Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Roseville during CMS and state inspections, most recent first.
Dumpster Area Not Kept Clean: Surveyors observed a buildup of trash and debris behind the facility's two exterior dumpsters, including gloves, cups, paper, cardboard, bottles, plastic bags, leaves, and sticks. The Maintenance Supervisor stated that Maintenance was responsible for keeping the area clean, and the facility's exterior maintenance policy required the grounds to be cleaned of trash, rubbish, debris, and problem areas.
Water-Damaged Ceiling Tile and Active Leak in Hallway: A ceiling tile in the hallway outside the basement boiler room was observed with water damage across the entire 2'x4' tile, bulging downward, and stained with a large ring of black, mold-like substance. The Mnt Supervisor confirmed a leak above the ceiling tile, noted an outside repair company had been unable to fix it, and no further plan was provided. When the tile was removed, it crumbled apart and a leak was seen coming from piping above the ceiling with water dripping onto the floor.
Non-Functional Mechanical Ventilation: The facility failed to maintain mechanical ventilation in good working order. A shower room on the 1st floor South had humid, heavy air and no suction at the ceiling vent, and the Maintenance Supervisor I stated the vent was not drawing air and may have needed belt checks. Soiled utility room vents on the North and South Halls and bathroom ceiling vents for listed rooms were also found non-functional, with broken belts cited as the cause.
Unsafe and Unclean Resident Areas: The facility failed to maintain a clean, homelike environment in shower rooms, resident rooms, and a shared bathroom area. Surveyors observed black mildew in shower rooms, a torn chair cushion with exposed foam, dirt buildup, crumbling drywall, peeling paint, chipped surfaces, and a soiled toilet area in one resident’s room and bathroom. Another resident had a bedside commode blocking access to the toilet; it was later found full of urine, feces, and toilet paper, and staff were unsure why it remained in the bathroom.
A resident with repeated falls and muscle weakness had an active order for a right wrist brace, but staff did not observe the brace in use during multiple observations. The resident said they had not worn it in a while and needed help applying it, while the DON said therapy usually provides the restorative plan and device. An OT later applied the brace and confirmed the resident needed assistance, and the resident said the brace provided significant support.
Failure to provide timely pain management: A resident admitted after hip fracture repair reported excruciating pain for about 48 hours after arrival, with staff saying oxycodone was back ordered and no alternative offered. The MAR showed blank entries for oxycodone on two days, no pain assessments or explanation for missed doses, and only one documented dose given the night before discharge.
The facility failed to develop PTSD care plans for two residents reviewed for mood/behavior. One resident had PTSD and schizoaffective disorder with intact cognition, and the care plan lacked goals and interventions for PTSD. Another resident had chronic PTSD, intact cognition, needed ADL assistance, and had psychiatry notes documenting intermittent depression and visual hallucinations, but the care plan still did not address PTSD.
Failure to revise fall care plan after a bed fall: A resident with COPD, CKD, and dementia, with a BIMS score of 3, was found on the floor beside the bed after rolling out of bed. The IDT identified use of a fall mat while the resident was in bed, but the care plan was not updated to include that intervention. Staff later observed the resident in bed without the mat in place, and an LPN was unsure whether it had been implemented; the DON confirmed the care plan should have been revised.
An LPN administered Oxycodone, Pregabalin, and Lorazepam to a resident from a medication cart but did not sign the doses out of the controlled substance logbook until later, leaving the logbook inaccurate when compared with the on-hand blister pack counts. The MAR showed the meds were given in the morning, while the logbook still did not reflect the doses later that afternoon; the DON confirmed controlled substances must be signed out at the time they are administered, and the facility policy required immediate documentation by the administering nurse.
Unattended Medication Left at Resident Bedside: A resident with intact cognition and diagnoses including CKD and Adult Failure to Thrive had a plastic medication cup with four pills left unattended on the bedside table while no staff or other residents were present. The cup remained there later that morning and was still untouched when the resident returned to the room. The DON stated medication should not be left with the resident if not taken, and the LPN said they were unaware the resident had not taken the medication.
