The Estates at Roseville LLC

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the proper use of beard restraints during food preparation. This practice had the potential to affect all 134 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a roach infestation for 1 of 1 resident (R76) reviewed for environment. This had the potential to affect all 142 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure self-administration of medications was assessed and determined to be appropriate for 1 of 1 resident (R59) reviewed for the self-administration of medications.

Inspectors wroteBased on interview and document review the facility failed to ensure quarterly Minimum Data Set (MDS) was completed in a timely manner for 1 of 1 residents (R39) reviewed for MDS completion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for 1 of 1 resident (R59) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff followed proper personal protective equipment was used for 2 of 3 residents (R31, R83) observed who required infection control precautions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident rooms were kept in good working condition for 1 of 1 resident (R45) reviewed for a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 residents (R1) who was identified as an elopement risk and had exit-seeking behavior. This resulted in Immediate Jeopardy (IJ) for R1 when he left the facility and independently wheeled his wheelchair approximately 0.6 miles from the facility before being found, which placed R1 at likelihood for serious harm or death. The IJ began on 6/1/26 when R1 exited the building without staff awareness through the secured unit doors and then through an unknown door to the outside of the building. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 resident (R3) observed with medications at their bedside.

Inspectors wroteBased on interview and document review, the facility failed to monitor a skin concern and notify the provider for 1 of 3 residents (R2) reviewed for wound care.

Inspectors wroteBased on interview and document review, the facility failed to employ either a full-time registered dietician (RD) or a qualified culinary director (CD) to carry out the functions of the food and nutrition services. This had the potential to affect all 135 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt alternative devices before the installation of bed rails on resident's beds, identify medical needs to be met with bed rail use, and assess potential entrapment zones for 4 of 4 residents (R76, R23, R103, and R35) reviewed for bed rails.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food items were labeled and dated, milk was discarded past the best by date, cups were not stored in food bins, dented cans did not remain on the shelf, and failed to ensure kitchen floors and equipment were clean.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure call lights were within reach for 2 of 2 residents (R42, R440 ) reviewed for call lights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure freedom of movement was not restricted for 2 of 2 residents (R122, R335) who were observed during activities.

Inspectors wroteBased on interview and document review the facility failed to provide monthly catheter changes for 1 of 1 resident (R46) reviewed for catheters.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure provider orders to wean supplemental oxygen were followed for 1 of 1 residents (R34) reviewed for oxygen use.

Inspectors wroteBased on interview and document review, the facility failed to ensure the provider maintained coordination of care with an outside provider in order to ensure an appropriate diagnoses and end date for an antibiotic, for 1 of 1 resident (R46) reviewed for prophylactic antibiotics.

Inspectors wroteBased on interview and document review the facility failed to ensure there was an end date or to investigate and/or document the justification for a prophylactic antibiotic for 1 of 1 resident (R46).

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide the ordered therapeutic diet for 1 of 1 resident (101) reviewed for provision of modified diet.

Inspectors wroteR123 R123's admission MDS dated [DATE], indicated R123 had moderate impaired cognition and diagnoses of dementia and frostbite to bilateral hands. R123's provider order dated 5/7/25 instructed staff to follow EBP while providing wound cares and other high contact activities. R123's care plan dated 4/3/25, indicated R123 required EBP related to frostbite of bilateral hands and surgical amputations. Furthermore the care plan directed staff to don personal protective equipment per EBP precautions when providing high contact cares. An observation on 5/20/25 at 10:45 a.m., registered nurse (RN)- B entered R123's room to perform a dressing change to their bilateral hands. R123's door had a sign that stated EBP and instructed staff to don gown and gloves when performing cares that require contact with the resident. RN-B performed hand hygiene and donned gloves, however, did not don a gown. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to knock on a shared resident bedroom door and introduce themselves for 1 of 1 resident (R57) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to clean and maintain a resident's wheelchairs for 1 of 1 resident (R326). Reviewed for safe, clean, and homelike environment.

Inspectors wroteBased on interviews, and document review the faciltiy failed to ensure an injury of unknown source was reported to the state agency (SA) in a timely manner and thoroughly investigated for 1 of 1 residnet (R100) reviewed for reporting of alleged violations

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure transdermal pain patch placement was maintained for 2 of 2 residents (R14, R68) reviewed for medication patch application.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure heel protectors were applied as ordered for 1 of 2 residents (R14) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure supply and administration of ordered medications for 2 of 2 residents (R50, R57) reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement procedures to ensure monthly medication regimen reviews were addressed in a timely manner for 2 of 5 residents (R4, R41) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene during wound care for 1 of 1 resident (R57) reviewed for infection control practices.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 resident (R4, R19) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.