Below average — CMS composite of the measures below.
The next survey window likely opens around July 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 Estates At Roseville Llc during CMS and state inspections, most recent first.
A cook prepared carrots without wearing a beard restraint, despite acknowledging that one was required and that he had previously been counseled for not wearing it. The ADCS confirmed dietary staff are expected to wear hairnets or beard restraints during food prep, and the administrator stated employees are expected to keep their hair covered. A facility dietary policy also required hair restraints, including beard restraints, in kitchen and food prep areas.
Roach Infestation and Dining Room Sanitation Issues A resident reported seeing cockroaches in the dining room for about a year, and staff later observed roaches crawling in the dining room and near food stored in cabinets. Food debris, open cereal, and covered plates with meal remnants were found in the dining room, along with buildup, missing caulking, warped surfaces, and other areas where pests could be present. Staff also reported seeing roaches in the kitchen and dining room, while the facility had recently changed pest control vendors and had limited documented pest control follow-up.
A resident who was cognitively intact had unlabeled hydrocortisone cream and antifungal powder at the bedside and said staff had given them to him for PRN use. The record lacked provider orders and any self-administration assessment for the topical medications, and staff gave conflicting accounts about whether the resident was allowed to keep and use them. The care plan also did not address bedside storage or self-administration of these medications.
A resident with moderate cognitive impairment and diagnoses including Alzheimer's disease, dementia with agitation, type 2 DM with nerve damage, and HTN had a quarterly MDS completed 29 days late. The DON stated quarterly MDSs are tracked in PCC and are used to monitor resident status and quality outcomes, but acknowledged the assessment was missed when the facility's assessment calendar reset and it was not identified as due.
A resident with cognitive intactness, wheelchair use, and multiple diagnoses had groin redness and a provider order for nystatin powder, but staff also kept an unlabeled bottle of 2% miconazole nitrate at the bedside without a provider order. Staff and the resident described self-administration, yet the TMA documented the ordered nystatin as given even though she later said it remained in the cart and was not administered, and staff were unclear about which antifungal powder was being used.
Staff failed to follow contact precautions and PPE requirements for two residents on isolation precautions. An LPN and NAs entered rooms without hand hygiene or PPE, handled resident care items and equipment, and in one case a portable vital signs machine was not disinfected before being taken to another area. Both residents had active infections and posted contact precaution signs, and staff acknowledged they did not follow the required precautions.
Peeling Wallpaper Left Unrepaired in Resident Room: A resident with severe cognitive impairment and diagnoses including Alzheimer's dementia, CKD, HTN, and depression was observed in a room where wallpaper next to the bed was loose and peeling away from the wall. A NA said the damage had been present for months and the resident had been pulling at it, while an LPN said they were not aware of the issue. The maintenance director said the wallpaper needed repair, but no maintenance requests were found for the room.
Failure to Supervise an Elopement-Risk Resident: A resident with dementia, severe cognitive impairment, and a long history of wandering and exit-seeking was not adequately supervised on a secured memory care unit. Staff observed repeated attempts to get out, then left him alone in his room while attending to others. He later exited the building without staff awareness and was found by a Good Samaritan about 0.6 miles away on a residential street near a highway/collector road, with staff unsure how he got out and reporting that the door alarm did not sound.
A resident with intact cognition and a stroke diagnosis had opened Aspercreme with lidocaine and artificial tears at the bedside without a completed self-administration assessment, care plan indication, or provider orders. The resident said he used both items himself, while an LPN and the DON confirmed the resident should not have bedside medications without the required assessment and orders.
A resident with severely impaired cognition, metabolic encephalopathy, and PVD had a coccyx skin concern noted on admission, but the area was not consistently documented, monitored in the TAR, or reported to the provider for orders. Staff interviews and record review showed the coccyx redness/foam dressing lacked provider orders, and the receiving RN later found a 5 cm by 5 cm pressure injury on admission to AL.
The facility did not employ a full-time registered dietician or a qualified culinary director to oversee food and nutrition services, as required. Documentation and interviews revealed that the dietician split her time between multiple buildings and her hours at the facility were unclear, while the culinary director and assistant culinary director lacked necessary certifications and proof of qualifications. Personnel files and documentation of staff credentials were incomplete or missing.
