Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lifecare Roseau Manor during CMS and state inspections, most recent first.
Surveyors found that staff failed to use care-planned sling and harness sizes when performing mechanical lift and stand transfers for three dependent residents with conditions such as multiple sclerosis, dementia, arthritis, weakness, and severe cognitive impairment. Assessments and care guides specified small or medium slings/harnesses based on each resident’s status and weight, but staff instead used larger devices that were already in the room or on the unit, without checking the care guides beforehand. Nursing assistants acknowledged using the available large or medium slings and later confirmed, upon review, that the care-planned sizes were smaller than those actually used, despite facility expectations and policy that mechanical lifts be used according to instructions and training.
A resident with severe cognitive impairment and dementia had a grievance after family found a pill in her chair and another on the floor, despite her meds being crushed. Family also reported the resident’s Wanderguard was found on the bed footboard. Nursing could not identify the pill, no formal grievance was completed, and the concern was not fully investigated or documented.
Failure to Complete Comprehensive Assessment After Resident-to-Resident Aggression: A resident with severe cognitive impairment, dementia, anxiety, depression, wandering, and aggressive behaviors was involved in multiple resident-to-resident incidents, including hitting, swinging, grabbing, and verbal aggression. Incident documentation and nursing notes identified that behaviors often occurred when the resident was told no or during ADL care, but the record did not show a comprehensive assessment after each incident to identify triggers or new interventions. Staff and family described the resident as combative, unpredictable, and often difficult to manage, with limited use of nonpharmacological approaches documented.
The facility failed to double-lock an unopened bottle of liquid morphine, a schedule 2 narcotic, in the Maple Unit medication room. During the same observation, the medication refrigerator had no thermometer and there was no evidence its temperature was being monitored, even though it contained injectable lorazepam for a resident. The DON and consulting pharmacist both stated controlled medications require double locking and refrigerator temperatures need monitoring for medication stability.
A resident with an indwelling urinary catheter did not receive proper catheter care when a nursing assistant failed to use hand hygiene after glove removal, placed a urine collection graduate directly on the floor without a barrier, and used double gloves instead of following facility protocols. Staff interviews confirmed these actions were not in line with established infection control and Enhanced Barrier Precautions policies.
Staff did not consistently follow enhanced barrier precautions or perform proper hand hygiene during high-contact care activities for two residents, including one with a history of VRE infection and another dependent on staff for all ADLs. Despite clear care plans and signage, staff failed to wear required PPE and did not sanitize hands after glove removal, contrary to facility policy and CDC guidelines.
A resident with Alzheimer's and dementia exited a facility without staff knowledge, resulting in injuries after being found outside. Despite being identified as an elopement risk, the resident was able to open doors and leave, as a housekeeper turned off the alarm without checking for residents. Previous elopement attempts had been documented, highlighting a need for better supervision.
Improper Sling and Harness Sizes Used for Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate sling and harness sizes were used with mechanical lift and stand devices for multiple dependent residents, contrary to their assessments and care guides. One resident with multiple sclerosis, dementia, weakness, and dysphagia was assessed as unable to safely bear weight and required a full body lift with a medium (yellow) sling; however, surveyors observed a large (green) sling under her in the dining room and in her room, and a nursing assistant confirmed the large sling had been used for transfers despite the care guide specifying a medium sling. Another resident with arthritis, reduced mobility, weakness, and severe cognitive impairment was assessed to transfer with a mechanical lift using a small (red) sling, but was observed seated on a large (green) sling in the dining room and had a large sling on her wheelchair in her room. Two nursing assistants confirmed they had transferred this resident using the large sling, acknowledged the care guide called for a small sling, and stated they typically used whatever sling was already in the room without reviewing the care guide prior to transfers. A third resident with dementia, weakness, unsteadiness on feet, and severe cognitive impairment was assessed as non-ambulatory and required transfers with a mechanical stand and a small (red) harness, but was observed being transferred from the toilet to bed using a medium (yellow) harness. The nursing assistant involved initially stated the resident should have a medium harness, then, upon reviewing the care guide, verified that a small harness was care planned and explained she used what was already in the room. Another nursing assistant stated that sling size was based on height and weight and that staff used the sling available on the unit. The assistant administrator stated that staff were expected to ensure the sling was placed properly, the lift was in good condition, and the sling/harness size was appropriate for the resident prior to transfers, and facility policy required employees to use mechanical lift devices in accordance with instructions and training.