Failure to notify guardian of hospital transfer. A resident with COPD, hypertensive heart disease, and chronic respiratory failure was sent by 911 from an outside vascular appt to the hospital after complaining of chest pain. The clinical record had no documented communication about the transfer, and the NHA confirmed the guardian was not notified of the resident's change in condition.
Unnecessary Medication Administration: A resident with fibromyalgia and schizoaffective disorder continued to receive Tramadol after an order directed it be discontinued once Norco arrived. The MAR showed the resident received both pain meds on the same days, and the Tramadol order was not discontinued until later. The NHA stated physician orders should be followed as written, and the facility policy required meds to be administered per the attending physician’s written orders.
A resident with pressure ulcers and malnutrition did not receive wound care as ordered, with several days lacking documentation of treatment. The issue was identified when a wound care provider found a bandage unchanged for six days, and the DON confirmed missed treatments were discovered after a wound care appointment.
Three residents with severe cognitive impairment and enrolled in hospice care did not have collaborative care plans specifying hospice and facility responsibilities, and staff were unaware of hospice schedules or duties. Documentation of coordination was lacking, and a required hospice agreement was unsigned after a company name change, contrary to facility policy.
A facility failed to maintain a safe, clean, and homelike environment for a resident. The resident's room had a bathroom sink with a broken caulk line, unrepaired holes in the wall from a removed toilet paper holder, and an exposed heating coil due to missing cover plates. The facility Administrator acknowledged these issues, and a policy on maintaining a homelike environment was not provided during the survey.
A facility failed to conduct an initial skin assessment and place wound care orders for a resident admitted with a stage 4 pressure ulcer. The resident, with diagnoses including Metabolic Encephalopathy and Sepsis, did not receive documented wound care until three days post-admission, contrary to facility policy requiring immediate assessment and treatment orders.
A resident with moderate cognitive impairment and a high risk to wander eloped from the facility through a fire door. Despite previous elopement risk assessments, no additional interventions were implemented after the resident initially attempted to open the door. The resident was found outside after setting off alarms, and a Code for missing residents was initiated. The Nursing Home Administrator emphasized the expectation for resident safety and adherence to facility policies.
A resident reported being assaulted by a CNA during a dialysis appointment, but the facility failed to report the allegation to the State Agency as required. Despite the resident's cognitive intactness and police involvement, the Nursing Home Administrator deemed the incident unsubstantiated and did not report it, violating the facility's policy on reporting abuse allegations.
A resident with a stage II pressure ulcer did not receive consistent wound care or repositioning as ordered. The resident was observed lying in bed without repositioning, and the Treatment Administration Record showed missing treatments. The facility's guidelines for skin management were not followed, resulting in a deficiency.
The facility failed to maintain a clean and homelike environment, with surveyors observing mold, debris, and insects in resident rooms and shower areas. Residents reported dissatisfaction with cleanliness, and records showed ongoing concerns about housekeeping and maintenance. Staff interviews revealed unclear responsibilities for maintaining cleanliness, contributing to the deficiency.
The facility failed to provide adequate incontinence care and assistance with ADLs for several residents, leading to prolonged periods in soiled briefs and unmet hydration needs. Staffing shortages were a significant factor, with CNAs unable to meet care demands due to insufficient numbers and recent staff attrition. Management acknowledged these challenges, but the issues persisted, as highlighted in resident council meetings.
Dumpster Area Not Kept Clean
Penalty
Summary
The facility failed to maintain the exterior dumpster area in a clean manner. On 06/02/2026 at 11:30 AM, surveyors observed the facility's two exterior trash dumpsters and noted a buildup on the ground behind them consisting of disposable gloves, straws, cups, paper, pieces of cardboard, water bottles, plastic bags, leaves, and sticks. On 06/03/2026 at 9:50 AM, the Maintenance Supervisor stated that Maintenance was responsible for keeping the area clean but provided no further explanation. Review of the facility's undated Physical Plant Exterior Maintenance policy on 06/03/2026 at 2:40 PM stated that the building's exterior and grounds are to be cleaned of all trash, rubbish, debris, unused equipment/furniture, in addition to periodic cleaning of problem areas.