The facility did not attempt alternative devices or adequately assess medical need and entrapment risks before installing bed rails for four residents with cognitive and mobility impairments. Documentation was incomplete, care plans lacked necessary interventions, and staff did not consistently inform residents or representatives about risks and benefits. Maintenance installed bed rails without full assessment of compatibility or entrapment zones, and facility policy did not address these requirements.
Surveyors observed multiple deficiencies in food storage and kitchen sanitation, including unlabeled and undated food items in the freezer, expired milk in the cooler, improper storage of cups in bread crumb bins, dented cans on shelves, and a persistent brown stain on the dry storage floor. Kitchen equipment, such as ovens, showed significant grease buildup and lacked regular cleaning, with no cleaning logs maintained. Staff confirmed inconsistent cleaning practices and failure to follow facility policy for food storage and sanitation.
Two residents with cognitive impairment were found with their wheelchair brakes locked, restricting their movement during activities. Neither had assessments or physician orders for this restraint, and staff were unsure if the use of locked brakes was care planned. Facility policy required assessment and documentation for restraints, which was not completed in these cases.
A resident with a suprapubic catheter and multiple medical conditions did not have documentation of monthly catheter changes as ordered by the physician. Nursing staff and the DON confirmed that the required catheter changes were not performed or recorded, and the facility's catheter care policy lacked guidance on change frequency.
A resident with severe cognitive impairment and chronic respiratory failure was not weaned from supplemental oxygen as ordered by the provider. Despite instructions to reduce oxygen as tolerated and maintain saturations above 90%, staff did not attempt or document weaning, and records lacked details on oxygen flow rates. Nursing staff and the DON confirmed the absence of weaning attempts and documentation, and the facility could not provide a policy for oxygen use.
A resident with a history of kidney stones and multiple sclerosis continued to receive Ciprofloxacin without an end date after returning from a urology visit. Despite pharmacy recommendations and staff awareness of the missing stop date, the PA and nursing staff did not obtain clarification from the urology clinic or document follow-up, resulting in prolonged, unjustified antibiotic use.
A resident with a history of multiple sclerosis, neuromuscular bladder dysfunction, and a kidney stone continued to receive Ciprofloxacin without an end date or documented justification, despite pharmacy recommendations and facility policy requiring clarification. Staff interviews confirmed awareness of the issue, but there was no evidence of adequate follow-up with the prescribing provider or documentation of the need for ongoing antibiotic therapy.
A resident with a history of stroke and recent dental extraction continued to receive a minced and moist (IDDSI Level 5) diet after the temporary order for this texture had ended, instead of returning to the prescribed soft, bite-sized (IDDSI Level 6) diet. The resident was not reassessed for mouth comfort or diet preferences, and staff interviews revealed a breakdown in communication and documentation, resulting in the resident receiving the incorrect diet despite an active order for the appropriate texture.
Two residents with cognitive and mobility impairments did not have their call lights within reach on multiple occasions, despite care plans and facility policy requiring accessibility. Staff and family observations confirmed repeated instances where call lights were on the floor, tangled, or out of reach, and staff interviews acknowledged the expectation for call lights to be accessible at all times.
Staff did not consistently follow required enhanced barrier and respiratory precautions for two residents—one with wounds requiring EBP and another with COVID-19 on enhanced respiratory precautions. During wound care, a nurse failed to don a gown as required, and multiple staff entered the COVID-19 positive resident's room without full PPE, such as N95 masks and eye protection, despite clear signage and facility policy. Staff interviews revealed confusion about PPE requirements for different precaution types.
Failure to Use Beard Restraint During Food Preparation
Penalty
Summary
The facility failed to ensure proper use of beard restraints during food preparation. During observation and interview, a cook prepared carrots without wearing a beard restraint, even though he acknowledged that a beard restraint was required, said management had previously instructed him to wear one, and admitted he had been counseled before for not wearing it. The assistant director of culinary services confirmed that dietary staff are expected to wear hairnets or beard restraints whenever preparing food and stated the cook should have been wearing a beard restraint while preparing the carrots. The administrator also stated that employees are expected to keep their hair covered while preparing food. A facility dietary policy dated 10/2017 directed staff to wear hair restraints, including beard restraints, in kitchen and food preparation areas in accordance with MDH guidelines.
