Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Estates At Roseville Llc during CMS and state inspections, most recent first.
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 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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,042 citations issued within 25 miles in the last 12 months — including the 33 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.
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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 | ★★★★★ | 3 | 0 |
| Lyngblomsten Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Maplewood | 3.5 mi | ★★★★★ | 16 | 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 July 2026) and official state health department websites.