Average — CMS composite of the measures below.
The next survey window likely opens around March 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 The Villas At Roseville during CMS and state inspections, most recent first.
Lack of Qualified Dietary Leadership: The facility failed to employ either a full-time RD or a qualified DM to oversee food and nutrition services, affecting all 54 residents. The CSD stated she had only recently enrolled in the CDM program and had no other food service certification or training, while the administrator said an RD worked one day a week and was on call. Requested documentation for the CSD’s qualifications and the dietary staff qualification policy were not provided.
A resident with dementia and an amputated leg was dependent on staff for ADLs, transfers, and mobility. Staff twice placed a pillow along the resident's side under the fitted sheet after a mechanical lift transfer, and one NA stated the pillow was placed there so it would not fall out and that the resident could not easily remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint.
Failure to hold required care conferences for a resident with TBI, seizure disorder, depression, opioid dependence, legal blindness, and dizziness. The resident’s EHR had no documentation of care conferences since admission, and the resident said she did not remember being invited or involved in any meetings about her care. The SS director confirmed the missing documentation, while staff stated conferences were expected within 48 hours of admission, quarterly, and as needed, with the resident and family invited.
A resident with ataxia and significant assistance needs had a provider-ordered ophthalmology referral for a skin tag under the left eye, but the appointment was not arranged. The resident said the issue was discussed with the doctor and nothing happened afterward. Staff stated the MRD handled referrals and transportation, but she had not acted on the order and said it may have been lost in paperwork; the DON and NP expected the referral to have been completed by then.
A resident with an infected tooth, severe toothache, and visible decay had provider orders for urgent dental referral and priority scheduling, but the appointment was never arranged or completed. Staff gave conflicting accounts about who handled referrals, and the MRD could not find evidence of a dental visit, a waitlist entry, or a documented refusal. The DON and NP stated the referral should have been followed up timely.
Failure to coordinate psychiatry services for a resident with BPD, PTSD, and MDD. The resident had an order for psychiatry follow-up, medication review for increased anxiety, and social work involvement for a possible transfer to a setting supporting her mental health, but the referral was not completed because social services was unaware of the order. The resident stated she felt unheard and misunderstood by staff and reported she was not offered additional therapy or mental health support beyond speaking with a grief therapist on an iPad.
A resident with stroke-related deficits, incontinence, and wound issues had an indwelling Foley catheter ordered to support wound healing, but the care plan did not include the catheter or daily catheter care needs. Staff interviews identified the DON, nurse manager, ADON, and nurses as responsible for care plan development and maintenance, and the DON stated a Foley catheter should be documented in the care plan. The facility also reported it had no Foley catheter policy, despite its care planning policy stating the plan guides daily care and staff services.
The facility failed to accurately code the MDS for two residents, one with pressure ulcers and another with psychotropic medications. A resident's pressure ulcer was incorrectly staged, and another resident's use of antianxiety medication and GDR attempts were inaccurately reported. The MDS coordinator acknowledged the errors, and the DON confirmed the inaccuracies.
A facility failed to complete and retain the necessary PASARR documentation for a resident with mental health diagnoses, including bipolar disorder and schizophrenia. The admission coordinator and social services director acknowledged the absence of the required documentation, which was supposed to be completed prior to admission and uploaded into the electronic medical record. The director of nursing and a registered nurse also confirmed the lack of PAS documentation in the resident's paper chart, highlighting a deficiency in the facility's care planning and assessment process.
The facility failed to conduct timely care conferences for a resident with chronic kidney disease, who required assistance with most ADLs and mobility. The last documented care conference was several months prior, and the resident could not recall attending one. The director of social services acknowledged the oversight and mentioned efforts to improve scheduling. A policy on care conferences was requested but not provided.
A facility failed to accurately assess and document a resident's pressure ulcer, leading to a deficiency in care. The resident, with a history of anemia, heart failure, and diabetes, had a stage 2 pressure ulcer incorrectly documented despite containing granulation tissue, slough, and eschar. Staff interviews revealed confusion and incorrect staging, with the MDS coordinator acknowledging the need for modification. The facility's policy on skin assessment and wound management was not effectively implemented, resulting in the deficiency.