Roach Infestation and Poor Dining Room Sanitation
Penalty
Summary
The facility failed to implement effective and timely pest control measures to reduce and/or eliminate a roach infestation in the dining room and kitchen areas. A cognitively intact resident with diagnoses including CHF, pulmonary edema, hyperlipidemia, and a thyroid disorder reported seeing cockroaches in the dining room for about a year and said she had previously caught some while staff were present. During observation, a roach was seen crawling across the dining room floor near the sink, and later another roach was observed crawling alongside a covered plate stored in a cabinet under the dining room sink. The dining room environment showed multiple conditions that were observed alongside the pest activity. Food debris was noted on the dining room floor after lunch, including noodles, lettuce, and carrot pieces. Under the sink cabinet, a clear plastic bin without a cover contained a covered plate with lunch remnants, and the plate cover had a hole with condensation inside. The floor near the refrigerator and lower cabinets had black buildup and crumb-like debris. Additional observations found a napkin, spoon, and Cheerio under the refrigerator, a red-colored buildup under the refrigerator, missing caulking around the sink, a section of backsplash pulled away from the wall, warped countertop material, black discoloration around the sink, and staining on the cabinet bottom. Open cereal boxes with unsealed inner bags and another covered plate with lunch remnants were also found stored in cabinets. Staff interviews confirmed ongoing pest sightings and inconsistent control measures. A dietary aide stated roaches were frequently seen in the kitchen and sometimes in the dining room, and that fruit fly traps were everywhere. Housekeeping staff said old food had been found under the refrigerator and that it had not looked cleaned in a while. The Director of Maintenance confirmed the worn countertop and missing caulking and stated the facility had recently switched pest control companies. The new pest control vendor reported it had only just begun service and had placed traps, while facility documentation showed earlier pest control reports noting straggler roaches and later no pest activity. Additional documentation on pest control measures and facility policies was requested but not provided.
Failure to Assess Self-Administration of Topical Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was assessed and determined to be appropriate for one resident who was cognitively intact and required varying levels of assistance with activities of daily living and mobility. The resident’s diagnoses included bilateral subdural hematomas related to a fall, congestive heart failure, hypertension, atrial fibrillation, and chronic kidney disease. The resident’s care plan did not identify interventions related to bedside storage or self-administration of topical medications, and the medical record lacked provider orders for 1% hydrocortisone cream and 2% miconazole nitrate powder, as well as any assessment showing that self-administration was appropriate. During observation, an open container of 1% hydrocortisone cream and a bottle of 2% miconazole nitrate antifungal powder were seen on the resident’s bedside table without pharmacy prescription labels. The resident stated that staff had given him the cream and crotch powder and that he was allowed to use them as needed. Staff interviews showed conflicting understanding about whether the medications should be in the room, whether orders existed, and whether a self-administration form had been completed. One LPN stated that the resident should not be self-administering anything because no completed self-administration form was found, while the DON stated that all residents were expected to be assessed before self-administering medications and that provider orders were expected for any self-administered medications.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed within the required timeframe for one resident. The resident had an initial admission date of 3/18/24 and an MDS that identified moderate cognitive impairment along with diagnoses including Alzheimer's disease, dementia with agitation, type 2 diabetes with nerve damage, and high blood pressure. Document review showed the resident's previous quarterly assessment was dated 3/24/26, making the next quarterly assessment due by 6/24/26; however, it was not completed until 7/23/26, 29 days late. During interview, the DON stated quarterly MDS assessments are completed every three months in accordance with the RAI schedule and are used to monitor resident status and quality outcomes, and acknowledged the assessment was missed because the facility's assessment calendar reset and the assessment was not identified as due.
