets, and bathroom walls with missing paint. Additionally, air conditioner vents in resident bathrooms were covered in debris. The main dining room's large heating/cooling vent was completely covered in thick, brown debris. These conditions were confirmed by the facility's Administrator during a follow-up tour. Interviews with residents revealed dissatisfaction with the cleanliness and maintenance of their bathrooms, with one resident expressing concern about the air quality due to a dirty vent, particularly given their asthma. Staff interviews indicated a lack of clarity regarding responsibility for cleaning the dining room vent, with both housekeeping and maintenance staff stating they had never cleaned it. The Director of Nursing confirmed that all residents, including those with special feeding needs, use the main dining room. The Administrator acknowledged awareness of the need for repairs and updates in many resident bathrooms.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all employees, as required by its own Facility Assessment Tool. A review of the facility's census confirmed that 40 residents were present at the time of the deficiency. Examination of the Annual In-Service Schedule and staff in-service records from 9/1/24 through 9/6/25 revealed that QAPI training was not included. This was further verified by the Director of Nursing, who confirmed that staff had not received QAPI training.
Lack of Staff Training on Compliance and Ethics Program
Penalty
Summary
The facility failed to provide training on its Compliance and Ethics Program to all employees, as evidenced by a review of records and staff interviews. The Annual In-Service Schedule did not include any sessions related to the Compliance and Ethics Program, and the Facility Assessment Tool did not list this program as a required staff training. Additionally, a review of staff in-service records over a one-year period confirmed the absence of such training. This was further verified by the DON, who acknowledged that staff had not received training on the Compliance and Ethics Program. The facility census at the time documented 40 residents residing in the facility.
Failure to Maintain Functioning Nurse Call System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning nurse call system in resident bathrooms and bathing areas for all residents, as required by facility policy. Observations, interviews, and record reviews revealed that the nurse call system in resident bathrooms had been non-functional for an extended period. Multiple residents reported that the system had been down for months, and staff confirmed ongoing issues with the system despite attempts at repair. In several instances, activating the call system in resident bathrooms did not result in any visual or audible alert at the room door or nurse's station, and this was verified by both nursing and maintenance staff. Four residents with significant medical conditions and varying levels of dependence for toileting were directly affected by the non-functioning call system. These residents included individuals with diagnoses such as hemiplegia, chronic pain, osteoarthritis, diabetes with neuropathy, and a history of falls. Each resident's care plan emphasized the need for prompt response to call lights and the importance of having the call system within reach, especially given their fall risk and dependence on staff for toileting assistance. Despite these documented needs, residents were left without a reliable means to summon help while in the bathroom. Residents described experiencing fear, anxiety, and in some cases, actual harm due to the inability to call for assistance. One resident reported waiting up to 30 minutes for help after being left on the toilet, while another described falling in the bathroom and being unable to reach the provided bell or call for help, resulting in injury and a subsequent emergency room visit. Staff and residents both reported that complaints about the broken system had been made to the facility administrator over several months, but the issue remained unresolved at the time of the survey.
Failure to Maintain Functioning Bathroom Nurse Call Light System
Penalty
Summary
The facility failed to provide a functioning bathroom nurse call light system for its residents. Multiple facility documents, including Concern Forms and Resident Council Minutes from March through June, documented ongoing issues with non-functioning call lights. Observations on June 2nd confirmed that the nurse call buttons in several residents' bathrooms did not activate lights or audible alerts, either outside the rooms or at the nurse's stations. Residents reported that they had complained about the broken system for months, and staff, including an LPN and CNA, confirmed that the bathroom nurse call system had been down for an extended period. The Maintenance Director stated that the system had been inoperable since he began employment in February and that repeated repair attempts by a local company were unsuccessful due to the outdated nature of the system and lack of available parts. The Administrator confirmed that the system had been down since at least early January, that corporate staff were notified in January, and that bids for a replacement system were obtained in May, but there was no information on when the system would be replaced or operational. At the time of the report, 44 residents resided in the facility.