A resident with hemiplegia experienced pain during mechanical lift transfers, as staff failed to ensure proper positioning and did not report unsafe transfers for reassessment. The resident was observed hanging by his shoulders during a transfer, contrary to the expected safe transfer protocol. The facility lacked a documented policy on safe transfers.
A resident with cognitive impairments was prescribed Nystatin powder for candidiasis without an end date. Despite the resident's skin condition improving, the medication continued to be administered without reassessment. Interviews revealed that staff did not actively monitor the necessity of the medication, and the DON acknowledged it should have been discontinued once the condition improved.
A resident was not offered the pneumococcal vaccination series as recommended by the CDC, despite being eligible due to their age and previous vaccination history. The resident's medical records lacked documentation of shared decision-making with a physician or evidence of being offered the vaccine. The facility's infection preventionist and DON acknowledged the oversight, citing additional responsibilities as a contributing factor. This failure was contrary to the facility's policy to offer pneumococcal vaccines to all residents.
A resident with atrial fibrillation missed 12 doses of apixaban due to a transcription error, leading to a stroke and ICU hospitalization. The error occurred because the health unit coordinator entered an incorrect end date, and the verification process was not properly followed by the nursing staff.
The facility did not update the daily nurse staffing information, with the last update being over a month old. The DON acknowledged the outdated posting, and the administrator was unaware of the lapse. A policy on nurse staff posting was requested but not provided.
A resident with a history of respiratory failure and other conditions missed a dose of lorazepam due to the nurse's failure to use the emergency medication kit. Despite the facility's policy and training, the nurse did not administer the medication from the emergency kit, leading to increased anxiety and restlessness for the resident.
The facility failed to comprehensively assess two residents for the use of bedrails and did not review the risks and benefits or obtain written informed consent before installation. Both residents were cognitively intact, but the necessary evaluations and informed consent procedures were not followed, leading to the deficiency.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since January 2020, affecting all 54 residents in the facility. During the initial kitchen tour, the Culinary Services Director (CSD) stated she worked full time at the facility and that an RD worked one day a week and was available by phone for questions. On follow-up interview, the CSD stated she had recently enrolled in the certified dietary manager (CDM) program about a month earlier and had no other certification or food service training, and she had originally enrolled during COVID but did not finish. The administrator stated the facility had an RD who worked once a week and was on call, and that the CSD had started as kitchen manager in January 2020 and was currently enrolled in school for her CDM license; the administrator also stated she believed the CSD only needed to be enrolled in the program to be qualified as the CSD. Requested documentation for the CSD’s qualifications and a facility policy regarding dietary staff qualifications were not received.
Pillow Placed Under Fitted Sheet Restricted Resident Movement
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when a pillow was placed adjacent to the resident's body underneath the fitted sheet, making it difficult for the resident to remove it independently. The resident, R44, had diagnoses of dementia and acquired absence of the right leg below the knee, and the quarterly MDS indicated the resident was dependent on staff for all ADLs, transfers, and mobility. R44's care plan identified impaired cognitive function/dementia, altered mood and behavior, and a history of putting self on the floor and crawling. The plan directed staff to keep the bed low and place a mat on the floor. During two separate observations, nursing assistants transferred R44 to bed using a mechanical lift, performed care, lowered the bed, and placed a pillow along the left side of the resident under the fitted bottom sheet. One NA stated the pillow was placed there so it would not fall out if the resident became agitated and did not think the resident could remove it. RN staff and the DON stated pillows should not be placed under fitted sheets because that could be considered a restraint, and one RN stated that if a resident could not easily remove a pillow and it prevented getting out of bed, it would be considered a restraint.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to provide care conferences for 1 resident reviewed for care conferences. The resident’s quarterly MDS identified the resident as cognitively intact with diagnoses of traumatic brain injury and seizure disorder. The resident’s EHR did not show any care conferences since admission on 8/20/25, and the resident’s care plan dated 11/25/25 identified the resident as a vulnerable adult at risk for decreased cognitive and physical abilities related to traumatic brain injury, depression, opioid dependence, legal blindness, and dizziness. During interview, the resident stated she did not remember being invited or involved in any meetings about her care at the facility. The social service director confirmed the EMR lacked documentation of care conferences for the resident and stated the social service director and social service designee were responsible for scheduling conferences and sending information to the IDT, resident, and family or representatives. Staff stated care conferences were expected within 48 hours of admission, quarterly, and as needed, and the DON stated they were used to align care with the resident’s needs, revisit concerns, and follow up with the plan of care. The facility policy stated the comprehensive care plan was to be developed within 7 days and that every effort would be made to have the resident and family attend care conferences.