Medication Given and Documented Without Proper Order
Penalty
Summary
The facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for one resident who was cognitively intact, used a wheelchair, and had diagnoses including bilateral subdural hematomas related to a fall, congestive heart failure, and chronic kidney disease. The resident was occasionally incontinent of urine and required moderate assistance with lower body dressing and toileting. A nursing progress note documented redness in the groin related to moisture, and the provider later ordered nystatin external powder to the groin three times daily for 14 days for candidiasis related to rash and other nonspecific skin eruption. Despite that order, the resident’s record did not contain a provider order for 2% miconazole nitrate powder. Surveyors observed a container of 2% miconazole nitrate antifungal powder on the resident’s bedside table on two occasions, and the container did not have a pharmacy prescription label. The resident stated staff had given him the powder and that he could use it as needed, while a nursing assistant stated staff were supposed to help apply it but the resident preferred to do it himself and refused staff assistance or removal of the medication from the room. During interviews, nursing staff stated orders should be in the system for all medications, including topicals and self-administered medications. A review of the MAR showed the nystatin powder was documented as administered, but the TMA later stated it had remained in the cart that morning and was not given, and that she charted it as administered after the resident said he would do it later and later told her he had done it himself. The TMA also produced a separate bottle of 2% miconazole nitrate from the medication cart and confused it with the nystatin order, while the DON stated no medications should be administered without a provider order and that medication administration should be documented accurately.
Failure to Follow Contact Precautions and PPE Requirements
Penalty
Summary
The facility failed to ensure staff followed contact precautions and proper PPE use for two residents who were on isolation precautions for infectious conditions. One resident had diagnoses including acute pancreatitis, acute pyelonephritis, and severe sepsis with septic shock, and was ordered on contact precautions for MRSA. The resident’s care plan also required contact isolation precautions, staff to follow isolation procedures, and a contact precaution sign on the door. During observations, an LPN entered the resident’s room without hand hygiene or PPE, removed the water pitcher, filled it at the ice and water machine, and returned it to the room without performing hand hygiene or donning PPE before re-entering. A NA also entered the room without hand hygiene or PPE to deliver the breakfast tray and left without performing hand hygiene. Later, another LPN entered with a portable vital signs machine without hand hygiene or PPE, obtained vital signs and administered medications, and then exited without hand hygiene or disinfecting the portable machine before taking it to another area. Staff interviews confirmed the contact precaution sign was posted, and the staff acknowledged they had not followed the required precautions. A second resident had diagnoses including intracranial abscess and granuloma and sepsis due to MSSA, and was also ordered on contact precautions. Observations showed a NA entered the room without hand hygiene or PPE to obtain vital signs and disinfected the machine only after leaving, and an LPN entered without hand hygiene or PPE to administer medications and exited without hand hygiene. Interviews with staff confirmed the resident’s door had a contact precaution sign, that PPE should have been worn before entering, and that staff were expected to follow the posted contact precaution instructions and the resident-specific care plan and provider orders.
Peeling Wallpaper Left Unrepaired in Resident Room
Penalty
Summary
The facility failed to keep a resident room in good working condition for a resident who was severely cognitively impaired and diagnosed with Alzheimer's dementia, chronic kidney disease, hypertension, and depression. During observation, the resident was lying in bed with the bed positioned with its long side against the wall. Next to the bed, the wallpaper seam by the wall light was loose, and approximately 2 feet of wallpaper was peeling away from the wall, exposing a beige wall and some loose white matter where the wallpaper had been attached. During interviews, the maintenance director observed the room and stated the wallpaper needed to be repaired, and noted loose wallpaper may be a safety issue due to the possibility of lead paint in buildings, although they did not believe the facility had lead paint. A nursing assistant stated the wallpaper had been damaged for a few months and that the resident had been pulling at it and removing pieces. The assistant said staff normally notify the nurse when repairs are needed so a maintenance request can be entered. An LPN stated they had not been told about the damage and were not aware the resident was pulling on the wallpaper, and the interim DON and regional nursing consultant stated resident rooms should not have peeling wallpaper. Review of maintenance work orders from 1/1/26 through 8/5/26 showed no maintenance requests were placed for wallpaper repair in the resident's room.