Failure to Assess Entrapment Risk with Bed Rails
Penalty
Summary
The facility failed to assess the risk of entrapment from side rails for five residents out of thirteen reviewed for siderails, within a total sample of 28 residents. The facility's policy requires an assessment for safety risks before installing bed rails, including checking compatibility with the bed frame and mattress, ensuring proper installation, and regularly inspecting for potential entrapment areas. However, the facility did not document any entrapment risk assessments for the residents in question, despite their use of side rails for mobility assistance and positioning. Observations revealed that the residents' beds had side rails in various positions, and interviews confirmed that the residents used these rails for assistance. The facility's administrator acknowledged the lack of documentation for entrapment assessments for these residents and mentioned ongoing training for the new Maintenance Director regarding these assessments. The absence of documented assessments indicates a failure to adhere to the facility's policy and ensure resident safety concerning the use of side rails.
Failure to Conduct Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to obtain a Level Two PASRR (Preadmission Screening and Resident Review) for a resident who was identified as needing further evaluation. The resident's PASRR Level I Form, dated August 1, 2023, indicated that the resident had never undergone a PASRR Level I screen before and documented mental health diagnoses including suspected schizophrenia, current major depression, and current anxiety. The PASRR Level I screen concluded that a face-to-face Level II evaluation was required, as mandated by Federal law, due to the potential presence of a serious mental illness or an intellectual/developmental disability. However, the resident's medical record lacked any documentation of a completed Level II PASRR evaluation. This oversight was confirmed by the Regional Operation Manager, who acknowledged the absence of the necessary documentation and indicated that the evaluation had been missed.
Failure to Assess Indwelling Urinary Catheter Removal
Penalty
Summary
The facility failed to assess a resident, identified as R45, for the removal of an indwelling urinary catheter. R45 was admitted to the facility with several diagnoses, including unspecified diastolic congestive heart failure and chronic kidney disease. Initially, R45 was usually continent and required assistance to use the bathroom. However, after a hospitalization for sepsis, upper respiratory infection, and hypoxia, R45 returned to the facility with an indwelling urinary catheter. Despite this change, there was no documentation in R45's electronic medical record regarding any discussions about the necessity or potential removal of the catheter. Observations and interviews revealed that R45 was unaware of the reason for the catheter and had not been consulted about its removal. A Certified Nursing Assistant confirmed that R45 did not have a catheter before the hospitalization and used the bathroom with assistance. The Director of Nursing stated that it is expected for nursing staff to obtain orders for catheter removal if a resident returns from the hospital with a catheter they did not have before. This expectation was not met, leading to the deficiency noted in the report.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to adhere to its dietary policy by not weighing a resident as recommended, which led to a deficiency. The policy stated that residents identified at nutritional risk should be weighed weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. A resident's medical record documented a weight of 237 pounds on January 9, 2025, and a subsequent weight of 222 pounds on February 11, 2025, indicating a 6.3% weight loss in one month. Following this, a dietitian recommended weekly weights for four weeks due to the weight loss. However, the resident's medical record did not contain any documentation of weights after February 11, 2025. On March 5, 2025, the Dietary Manager confirmed the absence of any weight documentation after the specified date, despite the dietitian's recommendation.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medication for one resident, identified as R47, who was part of a sample of 28 residents reviewed for unnecessary medications. R47 was admitted to the facility with multiple diagnoses, including Vascular Dementia with Mood Disturbance. Despite having a physician's order for Seroquel, an antipsychotic medication, to be administered daily for mood disorder related to Vascular Dementia, there was no documented evidence of behaviors that would necessitate the continued use of this medication. Observations and interviews revealed that R47 exhibited no aggressive behaviors towards others and had not shown any documented behaviors in the electronic medical record for the past month. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition and at the lowest therapeutic dose. However, the Director of Nursing was unsure of the regulations regarding antipsychotic medications, and the Licensed Practical Nurse confirmed that R47 had not displayed aggressive behaviors for some time. This lack of documented behavioral symptoms and the absence of a clear indication for the continued use of Seroquel suggest a failure to adhere to the facility's policy and regulatory standards for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions for Resident with Hepatitis C