Failure to Follow Up on Ophthalmology Referral
Penalty
Summary
The facility failed to ensure follow-up on a provider-ordered ophthalmology referral for a resident who was cognitively intact and required substantial to maximal assistance with transfers and mobility. The resident’s diagnoses included ataxia and need for assistance with personal care. A provider visit note documented that the resident asked about a small yellowish skin tag under the left eye, and an ophthalmology appointment was ordered for the skin tag under the left eye on 1/20/26. During observation and interview, the resident stated he had discussed the skin tag with the doctor and was told they would look into getting it removed, but that never happened. Staff interviews showed the medical records director was responsible for arranging referrals and transportation, and the DON expected routine and non-routine appointments to be scheduled timely. The medical records director stated she had just seen the ophthalmology referral the prior week and had not made any arrangements yet, explaining it may have been lost in paperwork while reorganizing her office. The DON and NP both stated the appointment should have been arranged and completed by then, and the facility did not provide a policy on appointment scheduling or provider orders.
Failure to Follow Up on Emergency Dental Referral
Penalty
Summary
The facility failed to ensure follow-up for an emergency dental referral for a resident with an infected tooth. The resident’s quarterly MDS indicated he was cognitively intact, needed setup or clean-up assistance with oral hygiene, and required substantial to maximal assistance with transfers and mobility. His diagnoses included ataxia and need for assistance with personal care. A provider visit note documented severe toothache, left upper molar decay with partial breakage, and erythema around the gum line, and the provider placed an order for referral to a dentist for definitive treatment of the infected left upper tooth with priority escalation for scheduling. The next day, another provider order again instructed referral to a dentist for treatment of the infected left upper tooth. During interviews, the resident stated he had a tooth infection and was supposed to see a dentist but never did. Staff gave conflicting accounts about how dental referrals were handled, with the LPN, DON, and MRD identifying the MRD as responsible for scheduling, while the MRD initially stated she thought an appointment had been set up and the resident refused care. The MRD could not locate evidence that the resident was ever seen by the outside dental provider, was on a list to be seen, or had a documented refusal. The outside dental appointment coordinator stated the resident was not enrolled for dental care and had only elected podiatry services. The MRD later stated the resident would have needed an external dental clinic of his choice and that an appointment should have been arranged when originally ordered, but she could not explain why it was missed. The DON and NP stated they expected referrals to be followed up timely and that the resident should have been seen by a dentist by then.
Failure to Coordinate Psychiatry Services
Penalty
Summary
The facility failed to ensure coordination of mental health care services for a resident who had diagnoses of borderline personality disorder, post-traumatic stress disorder, and major depressive disorder. The resident’s quarterly MDS identified her as cognitively intact, and a provider order dated 3/11/26 directed psychiatry to see her the following week, social work to contact the case manager to expedite transfer to a setting that would support her mental health, and changes to psychiatric medications due to increased anxiety; the resident also requested female caregivers. Her care plan identified her as at risk for altered behavior related to trauma and noted a need for referral for psychiatry services and collaboration with social services and psychiatry to improve social connections and minimize symptomology. Psychiatry provider notes were requested but not provided. During interview, the resident stated her PTSD, anxiety, and depression made her feel that she was not heard and understood by staff, and that although she used an iPad to speak with a grief therapist, she was not offered additional therapy or mental health support. Nursing staff stated therapeutic communication should be used with residents having stress-based outbursts, and the RN stated provider orders were to be followed and referrals were important for cohesive care, but she was unaware of the psychiatry referral. Social services stated the psychiatry appointment process was handled by that department and that the resident’s order was not completed because social services was unaware of it. The DON stated provider orders were expected to be entered into the medical record as soon as possible and outside psychiatric appointments were expected to be arranged per orders, but staff were unsure why the order was missed and whether the resident accepted or declined additional services.