Failure to Supervise an Elopement-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident who was identified as an elopement risk and had a history of exit-seeking behavior. The resident was admitted with diagnoses including dementia, major depressive disorder, and type 2 diabetes mellitus. His MDS indicated severe cognitive impairment, need for staff assistance with ambulation, wheelchair use, wandering behaviors, and delusions. His care plan identified him as at risk for elopement and directed staff to invite him to activities, keep family informed, ensure he followed sign-out procedures, and answer door alarms promptly. The resident’s record showed repeated exit-seeking and wandering behaviors over several months. Progress notes documented that he pushed on exit doors, sounded door alarms, tried to leave the unit overnight, and was often redirected by staff. On the day of the incident, staff observed him pushing on the unit exit door and redirecting him away from the door about every ten minutes. He was later wheeled to his room to watch television and left there alone while staff attended to other residents. Staff did not maintain continuous awareness of his whereabouts, and a nurse assistant later found that he was no longer in his room. The resident left the secured unit without staff awareness and exited the building through an unknown door. A Good Samaritan called the facility after seeing a confused person in a wheelchair outside. Staff then located the resident on a residential street approximately 0.6 miles from the facility, near a highway/collector road, where he was alone and wheeling himself. Staff interviews indicated uncertainty about how he exited the secured unit, and one staff member stated the unit door alarm did not sound. The resident was returned to the facility after being found outside by himself.
Failure to Assess and Order Bedside Self-Administration Medications
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed and provider orders were obtained for medications kept at the bedside for one resident with intact cognition and a diagnosis of stroke. The resident’s quarterly MDS indicated intact cognition, but the electronic medical record did not contain a self-administration form, and the care plan did not indicate self-administration of medications. The current provider order list also lacked orders for muscle rub with lidocaine and artificial tears. During observation, an opened bottle of Aspercreme with lidocaine and an opened bottle of artificial tears were found on the resident’s bedside table. The resident stated he used the Aspercreme on his arm when it was sore and administered the eye drops when his eyes were scratchy, and he did not know whether he had a doctor’s order for either medication. An LPN stated a self-administration form had to be completed before medications could be kept at bedside and confirmed the resident should not have medications at his bedside. Another LPN stated a resident needed a self-administration form and provider order to self-administer medications, and the DON confirmed the resident did not have an order for the Aspercreme and that the bottle had been removed from the room.
Failure to Monitor and Report Coccyx Skin Concern
Penalty
Summary
The facility failed to monitor and notify the provider about a skin concern for a resident with severely impaired cognition, metabolic encephalopathy, and peripheral vascular disease who was at high risk for pressure injuries. On admission, the resident had a coccyx foam dressing and a small area of redness documented, and later skin documentation described a 1 cm pink coccyx wound with a foam dressing in place. The resident’s care plan called for documenting skin condition and keeping providers informed of changes, but the daily skilled notes did not document the coccyx concern, the TAR lacked daily monitoring for the coccyx, and the provider orders from admission through discharge did not include an order for the coccyx foam dressing. The resident’s weekly skin assessment later noted a small red spot on the coccyx with foam dressing applied, but the admission and provider documentation still lacked orders or clear follow-up for the coccyx area. After discharge to assisted living, the receiving RN found a 5 cm by 5 cm pressure injury to the coccyx during the admission skin assessment. Staff interviews showed the admission nurse could not recall notifying the nurse manager or provider, and other nurses and the DON stated that new skin concerns should be assessed, documented, reported, and provider orders obtained. The NP stated he was not alerted to any redness on the coccyx and confirmed that all skin concerns, including coccyx redness, should be reported to him.
Failure to Employ Qualified Food and Nutrition Services Staff
Penalty
Summary
The facility failed to employ a full-time registered dietician (RD) or a qualified culinary director (CD) to oversee the food and nutrition services, which had the potential to affect all 135 residents. Documentation showed that while the dietician held a valid license, her timecards did not specify the exact hours or days spent at the facility, and she split her time between multiple buildings. The administrator stated that 30 hours per week was considered full-time for the dietician, but the records did not clearly confirm her presence at the facility for those hours. Additionally, the dietician herself confirmed she was not a Certified Dietary Manager (CDM) and that her hours varied week to week. The culinary director (CD) and assistant culinary director (ACD) also lacked the required qualifications. The CD had a certificate from Le Cordon Bleu but was not a CDM, had not completed coursework in food management, and did not have an associate's degree or higher. The CD was reportedly being enrolled in a CDM program at the time of the survey. The ACD had a bachelor's degree in culinary arts and was a Certified Food Protection Manager (CFPM), but proof of credentials and certifications was not available in the personnel file. The ACD had only recently started working at the facility and had not yet provided documentation of his qualifications. Interviews with staff and administrators revealed confusion and inconsistencies regarding the credentials and roles of the dietician, CD, and ACD. The facility was unable to provide complete personnel files or clear documentation of staff qualifications and hours worked. Job descriptions for the CD and ACD outlined requirements for education and experience, but the individuals in these roles did not meet all the stated qualifications, and supporting documentation was incomplete or missing.