Failure to Complete Grievance Investigation for Unknown Medication Found in Resident’s Chair
Penalty
Summary
The facility failed to follow through on a grievance involving an unknown medication found in a resident’s recliner. The resident had severe cognitive impairment and diagnoses of dementia, anxiety, and depression, and her care plan stated that medications were to be crushed in vanilla pudding. Family members reported finding a whole or partially broken pill in the resident’s chair and another pill on the floor, despite the resident’s medications being crushed before administration. They also reported the resident’s Wanderguard was found wrapped around the footboard of the bed. Family members notified nursing and later sent an email with photos of the pill and the Wanderguard. One family member stated the facility told them it could not determine what the medication was or where it came from, and that the concern was not really addressed. The care coordinator acknowledged awareness of the concern but stated no formal grievance was documented and no formal grievance was completed. She reviewed the resident’s medication cassettes from the medication cart and did not find a match, but did not review other residents’ medication cassettes and did not call the family member to obtain clarifying information. Facility staff described a grievance process in which complaints were to be forwarded to administration, investigated, tracked, and responded to in writing. However, the care coordinator stated there was no way to run a report to track concerns for patterns, and the social worker and DON stated that if they were able to solve a problem, the formal grievance process was not followed. The administrator stated complaints were expected to be reported and that investigation and resolution should be documented.
Failure to Complete Comprehensive Assessment After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to complete a comprehensive assessment after resident-to-resident incidents involving a resident with severe cognitive impairment and diagnoses of dementia, anxiety, and depression. The resident’s quarterly MDS documented physical aggression toward others, verbal behavioral symptoms directed toward others, rejection of care, wandering, and dependence on staff for most ADLs. Care area assessments identified baseline inattention, disorganized thinking, altered level of consciousness, communication difficulty, and behavioral symptoms, with staff directed to use calm, simple communication, reassurance, and other nonpharmacological approaches. The resident was involved in multiple incidents with other residents. In one incident, the resident entered another resident’s room, used profanity, swung at the resident’s face, and struck the resident before staff separated them. In another incident, the resident hit another resident’s shoulder several times while staff tried to get the resident to release the other resident’s walker. In a later incident, the resident became aggressive while trying to squeeze past another resident’s wheelchair, swinging at staff, pulling hair, pinching skin, and hitting another resident on the neck. The incident documentation described immediate redirection or separation, but did not identify potential triggers or interventions to prevent further incidents. Nursing notes documented behavioral health video appointments for psychotropic medication management related to dementia with aggressive behaviors and anxiety, and staff noted increased verbal and physical aggression toward staff and other residents. The notes stated the incidents appeared to be triggered by the resident not getting her way or during ADL care, but no nonpharmacological interventions were discussed. Family members reported the resident was often left in bed all day, had not received cares or meals at times, and staff had discussed providing more training on dementia care. Staff interviews described the resident as combative, unpredictable, and difficult to manage, and the DON stated behaviors often occurred when the resident was told no or during cares. The medical record lacked evidence that a comprehensive assessment was completed after each resident-to-resident incident to identify new interventions to keep the resident and others safe.
Improper Storage of Controlled Medication and Unmonitored Medication Refrigerator
Penalty
Summary
The facility failed to ensure a schedule 2 narcotic was stored in a manner to prevent diversion on Maple Unit. During observation, the DON entered the locked medication room and found keys in a lock on one of the cupboards. The cupboard door was able to be opened because it was not locked, and inside was an unopened 30-ml bottle of liquid morphine, a schedule 2 narcotic. The DON stated the liquid morphine needed to be double locked and it was not. The facility’s Labeling and Storing of Medication policy dated May 2009 identified schedule 2 medications were to be locked with double locks. The facility also failed to monitor the temperature of a medication refrigerator on Maple Unit. The refrigerator did not have a thermometer inside and there was no evidence the temperatures were monitored. The refrigerator contained two vials of injectable lorazepam 2 mg/ml for R22, and the freezer had some frost buildup. The DON stated the refrigerator temperature should be monitored daily and there should be a thermometer in the refrigerator to ensure the efficacy of residents’ medications was maintained. The consulting pharmacist stated schedule 2 narcotics are to be double locked for safety and the refrigerator needed temperature monitoring to ensure medication stability.