Failure to Include Foley Catheter Needs in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident whose care needs changed after an indwelling Foley catheter was ordered. The resident was admitted with cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, morbid obesity, peripheral vascular disease, difficulty walking, and cognitive communication deficit. A bladder evaluation showed urge incontinence, and the initial care plan addressed altered elimination related to impaired mobility and metabolic acidosis, but it did not include the resident’s Foley catheter needs. The resident’s MDS later showed frequent bowel and bladder incontinence and triggered a CAH. Provider notes and orders then documented the start of a 16 French indwelling Foley catheter with a 10-cc balloon to promote wound healing for decubitus ulcers on both buttocks, and a later order changed the catheter to the same size and balloon for further wound healing. The resident’s BIMS score indicated cognitive intactness, and the discharge MDS still reflected frequent bladder incontinence with urinary continence not rated because of the catheter. Staff interviews identified the DON, nurse manager, ADON, and other nurses as responsible for care plan creation and maintenance, and the DON stated she would expect the Foley catheter to be documented in the care plan. The facility also stated it did not have a policy on Foley catheters, while its care planning policy stated the care plan would be used to develop daily care routines and guide staff in providing care or services.
Inaccurate MDS Coding for Pressure Ulcers and Psychotropic Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, one with pressure ulcers and another with psychotropic medications. For the resident with pressure ulcers, the MDS inaccurately reported the stage of the pressure ulcer. The resident had a pressure ulcer on the right Achilles, which was documented as a stage two ulcer. However, the wound contained granulation tissue, slough, and eschar, which are not characteristics of a stage two ulcer. The wound was actually unstageable due to the presence of slough and eschar, which obscured the wound bed. The MDS coordinator acknowledged the error and stated that the staging was not completed correctly. The second resident's MDS inaccurately reported the use of psychotropic medications. The resident was taking hydroxyzine for anxiety and quetiapine for depression. The MDS failed to report the use of an antianxiety medication and did not document a gradual dose reduction (GDR) attempt for the antipsychotic medication, despite a failed GDR and clinical contraindication being documented. The MDS coordinator admitted to missing the hydroxyzine and acknowledged the need to modify the MDS to correct the errors. Interviews with the Director of Nursing (DON) and the MDS coordinator revealed expectations for accurate documentation and alignment with provider documentation. The DON confirmed the inaccuracies in the wound staging and the psychotropic medication reporting. Despite requests, the facility did not provide a policy on MDS accuracy, relying instead on the RAI manual for guidance.
Failure to Complete and Retain PASARR Documentation
Penalty
Summary
The facility failed to ensure that a Level 1 Pre-Admission Screening (PAS) and, if necessary, a Level II Pre-Admission Screening and Resident Review (PASARR) were completed and retained in the medical record for a resident with mental health needs. The resident, who was admitted with diagnoses of bipolar disorder and schizophrenia, did not have the required PASARR documentation in their medical record. The admission Minimum Data Set (MDS) indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite having active diagnoses that could require active treatment. The admission coordinator (AC-E) and the social services director (SSD) both acknowledged the absence of the PASARR documentation in the resident's medical record. AC-E, who was responsible for requesting preadmission screens, initially believed the resident had a PAS but later realized that the form in the record was only a referral and not the actual PAS. SSD confirmed that the PAS screenings were supposed to be completed prior to admission and uploaded into the electronic medical record. Both AC-E and SSD recognized the importance of the PAS in determining the necessary level of care and services for the resident. The director of nursing (DON) and a registered nurse (RN-C) also verified the absence of the PAS in the resident's paper chart. The facility's policy on Pre-Admission Screening (PASSR) outlined the requirement for social services to ensure that the initial PAS results state that the resident meets the level of care for medical assistance payment before admission. However, this process was not followed, leading to the deficiency in the resident's care planning and assessment.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for a resident, identified as R14, who was reviewed for care planning. R14's annual Minimum Data Set (MDS) indicated intact cognition and a diagnosis of chronic kidney disease, requiring staff assistance with most activities of daily living and mobility. During an interview, R14 could not recall if a care conference had occurred. The last documented care conference for R14 was on 8/27/2024, and there was no documentation of any subsequent care conferences. The director of social services acknowledged the lack of a recent care conference and mentioned efforts to develop a better system for scheduling them. A facility policy on care conferences was requested but not provided.