Failure to Assess Alternatives and Risks Prior to Bed Rail Installation
Penalty
Summary
The facility failed to attempt alternative devices before installing bed rails on the beds of four residents, did not identify the specific medical needs to be met with bed rail use, and did not assess potential entrapment zones. For each of the four residents reviewed, documentation was lacking regarding the evaluation of alternatives to bed rails, and care plans did not consistently include interventions related to bed rail use prior to their installation. In several cases, sections of the interdisciplinary team (IDT) care conference forms related to positioning devices were left blank, and bed mobility device evaluations were either missing or incomplete. Residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as stroke, dementia, and depression. Some residents required substantial or maximal assistance with bed mobility and transfers, while others had no functional impairment to upper or lower body. Despite these differences, the process for assessing the need for bed rails and documenting alternatives was not followed. In some cases, residents or their representatives were not informed about the use of bed rails or the associated risks and benefits prior to installation. Observations revealed that bed rails were in use for all four residents, and maintenance staff were responsible for installation and ensuring compatibility. However, bed rails were found to be loose in some instances, and maintenance staff were not always notified of issues. Manufacturer guidelines for the bed rails were not readily available, and there was a lack of clear process or policy for assessing entrapment risks. The facility's policy did not address the need to attempt alternatives before bed rail installation or provide resources for entrapment risk assessment.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and cleanliness as evidenced by multiple observations during a kitchen tour and staff interviews. Surveyors found several food items in the freezer, including fish, chicken, tator tots, and breadsticks, that were not labeled or dated. An opened box of hamburgers was left exposed to air, and a gallon of milk was found in the cooler past its best by date. In dry storage, cups were improperly stored in a bin of bread crumbs, and dented cans of peaches and applesauce were found on the shelf with other cans. Additionally, a large, thick brown stain was observed on the floor under shelving in dry storage, which staff acknowledged had been present for an extended period and had not been effectively cleaned. Further observations revealed that kitchen equipment, such as ovens, had significant grease buildup and had not been cleaned regularly, with one oven missing a knob and brownish residue present on the doors and handles. Staff interviews confirmed that cleaning logs were not maintained for kitchen floors or equipment, and cleaning tasks were inconsistently performed due to staffing issues. The facility's policy required food storage areas to be kept clean at all times and for all foods to be properly labeled, dated, and covered, but these standards were not met as documented by surveyors.
Failure to Assess and Document Use of Wheelchair Brakes as Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, specifically the use of locked wheelchair brakes, without proper assessment or physician orders. Both residents had significant cognitive impairments, including dementia, and required varying levels of assistance with mobility and transfers. Despite this, their care plans and medical records did not indicate any assessment to determine if they could independently unlock their wheelchair brakes, nor were there orders for the use of locked brakes as a restraint. During observations, both residents were found in the common area with their wheelchair brakes locked, restricting their ability to move. One resident attempted to stand and propel the wheelchair but was unable to do so due to the locked brakes, resulting in repeated unsuccessful attempts to move or stand. The other resident, who was dependent on others to lock or unlock the brakes but could self-propel, was also unable to move the wheelchair or reach for support due to the brakes being locked. Staff interviews revealed uncertainty about whether these residents could unlock their brakes and whether the use of locked brakes was part of their care plan. Further interviews with nursing staff and the DON confirmed that wheelchair brakes should not be locked unless the resident can unlock them, as this would otherwise constitute a restraint. The facility's own policy required a comprehensive assessment, education on risks and benefits, and a physician's order for the use of physical restraints, none of which were documented for these residents. The lack of assessment and documentation led to the inappropriate restriction of movement for both residents.