Water-Damaged Ceiling Tile and Active Leak in Hallway
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises when a ceiling tile in the hallway outside the basement boiler room was observed with water damage across the entire 2'x4' tile. The tile was bulging downward and had a large ring of black, mold-like staining. Maintenance Supervisor I confirmed the water-damaged ceiling tile and stated there was a leak somewhere above it, and that an outside repair company had looked at the leak but was unable to repair it. No further information was provided about a plan going forward for repairing the leak. When the stained ceiling tile was removed, it crumbled into several pieces, and a leak was observed coming from piping high up into the ceiling with a slow drip of water continuing onto the floor.
Non-Functional Mechanical Ventilation
Penalty
Summary
The facility failed to maintain the building mechanical ventilation in good working order, resulting in stagnant air and odors. On 06/02/2026 at 10:35 AM, the shower room next to the therapy room on the 1st floor South was observed with the Maintenance Supervisor I, and the ambient air felt humid and heavy. A piece of toilet tissue placed against the ceiling vent did not remain held by suction, and the Maintenance Supervisor I stated, "It's not drawing air. I'll have to check the belts." Later that morning, the North and South Hall soiled utility room ceiling vents were checked and found to be non-functional, and the bathroom ceiling vents for the listed rooms were also observed to be non-functional. On 06/03/2026 at 9:50 AM, the Maintenance Supervisor I stated the vents were not working due to broken belts, but provided no further explanation. A policy regarding mechanical ventilation was requested on 06/03/2026 at 2:14 PM but was not provided by the end of the survey.
Unsafe and Unclean Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for five residents in the 1st floor dining and shower rooms and the 2nd floor shower room. On 06/02/2026, the 1st floor South shower room was observed with black mildew in the corners of the shower area, and the 1st floor North shower room was observed with black mildew along the bottom wall tiles and in the grout between the tiles. On the same date, a chair used by R93 in the hallway outside the room was observed with two large tears in the vinyl seat cushion, with foam padding exposed and the surface no longer smooth and easily cleanable. R59, who had diagnoses including Alzheimer's disease and dementia and had severely impaired cognition with staff assistance required for all ADLs, was associated with the observed floor tile concerns. The Director of Housekeeping was shown the tiles and stated they would inform the Maintenance Director. R129, who was admitted with lymphedema, schizoaffective disorder, and tachycardia and had a BIMS score of 15, was observed with a built-up layer of dirt in the room corners and along the baseboards, crumbling drywall behind the baseboard, a partially detached outlet cover, peeling paint around the bathroom baseboards, and a dark brown ring around the toilet basin. Additional observations of R129's room showed dark discoloration and chipped paint on the bathroom door and doorframe, a dark line on the wall, curling and peeling wallpaper, scratches on the radiator, chipped paint on the windowsill, and dirt buildup near the bed. R129 stated the bathroom was filthy because the toilet and sink had not been cleaned for a week and voiced concern about the crumbling drywall and soiled floor areas. R130, who had repeated falls and muscle weakness and a BIMS score of 13/15, was observed with a bedside commode blocking access to the toilet; R130 stated they did not use the commode and did not know why it was in the bathroom. The commode was later found full of urine, feces, and toilet paper, and staff stated they were unsure who used it or why it remained there until the DON removed it.