Inaccurate Pressure Ulcer Staging and Documentation
Penalty
Summary
The facility failed to ensure accurate wound care assessments for a resident with pressure ulcers, leading to a deficiency in pressure ulcer management. The resident, who had a history of anemia, heart failure, peripheral vascular disease, and diabetes mellitus, was at risk of developing pressure ulcers and had a stage 2 pressure ulcer that was not present upon admission. The facility's documentation and assessment of the resident's pressure ulcer were inconsistent with clinical standards, as the wound was repeatedly documented as a stage 2 pressure ulcer despite containing granulation tissue, slough, and eschar, which are not characteristics of a stage 2 ulcer. The facility's staff, including registered nurses and the MDS coordinator, demonstrated a lack of understanding and adherence to proper pressure ulcer staging guidelines. Interviews with staff revealed confusion and incorrect staging of the resident's pressure ulcer, with some staff members incorrectly documenting the presence of slough and eschar in a stage 2 ulcer. The MDS coordinator acknowledged the incorrect staging and noted that the MDS would need to be modified. Additionally, the director of nursing confirmed that the wound documentation notes were not accurate for the wound staging according to the staging definitions. The resident's care plan and physician's orders included interventions for pressure ulcer management, such as turning and repositioning, using a pressure-reducing mattress, and monitoring the skin during care. However, the facility's failure to accurately assess and document the resident's pressure ulcer staging led to a deficiency in providing appropriate pressure ulcer care. The facility's policy on skin assessment and wound management required weekly skin inspections and proper documentation, but these procedures were not effectively implemented, resulting in the deficiency.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure safe patient handling during mechanical lift-assisted transfers for a resident with hemiplegia following a stroke. The resident, who was dependent on staff for transfers, reported experiencing pain during transfers using the EZ Stand lift, stating it caused discomfort to his ribs and lungs. During an observed transfer, the resident was unable to stand fully upright, resulting in him hanging by his shoulders from the lift, which was not reported to the nursing staff for further evaluation. The physical therapist assistant noted that such posturing could indicate the need for a therapy evaluation, but no concerns had been communicated to the therapy team. The director of nursing stated that a safe transfer should allow the resident to stand fully and grasp the lift bars without hanging. However, the observed transfer did not meet these criteria, and the staff did not follow the expected protocol of reporting unsafe transfers for reassessment and care plan updates. Additionally, the facility did not provide a policy on safe transfers when requested, indicating a lack of documented procedures to guide staff in ensuring resident safety during mechanical lift transfers.
Failure to Monitor and Reassess Antifungal Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically antifungal medications without an end date. A resident with a history of non-traumatic brain dysfunction, neurosyphilis, and non-Alzheimer's dementia was prescribed Nystatin powder for candidiasis, with the order dated several months prior and lacking an end date. Despite the resident's skin condition improving and eventually clearing, the medication continued to be administered as per the original order without reassessment or adjustment. Observations and interviews revealed that the nursing staff and the physician assistant were not actively monitoring the necessity of the continued use of the antifungal medication. The physician assistant, who was not involved in the initial prescription, indicated that the medication should have been reassessed and potentially discontinued after the condition improved. The director of nursing acknowledged that the medication should have been discontinued once the skin condition improved, and the facility's policy required staff to update the provider and care plan as needed for ongoing skin issues.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the pneumococcal vaccination series as recommended by the CDC. The resident, who was of advanced age, had previously received a PPSV23 vaccine over a decade ago. However, there was no evidence in the resident's electronic medical record or paper chart that a follow-up dose of PCV15, PCV20, or PCV21 was offered or administered, nor was there documentation of shared clinical decision-making with the physician regarding the vaccination. The resident confirmed in an interview that they were not offered the pneumococcal vaccine and expressed willingness to receive it if it had been offered. The facility's infection preventionist and director of nursing acknowledged the oversight, attributing it to the additional responsibilities they were handling, including fulfilling the nurse manager's duties. The facility's policy, which aligns with CDC and ACIP recommendations, mandates offering pneumococcal vaccines to all residents to prevent pneumococcal infections. Despite this policy, the resident was not identified as at risk and was not offered the necessary vaccination, leading to the deficiency noted in the report.