Failure to Provide Monthly Suprapubic Catheter Changes as Ordered
Penalty
Summary
A resident with moderately impaired cognition and diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and kidney calculus was identified as having a suprapubic catheter. The resident's care plan specified interventions such as regular toileting assistance, pericare, monitoring for urinary tract infection (UTI) symptoms, and changing the suprapubic catheter according to policy. Physician orders directed that the catheter be changed monthly and as needed. However, review of the resident's Medical Administration Record (MAR), Treatment Administration Record (TAR), and progress notes from November 2024 through April 2025 showed no documentation that the catheter had been changed since admission. Interviews with nursing staff, including a registered nurse, a nurse manager, and the director of nursing, confirmed that the physician's orders for monthly catheter changes were not followed, and there was no evidence of catheter changes in the records. Additionally, a nurse from the urology provider confirmed the necessity of monthly catheter changes to prevent complications. The facility's catheter care policy did not specify the required frequency for catheter changes, contributing to the lack of compliance with physician orders.
Failure to Follow Oxygen Weaning Orders and Document Care
Penalty
Summary
The facility failed to follow provider orders to wean supplemental oxygen for a resident with severe cognitive impairment, chronic respiratory failure, and dementia. The resident had been hospitalized for sepsis, pneumonia, and urinary tract infection, and was discharged with instructions to be weaned off supplemental oxygen as able, maintaining oxygen saturation at or above 90%. Provider orders and the care plan directed staff to wean oxygen as tolerated, but documentation in the treatment administration record, oxygen saturation summary, and nursing progress notes lacked evidence of any attempts to wean the resident from oxygen or to record oxygen flow rates during such attempts. Observations confirmed the resident was continuously on oxygen via nasal cannula, and interviews with nursing staff and the DON revealed that no recent weaning attempts had been made or documented. The DON verified that the order to wean oxygen was still active and acknowledged the lack of documentation regarding weaning efforts. The facility was unable to provide a policy for resident oxygen use when requested.
Failure to Clarify and Discontinue Prolonged Antibiotic Therapy Due to Lack of Provider Coordination
Penalty
Summary
The facility failed to ensure proper coordination of care between the provider and an outside urology clinic, resulting in a resident receiving prolonged antibiotic therapy without appropriate justification or an established end date. The resident, who had multiple sclerosis, neuromuscular bladder dysfunction, and a history of kidney stones, was dependent on staff for toileting and had a catheter. After a urology visit, the resident was prescribed Ciprofloxacin for nephrolithiasis, but the order lacked a specified duration. The physician assistant (PA) continued to sign monthly orders for the antibiotic without an end date, and the pharmacy flagged the issue, requesting clarification, which was not adequately addressed. Multiple staff interviews revealed that when a resident returns from the hospital with new orders, it is standard practice for nurses to verify and clarify any discrepancies, such as missing end dates for antibiotics, by contacting the provider. In this case, although staff were aware of the missing end date and the ongoing use of Ciprofloxacin, there was no documented follow-up or resolution. The PA stated he attempted to contact the urology clinic but did not receive a response and continued the order regardless. The medical director confirmed there was no clinical justification for prophylactic antibiotic use in this situation and expected the provider to follow through with the specialist for clarification. Documentation in the resident's medical record was incomplete, lacking evidence of follow-up with the urology clinic or justification for continued antibiotic use. Progress notes indicated attempts to contact the urologist, but there was no record of any response or further action. The deficiency was further compounded by the lack of communication and documentation among nursing staff, the PA, and the urology clinic, resulting in the resident receiving unnecessary antibiotic therapy beyond the intended period.
Failure to Ensure Antibiotic Orders Had End Date or Justification
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not providing an end date or documented justification for the continued use of a prophylactic antibiotic. The resident in question had multiple diagnoses, including multiple sclerosis, neuromuscular bladder dysfunction, and a kidney stone, and was dependent on staff for toileting and had a suprapubic catheter. Despite the original order for Ciprofloxacin being intended for a limited duration following a surgical procedure, the antibiotic was continued without an end date or clear clinical justification. Documentation showed that the pharmacy flagged the ongoing use of Ciprofloxacin and requested clarification on the duration of therapy, but the provider only handwrote 'prophylactic-urology' without specifying an end date. Interviews with nursing staff, the PA, and the DON revealed that staff were aware of the missing end date and the lack of justification for continued antibiotic use, but failed to follow up adequately with the prescribing urologist or to document any resolution. The medical record lacked evidence of appropriate follow-up or communication with the urology clinic regarding the necessity and duration of the antibiotic. Facility policy required that all antibiotic orders include a duration and that any discrepancies be clarified with the provider. Despite this, the resident continued to receive Ciprofloxacin without a documented indication or stop date, and there was no evidence that the facility’s antibiotic stewardship protocols were followed. The deficiency was further supported by the absence of documentation of follow-up actions or provider responses in the resident’s medical record.