Failure to Follow Catheter Care and Infection Control Protocols
Penalty
Summary
A deficiency was identified when a nursing assistant failed to provide proper urinary catheter care for a resident with severe cognitive impairment and an indwelling urinary catheter due to obstructive uropathy and an enlarged prostate. The resident's care plan required staff to use Enhanced Barrier Precautions, including wearing gloves and gowns during high-contact care activities, and to position the catheter bag appropriately, monitor for signs of infection, and use proper hand hygiene. During an observed care episode, the nursing assistant donned double gloves without using hand sanitizer, placed the resident's urine collection graduate directly on the floor without a barrier, and failed to perform hand hygiene after removing the top layer of gloves. The assistant stated that double gloving was a personal practice and acknowledged that it was not in line with facility expectations. The assistant also admitted to not using a disposable washcloth under the graduate, which was contrary to facility instructions to prevent the spread of infection. Interviews with nursing and administrative staff confirmed that facility policy required hand hygiene after glove removal and the use of a barrier between the floor and the graduate when draining catheter bags. The facility's policies on hand hygiene, indwelling urinary catheter care, and Enhanced Barrier Precautions all emphasized these practices to prevent contamination and infection. The observed failure to follow these protocols constituted a deficiency in providing appropriate catheter care and infection control.
Failure to Consistently Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) and appropriate hand hygiene practices as required by CDC guidelines and facility policy. In one instance, a cognitively intact resident with a history of vancomycin-resistant enterococci (VRE) infection in urine was care planned for EBP, which required staff to wear gloves and gowns during high-contact care activities such as transferring and toileting. Despite clear signage and care plan instructions, staff assisted the resident with transferring from bed to wheelchair and toileting without donning the required gowns. Staff interviews revealed a lack of awareness and adherence to EBP protocols, with one nursing assistant admitting to forgetting to wear PPE and another unsure of the reason for the precautions. Additionally, the facility failed to ensure proper hand hygiene during personal care for another resident with severe cognitive impairment and total dependence on staff for activities of daily living. During morning care, a nursing assistant removed soiled gloves after cleaning the resident but did not perform hand hygiene before donning new gloves or after completing care. This lapse was observed despite the facility's policy and staff interviews confirming the expectation to use hand sanitizer or wash hands after glove removal, especially after contact with body fluids or excretions. The observations and staff interviews demonstrated that the facility did not consistently follow its own policies or CDC recommendations regarding the use of PPE and hand hygiene during high-risk resident care activities. These failures were directly observed during care provision and confirmed by staff statements, indicating a breakdown in infection prevention and control practices for residents at risk of infection or colonization with multidrug-resistant organisms.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to adequately supervise and respond to an alarm sounding exit door, resulting in a resident with Alzheimer's and dementia exiting the facility without staff knowledge. The resident, who was identified as having severe cognitive impairment and was at risk for elopement, was found outside the facility on the ground next to his wheelchair with abrasions and bent glasses. The incident occurred when the resident was able to open a set of double doors and exit through the front entry, despite the alarm sounding. The resident's care plan had identified him as an elopement risk and included interventions such as allowing him to vent frustration and distracting him with activities. However, on the day of the incident, a housekeeper turned off the alarm without checking if a resident had exited the building. This oversight allowed the resident to leave the facility unnoticed, leading to his fall and injuries outside. Previous incidents of elopement involving the same resident had been documented, indicating a pattern of behavior and a need for increased supervision. Despite these prior events, the facility's response to the alarm was inadequate, as staff failed to verify the resident's whereabouts before silencing the alarm. This lack of proper supervision and response to the alarm contributed to the resident's elopement and subsequent injuries.
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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 Roseau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warroad Care Center | 19.7 mi | ★★★★★ | 13 | 0 |
| Lifecare Greenbush Manor | 22.3 mi | ★★★★★ | 2 | 0 |
| Karlstad Healthcare Center Inc | 39.3 mi | ★★★★★ | 7 | 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.