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 The Orchards At Roseville during CMS and state inspections, most recent first.
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.
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.
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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.
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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 | ★★★★★ | 1 | 0 |
| Regency At St. Clair Shores | 2.1 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Grosse Pointe | 2.5 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.