Failure to Provide Ordered Therapeutic Diet After Temporary Downgrade
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, aphasia, and type 2 diabetes did not receive the ordered therapeutic diet. The resident was initially placed on a regular diet with soft, bite-sized textures (IDDSI Level 6) due to their medical condition. Following a dental extraction, a temporary order was placed for a softer, minced and moist diet (IDDSI Level 5) for two days, after which the resident was to resume their normal diet as comfortable. However, after the temporary order ended, the resident continued to receive the Level 5 diet instead of returning to the Level 6 diet as ordered. There was no documented reassessment of the resident's mouth or dental comfort, nor any conversation about diet preferences during this period. Multiple interviews with staff revealed that the process for updating diet orders involved communication between nursing and dietary departments, with orders entered into the electronic health record system and meal tickets printed accordingly. Despite the active order for a Level 6 diet, the resident continued to receive Level 5 meals, and staff could not explain the discrepancy. The resident expressed dissatisfaction with the minced and moist diet, stating it was unappetizing and that they had not been reassessed or consulted about advancing their diet. Facility policy required regular review and documentation of residents' responses to therapeutic diets, but this was not followed in this case.
Failure to Ensure Call Lights Within Reach for Residents with Cognitive and Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who required extensive assistance and had cognitive impairments. One resident with severe cognitive impairment, dementia, and anxiety was observed on two separate occasions lying in bed with the call light on the floor, tangled and pushed against the wall, making it inaccessible. Staff interviews confirmed that the call light was not within reach and that it should have been accessible to the resident at all times, as directed by the care plan. Another resident with moderate cognitive impairment, a history of falls, and significant mobility limitations was repeatedly found without access to their call light, both in bed and in a wheelchair. Family members reported multiple instances where the call light was out of reach or under the bed, and documentation confirmed these occurrences. Staff interviews acknowledged the expectation that call lights should be within arm's reach of residents, and facility policy required call lights to be accessible to all residents.
Failure to Follow Enhanced Precautions for Wound Care and COVID-19
Penalty
Summary
Staff failed to follow appropriate transmission-based precautions for two residents requiring enhanced infection control measures. One resident with moderate cognitive impairment, dementia, and frostbite with surgical amputations had provider orders and a care plan directing staff to use enhanced barrier precautions (EBP), including donning gown and gloves during high-contact care. During a dressing change, a registered nurse performed hand hygiene and wore gloves but did not don a gown, despite signage and policy requiring both. The nurse later acknowledged the omission. The Director of Nursing confirmed that EBP required gown and gloves for wound care, as outlined in facility policy. Another resident with a recent COVID-19 diagnosis was on enhanced respiratory precautions, with care plan interventions for isolation and monitoring but lacking specific PPE instructions. Observations showed that staff entered the resident's room wearing only surgical masks or omitting required PPE such as N95 respirators and eye protection, despite signage indicating enhanced respiratory precautions. Interviews with staff revealed inconsistent understanding and implementation of required PPE protocols for both EBP and enhanced respiratory precautions, as well as a need for further education on the differences between these precautions.
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What surveyors actually found near you
We read the 1,190 citations issued within 25 miles in the last 12 months — including the 32 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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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) |
|---|---|---|---|---|
| The Villas At Roseville | 0.8 mi | ★★★★★ | 8 | 0 |
| Langton Shores | 0.9 mi | ★★★★★ | 1 | 0 |
| Presbyterian Homes Of Arden Hills | 2.2 mi | ★★★★★ | 1 | 0 |
| Lyngblomsten Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Maplewood | 3.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.