Failure to Apply Ordered Right Wrist Brace
Penalty
Summary
The facility failed to provide a right wrist brace for a resident with repeated falls and muscle weakness, despite a physician order for the brace dated 5/27/2026. The resident’s MDS assessment showed a BIMS score of 13/15, indicating intact cognition, and the resident required staff assistance with bed mobility and transfers. Observation on 06/02/2026 and again on 06/03/2026 showed the resident without the right wrist brace in use while in the hallway and while up in a wheelchair eating breakfast. When interviewed, the resident stated they had not worn the brace in a while, had worn it after a fall at home, and were unable to apply it independently, needing assistance. The DON stated the therapy department usually provides a restorative plan and the device, and staff enter the order to be followed. On 06/04/2026, an OT was observed applying the right wrist brace and confirmed the resident needed assistance applying it. The resident stated the brace made a big difference for support and that without it the right wrist was "just floppy." The facility policy stated the therapist should establish a schedule for the splint and communicate it to the restorative nurse, and that the physician order should include where, when, and why the brace is to be worn.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide adequate and timely pain management for one resident admitted for rehabilitation after a displaced intertrochanteric fracture of the right femur with surgical repair. The resident’s cognition was intact on the admission MDS, and the physician ordered oxycodone 5 mg four times daily as needed for pain beginning on 05/05/26. The care plan addressed pain/discomfort and included administering analgesics per orders and responding as soon as possible to complaints or signs of pain. The resident reported being in excruciating pain for about 48 hours after admission and stated they had received pain medication in the hospital but then had nothing when they arrived at the facility. The resident said staff told them the oxycodone was back ordered and no alternative was offered. The MAR was blank for oxycodone on 05/05/26 and 05/06/26, with no pain assessments or explanation for the missed doses, and progress notes did not document pain concerns, difficulty obtaining the medication, or any alternative pain medication being offered. The only documented oxycodone administration was on 05/07/26 at 7:05 PM for pain rated 6/10, the night before discharge.
Failure to Develop PTSD Care Plans
Penalty
Summary
The facility failed to develop PTSD care plans for two residents reviewed for mood and behavior. One resident was admitted with diagnoses of PTSD and schizoaffective disorder, bipolar type; the MDS showed a BIMS score of 14/15 indicating intact cognition and also coded PTSD as an active diagnosis, but the care plans did not include goals or interventions addressing PTSD. A Social Worker stated they were responsible for creating the PTSD care plans and had missed developing the care plans for this resident and another resident. The second resident was admitted and readmitted with chronic PTSD; the MDS showed intact cognition and assistance needed with activities of daily living, and a psychiatry follow-up note documented intermittent depression, denial of anxiety and suicidal ideation, and continued intermittent visual hallucinations that the resident recognized were not real and that sometimes caused distress, yet the care plan did not include interventions to address the PTSD diagnosis.
Failure to Revise Fall Care Plan After Bed Fall
Penalty
Summary
The facility failed to review and revise the fall care plan for one resident after a fall. The resident was admitted on 11/23/2020 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and unspecified dementia, and the most recent MDS showed a BIMS score of 3, indicating impaired cognition. A nursing progress note dated 5/24/2026 documented that the resident was found lying on the floor to the right side of the bed, and the physician recommended placement of a floor mat. An IDT meeting on 5/26/2026 reviewed the fall and determined through root cause analysis that the resident had rolled out of bed. The progress note from that meeting identified use of a fall mat while the resident was occupying the bed as an intervention, but the resident’s care plan for falls was not revised to include that intervention. On 6/03/2026, the resident was observed resting in bed without a fall mat in place, and later that day an LPN stated they were not sure whether fall mats had been put into place after the resident’s most recent fall and noted the hospice team had not yet provided the equipment. On 6/04/2026, the resident was observed resting in bed with a folded-up fall mat sitting in the corner of the room away from the bed. The DON confirmed the resident needed a fall mat because of the recent fall out of bed and stated the care plan should have been updated to include it.
Controlled Substance Logbook Not Updated at Time of Administration
Penalty
Summary
The facility failed to maintain an accurate record of receipt and disposition of controlled drugs for one of three medication carts reviewed. On 06/03/2026 at 3:53 PM, a reconciliation of the controlled substance logbook with the on-hand tablet count in three blister packs on the second floor back cart showed one fewer tablet in each pack of Oxycodone 15 mg, Pregabalin 50 mg, and Lorazepam 0.5 mg than the amount that should have been present according to the logbook. During the observation, an LPN stated they had administered those medications earlier that day from the second floor back cart but had not signed them out of the logbook, and said their expectation was to sign controlled substances out by the end of the shift. Review of the MAR showed Oxycodone 15 mg and Pregabalin 50 mg were administered at 9:00 AM and Lorazepam 0.5 mg at 10:00 AM, but a review of the controlled substance logbook at 3:50 PM did not show those medications had been signed out. The DON confirmed it is not acceptable to wait until the end of the shift to sign controlled substances out, and the facility policy stated the licensed nurse administering a controlled medication must immediately enter the date and time of administration, amount administered, and signature on the accountability record after the medication is actually administered.