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident diagnosed with Chronic Viral Hepatitis C, as required by their infection prevention and control program. The facility's policy mandates the use of EBP, which includes the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that there were no EBP signs or Personal Protective Equipment (PPE) available outside or inside the resident's room. The resident confirmed that staff only wore gloves during care and had never seen them wear a gown. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, indicated a lack of adherence to the EBP protocol. Both staff members acknowledged that the resident's condition warranted the use of EBP, yet confirmed that the necessary precautions were not in place. The Assistant Director of Nursing verified that the resident should have been on EBP due to the infection risk posed by Hepatitis C, but acknowledged that the protocol was not being followed for this resident.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged verbal, mental, and physical abuse of a resident to the State Agency as required by their policy. The policy mandates that any allegation of abuse be reported to the Department of Public Health immediately, but not more than two hours after the allegation. A resident, identified as R3, reported two incidents involving CNAs. In the first incident, a CNA was loud and called the resident 'crazy' when asked to be quiet. In the second incident, another CNA caused the resident pain while using a mechanical lift and subsequently denied causing harm, again calling the resident 'crazy.' The resident reported these incidents to the Director of Nursing, but the allegations were not documented or reported to the State Agency as required. The Director of Nursing confirmed that the allegations were not reported, and the facility was unable to provide documentation of any report being made.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse and ensure the protection of a resident during the investigation. A resident, identified as R3, reported two separate incidents involving CNAs V5 and V6. In the first incident, R3 stated that V6 was loud and called her crazy when she asked for quiet. In the second incident, R3 reported that V5 caused her pain while using a mechanical lift and subsequently called her crazy. R3 communicated these concerns to the Director of Nursing (DON), V2, who acknowledged the reports but did not conduct an investigation or report the incidents to the Administrator, V1. Interviews with the involved staff, V5 and V6, confirmed the interactions with R3 but did not result in any immediate action or investigation. V5 and V6 both stated they worked throughout the building and did not remain in one hall, which could have implications for monitoring and supervision. V2 admitted to not investigating R3's allegations and failing to report them to V1, who was aware of the incident involving V6 but did not initiate an investigation. This lack of action and failure to follow the facility's abuse prevention policy resulted in a deficiency in addressing and investigating potential abuse allegations.
Failure to Restrain Hair and Facial Hair in Kitchen
Penalty
Summary
The facility failed to ensure that staff had their hair and facial hair fully restrained during food production and clean-up activities. This was observed on multiple staff members, including the Dietary Manager, Cook, Dietary Aide, Dishwasher, and Maintenance Director. Specifically, the Cook, Dietary Aide, and Dietary Manager had large strands of hair unrestrained on the tops, sides, and backs of their heads. The Dishwasher wore a ball cap that left the sides and back of his hair unrestrained and had no restraint covering his beard. Similarly, the Maintenance Director wore a ball cap that left the front, sides, and back of his hair unrestrained and had no restraint covering his beard. These observations were made while the staff were engaged in various kitchen activities, including cooking, stacking clean plates and cups, washing dishes, and removing screens above the stove. The facility's policy, revised in October 2016, mandates that all food service employees adhere to a dress code that includes hair nets or appropriate hair coverings, including facial hair coverings, while involved in food production and clean-up activities. The Dietary Manager confirmed that all staff should have their hair fully restrained while in the facility kitchen. This failure to comply with the facility's dress code policy has the potential to affect all 43 residents currently residing in the facility.