Medication Error Leads to Resident's Stroke
Penalty
Summary
The facility failed to ensure that a resident received the prescribed medication, apixaban, which is crucial for preventing blood clots. The resident, who had a history of encephalopathy, atrial fibrillation, and heart failure, was admitted with orders to receive apixaban twice daily. However, due to an error in the medication administration record, the resident missed 12 doses over six days, leading to a stroke and subsequent hospitalization in the ICU. The error occurred because the health unit coordinator mistakenly entered an end date for the apixaban order, and the verification process for medication orders was not properly followed. The first nurse responsible for verifying the orders did not complete the verification process before leaving her shift, although she documented it as complete in the computer system. The second nurse also failed to notice the error and signed off on the admission checklist, indicating that the orders were accurate. The resident's family discovered the omission during a care conference, and by that time, the resident had already suffered a stroke and was unresponsive, receiving hospice care. Medical professionals confirmed that the missed doses of apixaban were directly linked to the stroke, as the medication is essential for preventing blood clots in patients with atrial fibrillation.
Removal Plan
- Review procedure for transcribing orders
- Audit all residents on apixaban
- Audit all new resident orders
- Education for all staff involved with order transcription
- Education on the medication apixaban
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily, which had the potential to affect all 58 residents and visitors. On March 4, 2025, it was observed that the daily nurse staffing form at the nursing station was outdated, displaying a date of January 23, 2025. The Director of Nursing (DON) acknowledged that the form should be updated daily and admitted it was very outdated. The purpose of the posting was to provide a rough idea of the nurse-to-patient ratio. The facility administrator, who had been responsible for staffing over the previous two months, was unaware that the posting had not been updated since January 23, 2025. A policy regarding the nurse staff posting was requested but not provided.
Failure to Administer Anti-Anxiety Medication from Emergency Kit
Penalty
Summary
The facility failed to provide pharmacy services for a resident who did not receive his anti-anxiety medication, lorazepam, when it was available in the emergency medication dispensing kit. The resident, who was cognitively intact and had a history of acute and chronic respiratory failure with hypoxia, congestive heart failure, morbid obesity, opioid dependence, chronic pain syndrome, and low back pain, missed a dose of lorazepam. The medication administration record indicated the missed dose, but there was no progress note or nurse's note explaining the missed medication. The resident reported increased anxiety and restlessness due to the missed dose. Interviews with the registered nurse, pharmacy manager, director of nursing, and the administrator confirmed that the facility had an emergency medication kit that included lorazepam and that staff were trained to use it when a resident's medication ran out. However, the nurse did not utilize the emergency medication kit as expected. The facility's policy and procedure indicated that if a current and active medication order could not be located in the medication cart, the medication should be removed from the emergency medication kit. Despite this policy, the nurse failed to administer the medication from the emergency kit, leading to the deficiency.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bedrails prior to their installation for two residents. Specifically, the facility did not review the risks and benefits or obtain written informed consent before installing bed rails for these residents. One resident, who was cognitively intact, had bed rails installed without a thorough assessment of medical diagnoses, size, weight, sleep habits, medications, and other relevant factors. The resident's bed mobility device evaluation did not indicate any alternatives attempted before the placement of the bed rails. Another resident, also cognitively intact, requested bed rails but did not receive a review of the risks versus benefits from the nursing staff before the installation. This resident was unaware of the risks associated with bed rails and did not sign an informed consent form prior to their installation. During interviews, the therapy director and the director of nursing both stated that the interdisciplinary team would typically meet to decide if a resident was appropriate for bed rails. However, they were unaware that bed rails had been installed for the residents in question. The interim nurse manager admitted to not reviewing the residents' medical diagnoses, height, or weight before the installation of the bed rails. The maintenance director, responsible for installing the bed rails, also did not consider the residents' height and weight and was unaware of the different types of bed rails available. The facility's policy and procedure for bed rails were requested but not provided. The interim nurse manager and the maintenance director both demonstrated a lack of knowledge regarding the different types of bed rails and their appropriate use. This lack of comprehensive assessment and informed consent before the installation of bed rails led to the deficiency identified in the report.
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Illustrative
What surveyors actually found near you
We read the 1,044 citations issued within 25 miles in the last 12 months — including the 34 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roseville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Roseville Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| Langton Shores | 1.7 mi | ★★★★★ | 1 | 0 |
| Lyngblomsten Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Presbyterian Homes Of Arden Hills | 2.6 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society - Maplewood | 3.3 mi | ★★★★★ | 16 | 0 |
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