Unattended Medication Left at Resident Bedside
Penalty
Summary
The facility failed to secure medications left unattended at the bedside for one resident. During an initial screening on 06/02/2026, a plastic medication cup containing four pills was observed sitting unattended on R37’s bedside table with no residents or staff in the room. The same medication cup remained unattended on the bedside table later that morning, and it was still untouched when R37 returned to the room that afternoon. R37 was admitted with diagnoses including chronic kidney disease and Adult Failure to Thrive, and the MDS assessment indicated the resident’s cognition was intact. The DON stated that medication should not be left with the resident and, if refused or not taken, should not be left in the room but secured until administered or disposed of. The LPN identified as R37’s nurse that morning reported being unaware that R37 had not taken the medication. The facility policy stated that only licensed nurses, the Consultant Pharmacist, and other lawfully authorized persons are allowed unsupervised access to medications.
Failure to Notify Guardian of Hospital Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's change in condition when the resident was sent to the hospital from an outside vascular doctor appointment. The resident had diagnoses including Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, and Chronic Respiratory Failure, and had a legal guardian who made decisions for the resident. On 10/29/25, the resident went to a vascular doctor's appointment outside the facility, complained of chest pain at the appointment, and was sent by 911 to the hospital. The clinical record contained no documented communication about the resident being sent to the hospital, and on 11/20/25 at 3:15 PM the NHA confirmed the facility did not notify the guardian of the resident's change in condition and transfer to the hospital.
Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when R700 continued to receive Tramadol after a physician order dated 9/22/25 directed that Tramadol be discontinued once Norco arrived from the pharmacy. R700 was admitted with diagnoses including fibromyalgia and schizoaffective disorder, and had a Brief Interview for Mental Status score of 13/15 indicating intact cognition. Although Norco arrived on 9/22/25, the Tramadol order was not discontinued, and the September 2025 MAR showed Tramadol was administered on 9/24/25, 9/29/25, 10/1/25, 10/2/25, and 10/3/25. The MAR also showed Norco was administered on 9/23/25, 9/26/25, 10/1/25, 10/2/25, 10/4/25, and 10/5/25, meaning R700 received both medications on 10/1/25 and 10/2/25. The Tramadol order was not discontinued until 10/13/25. When queried, the NHA stated physician orders should be followed as written, and the facility medication policy stated medications are administered in accordance with written orders of the attending physician.
Failure to Provide and Document Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care as ordered for one resident who was being treated for pressure ulcers and malnutrition. Observations and record reviews revealed that the resident's wound dressings were not changed according to physician orders, with documentation missing for several days. Specifically, the treatment record lacked entries for wound care on four separate dates, and a wound care provider noted that a bandage had not been changed for six days, which was deemed inappropriate. The resident was observed with dressings dated the current day and did not voice complaints when asked about their wound care. Further review of the medical record confirmed the resident had diagnoses including moderate protein calorie malnutrition and unstageable pressure ulcers. The DON acknowledged that the missed treatments were only discovered after the resident's wound care appointment, and confirmed that nurses are expected to complete and document care as ordered. The deficiency was identified through a combination of observation, interview, and record review, and was cited as past noncompliance after the facility had already implemented corrective actions.