Failure to Implement Isolation and Barrier Precautions
Penalty
Summary
The facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms (MDROs). This failure was observed in multiple instances involving residents with indwelling urinary catheters, which are high-contact care activities requiring enhanced precautions. Specifically, the facility did not post appropriate signage or provide necessary Personal Protective Equipment (PPE) for staff when caring for these residents, despite documented orders and policies requiring such measures. One resident with a urinary catheter and a confirmed case of Vancomycin Resistant Enterococcus (VRE) did not have isolation signage or PPE available at the entrance to his room. Staff members were observed providing care without wearing gowns, contrary to the facility's Contact Precautions policy. The resident's room lacked the necessary postings and PPE from the time the VRE was identified until the surveyor's visit, despite the resident being on contact isolation precautions. Another resident with an indwelling urinary catheter also did not have Enhanced Barrier Precautions signage or PPE available. Staff confirmed that no residents were on Enhanced Barrier Precautions, despite the resident's care plan and physician's orders indicating the need for such precautions. Similar deficiencies were noted with other residents requiring catheter care, where staff were observed providing care without the required PPE and without appropriate signage indicating isolation precautions.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required minimum of twelve hours of nurse aide training over a twelve-month period, which has the potential to affect all 43 residents in the facility. The Certified Nursing Assistant (CNA) training folder, provided by the Assistant Director of Nursing (ADON), did not contain the required training documentation for the past year for CNAs currently working in the facility. During an interview, the ADON stated that they could not find any CNA training records for the last year, except for those from January 2024 forward, which did not meet the twelve-hour requirement. Additionally, there was no proof that all CNAs received training in dementia care and abuse prevention.
Failure to Perform PASARR Level I Re-Screening
Penalty
Summary
The facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) level I re-screening for one of two residents reviewed for PASARR screening. The resident, identified as R4, was admitted with diagnoses including Bipolar Disorder, Depression, and Post-Traumatic Stress Disorder. The initial OBRA-I screen was conducted on 01/20/20 and was valid for 90 days. However, the current medical record for R4 did not include any subsequent PASARR screenings. The Administrator in Training confirmed that no additional screenings beyond the initial OBRA-I screen were available for R4.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for three residents, leading to deficiencies in their care. Resident R4 had a urine specimen that tested positive for Vancomycin Resistant Enterococcus (VRE) and was on contact isolation precautions. However, R4's care plan did not reflect this status. This was confirmed by the Licensed Practical Nurse/Care Plan Coordinator. Resident R32 had significant edema in the bilateral lower legs and was prescribed Lasix for the condition, but the care plan did not address the edema. This omission was also verified by the Care Plan Coordinator. Resident R35 had a previously documented stage 2 pressure ulcer on the right gluteal fold, which had resolved by the time of the survey. However, the care plan had not been updated to reflect the resolution of the skin issue, as confirmed by the Director of Nurses. The facility's policy on Comprehensive Care Planning mandates that care plans be reviewed and revised as necessary to reflect the resident's current medical, nursing, and psychological needs. The failure to update the care plans for these residents indicates non-compliance with this policy. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in the facility's adherence to its own care planning procedures. These lapses could potentially impact the quality of care provided to the residents, as their care plans did not accurately reflect their current medical conditions and required interventions.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to reduce the risk of falls for three residents. Resident R32, who has diagnoses including Alzheimer's Disease and is at high risk for falls, was found without a call light within reach, which was on the floor under the bed. This was confirmed by a Registered Nurse. Resident R41, diagnosed with Dementia and other conditions, was found in a wheelchair with a non-functioning chair alarm that was not connected to a power source, as verified by a Registered Nurse. Resident R23, who requires substantial assistance for mobility and has a high fall risk, experienced a fall while being assisted to bed. The fall occurred when the resident leaned forward and fell to her knees. The incident was witnessed by a CNA who was the only staff member present, contrary to the facility's policy requiring two staff members for lift assistance. The Assistant Director of Nursing confirmed the lack of a witness statement and the Director of Nursing acknowledged the policy breach. These deficiencies highlight the facility's failure to adhere to its fall prevention policies, including ensuring call lights are within reach, maintaining functional alarm systems, and providing adequate staff assistance during transfers. These lapses contributed to the increased risk of falls and potential harm to the residents involved.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was secured with a securement device for a resident diagnosed with Neuromuscular Dysfunction of the Bladder. During an observation, the resident's catheter was found unsecured while she was lying in bed. Certified Nursing Assistants confirmed the absence of a securement device and acknowledged that the catheter should have been secured. The Director of Nursing also confirmed that all indwelling urinary catheters should be secured with a securement device, as per the facility's policy.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop a dementia care plan for a resident diagnosed with Alzheimer's Dementia. The resident's electronic diagnoses dated 3/6/24 documented the diagnosis, but the current care plan dated 2/28/24 did not include a comprehensive care plan addressing this condition. This deficiency was confirmed by the Care Plan Coordinator on 4/17/24.