Failure to Coordinate and Document Hospice Services and Agreements
Penalty
Summary
The facility failed to ensure proper coordination and implementation of hospice services for three residents with severe cognitive impairment and dependence on staff for all activities of daily living. Each resident was enrolled in hospice care, but their care plans lacked specific interventions detailing the services to be provided by hospice or the facility staff. Documentation in both the electronic medical record and hospice binders did not show evidence of a collaborative plan of care for any of the residents reviewed. Interviews with nursing staff, including LPNs and CNAs, revealed a lack of awareness regarding the roles and responsibilities of hospice staff, the schedule of hospice visits, and the specific care or services hospice was expected to provide. Staff reported that they only became aware of hospice involvement when they observed hospice staff in the residents' rooms, and there was no written communication or documentation to inform them of hospice activities or responsibilities. Additionally, a review of the hospice agreement for one resident showed that the agreement was unsigned by both the hospice entity and the facility, with the administrator acknowledging that a new agreement had not been signed after the hospice company changed its name. Facility policy required a signed agreement before hospice care was furnished and mandated that each resident's plan of care include both the hospice plan and a description of services provided by the facility, which was not met in these cases.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, identified as R704, who was reviewed for environmental concerns. R704 had been admitted with diagnoses including Metabolic Encephalopathy, Sepsis, and Urinary Tract Infection, and was discharged to another facility. During an inspection of R704's former room, it was observed that the bathroom sink had a broken caulk line, giving the appearance of the sink detaching from the wall. Additionally, there were multiple holes in the wall with exposed drywall where a toilet paper holder had been removed and not repaired. The heat register in the bedroom area was missing cover plates, leaving the heating coil exposed and easily accessible. The facility Administrator acknowledged these issues during a tour of the room and stated that the expectation was for these repairs to have been completed. A facility policy addressing a homelike environment was requested but not provided by the time of survey exit.
Failure to Conduct Initial Skin Assessment and Wound Care
Penalty
Summary
The facility failed to complete an initial skin assessment and place initial wound care orders for a resident admitted with a stage 4 pressure ulcer on the buttock. The resident was admitted with diagnoses including Metabolic Encephalopathy, Sepsis, and a Urinary Tract Infection. Upon admission, the resident's condition was documented as alert and oriented x 2-3, with a stage 4 wound reported on the buttock. However, there was no initial skin assessment, treatment orders, or documentation of wound care provided from the date of admission until three days later. The facility's policy requires a licensed nurse to check for pressure ulcers and other skin conditions at admission or readmission. Despite this, the initial assessment and treatment orders were not completed until three days after admission, when wound care orders were finally documented. The facility's wound care nurse and NP confirmed the process for assessing and treating wounds was not followed, as the admitting nurse should have completed a full skin assessment and placed at least a dry dressing order until further assessment by the wound care nurse.
Failure to Implement Elopement Interventions
Penalty
Summary
The facility failed to implement interventions to reduce the risk of elopement for a resident, resulting in the resident eloping through a fire door and walking to the corner of the building. The incident occurred when the door alarms alerted staff that someone had opened the door and possibly left the building. The resident, who had been admitted with diagnoses including dementia and moderate cognitive impairment, was ambulatory without assistance. Despite previous elopement risk assessments indicating a high risk to wander, no additional interventions were put in place after the resident initially attempted to open the door. On the night of the incident, the Licensed Practical Nurse (LPN) on duty heard the door alarm go off and found the resident trying to open the door. The nursing assistant returned the resident to bed, but no further actions were taken to prevent another attempt. Later, while the LPN was in the bathroom, the alarms went off again, and the resident was found missing from their room. A Code for missing residents was initiated, and the resident was eventually found outside by another nurse. The Nursing Home Administrator stated that the expectation was for all residents to be safe and for facility policies to be followed to ensure their safety.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident to the State Agency as required. The incident involved a resident, identified as R902, who was allegedly assaulted by a Certified Nursing Assistant (CNA A) during a dialysis appointment. The resident, who was cognitively intact and required assistance for certain activities, reported the incident to the police. The police report documented the resident's claim of assault by the caretaker. Despite this, the facility did not report the incident to the State Agency, as the Nursing Home Administrator determined the incident to be unsubstantiated after an internal discussion. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported to the State Agency immediately, or within a specified timeframe depending on the severity of the incident. In this case, the facility did not adhere to its own policy, as the incident was not reported within the required timeframe. The failure to report was identified during a survey, where the Nursing Home Administrator acknowledged the decision not to report the incident based on their internal investigation's conclusion.
Failure to Provide Consistent Wound Care and Repositioning
Penalty
Summary
The facility failed to consistently complete and document ordered wound care treatment and timely implement treatment interventions for a resident with pressure ulcers. The resident, who was moderately cognitively impaired and required extensive assistance for bed mobility, was observed lying in bed without repositioning or the use of pillows or wedges. The resident reported not being repositioned, and the Treatment Administration Record showed missing treatments on several dates. The resident's medical record indicated a stage II pressure ulcer on the coccyx, which had resolved and then reopened. Despite new orders for wound care and repositioning, the resident's skin care plan was not updated with these interventions. The facility's Skin Management Guidelines required appropriate interventions and care plans for residents with skin impairments, but these were not followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a homelike and sanitary environment for residents, as evidenced by multiple observations of unclean and unsanitary conditions in resident rooms and shower areas. On several occasions, surveyors noted a strong odor of urine in the hallways, mold and mildew in shower areas, and debris and insects in resident rooms. Specifically, the north hall shower room had black mold-like substances on tiles and curtains, and the floor threshold of a resident's room was dirty with debris. Residents reported seeing insects and expressed dissatisfaction with the cleanliness of the shower rooms. The facility's records revealed that residents had intact cognition and required some supervision or were independent for Activities of Daily Living (ADLs). Despite this, the environment was not maintained to a standard that ensured their safety and comfort. The facility's deep cleaning schedule indicated that rooms were to be cleaned monthly, but observations showed that this was not effectively implemented. Resident council meeting minutes from April to June documented ongoing concerns about housekeeping and maintenance, highlighting persistent issues with cleanliness and repair. Interviews with staff revealed that the responsibility for maintaining cleanliness in shower rooms was not clearly defined, with CNAs expected to keep the areas tidy after initial cleaning by housekeeping staff. The Environmental Services Director acknowledged the presence of mold and insects and indicated that further cleaning was necessary. However, the facility's housekeeping care plan did not specifically address the cleaning of shower rooms, contributing to the deficiency in maintaining a safe and sanitary environment.
Inadequate Incontinence Care and Staffing Shortages
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) for nine residents, leading to deficiencies in incontinence care and hydration. Observations and interviews revealed that residents frequently waited extended periods to have their briefs changed, resulting in them sitting in soiled conditions. For instance, one resident reported waiting for hours to be changed, while another was found in a wet brief that had not been changed since early morning. The care plans for these residents indicated a need for frequent checks and assistance due to their conditions, such as impaired mobility and incontinence, yet these needs were not consistently met. Staffing shortages were a significant factor contributing to these deficiencies. Certified Nursing Assistants (CNAs) reported being overworked and unable to provide timely care due to insufficient staffing levels. On the day of the survey, there were only three CNAs available for the entire first floor, which was below the facility's scheduled staffing levels. This shortage was exacerbated by recent staff attrition and call-offs, leaving the remaining staff unable to meet the care needs of the residents effectively. The facility's management acknowledged the staffing challenges and the lack of a set schedule for rounding on residents to provide incontinence care. Despite efforts to cover shifts with restorative CNAs and managers, the facility struggled to maintain adequate staffing levels. Resident council meeting minutes from previous months also highlighted ongoing concerns with staffing, timely response to call lights, and the provision of basic care, such as water passing and incontinence care, indicating a persistent issue within the facility.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,000 citations issued within 25 miles in the last 12 months — including the 4 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
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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) |
|---|---|---|---|---|
| Shorepointe Nursing Center | 1.9 mi | ★★★★★ | 10 | 0 |
| Regency At St. Clair Shores | 2.1 mi | ★★★★★ | 2 | 0 |
| Optalis Health And Rehabilitation Of Grosse Pointe | 2.5 mi | ★★★★★ | 0 | 0 |
| The Orchards At Harper Woods | 3.4 mi | ★★★★★ | 11 | 0 |
| The Orchards At Warren | 4.1 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.