Failure to Document Physician Evaluation for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the physician evaluated and documented the rationale for the continued use of a PRN psychotropic medication for one resident. The facility's policy requires that residents must not have PRN orders for psychotropic medications unless necessary to treat a diagnosed specific condition, and PRN orders for antipsychotic medications are limited to 14 days unless re-evaluated by the physician. Resident R24 had a physician order for Haldol IM every 12 hours as needed for Anxiety Disorder, dated 3/8/24, with a second clarification order dated 3/15/24. However, the resident's chart lacked any physician visit notes after 11/16/2023, indicating that the required evaluation and documentation for the continued use of the antipsychotic medication were missing. This was verified by the Care Plan Coordinator on 4/17/24, who confirmed that R24 had not been seen by her physician since November 2023.
Failure to Implement Physician Orders for Laboratory Tests
Penalty
Summary
The facility failed to ensure physician orders were implemented for laboratory tests for a resident reviewed for Insulin. The resident had a physician's order for Insulin Glargine to be injected subcutaneously twice a day for Type 2 Diabetes Mellitus without complications. Additionally, there was an order for Hemoglobin A1C to be conducted every three months. However, the resident's medical record did not document any Hemoglobin A1C results since their admission to the facility on 7/12/23. The Director of Nursing confirmed that a Hemoglobin A1C test had not been completed for the resident since admission, acknowledging that it was missed and should have been monitored.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to residents whose personal funds were managed by the facility. According to the facility's Resident Right Manual, residents are entitled to receive a current, itemized written statement of their financial records at least once every three months. However, during a group meeting, several residents reported that they had not received any account balance statements for several months. One resident mentioned that it took two weeks to get information about their balance, which required the facility staff to contact the corporate office. This indicates a significant delay and lack of transparency in managing residents' funds. The Administrator in Training (V1) confirmed that the facility had not been providing the required quarterly financial statements. V1 admitted to not being aware of the necessity to keep these statements current manually. The facility manages funds for all 43 residents, and none of them had received a financial statement since the previous year. This lapse in providing financial statements affects all residents currently residing in the facility, as verified by the Center for Medicare and Medicaid Services Form 671.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the results of surveys, certifications, and complaint investigations conducted during the past three years were available for review. During a group meeting with residents who have previously attended Resident Council meetings, several residents did not know where to access the facility's previous annual and complaint survey results and were unaware that all State Agency survey results were accessible. A binder titled 'Certification Survey Results for Public Inspection' was found near the entrance to the building, but it only contained the most recent survey results from a complaint investigation conducted on 01/18/2023. The Administrator in Training confirmed that the binder had not been kept current and that the facility's 2023 annual survey and additional complaint investigations conducted after 01/18/2023 were not included.
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 71 citations issued within 25 miles in the last 12 months — including the 7 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) |
|---|---|---|---|---|
| Henderson County Ret Center | 14.5 mi | ★★★★★ | 0 | 0 |
| Wesley Village | 15.2 mi | ★★★★★ | 4 | 0 |
| Macomb Post Acute Care Center | 15.2 mi | ★★★★★ | 1 | 0 |
| Countryside Care Center | 15.2 mi | ★★★★★ | 21 | 0 |
| Elms, The | 15.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Goldwater Care Roseville.
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.