The Estates at Roseville LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Roseville LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 26, 2021

  Based on interview and document review, the facility failed to ensure residents were protected from abuse by staff for 1 of 4 residents (R1) reviewed for an allegation of abuse. The facility's failure to protect residents resulted in an immediate jeopardy situation. This had the potential to affect all 30 residents residing in the Lexington unit. In addition, an extended survey was completed. The IJ began on 1/16/21, when licensed practical nurse (LPN)-A allegedly grabbed R1's right arm resulting in an injury, and the facility failed to ensure all residents residing on the Lexington unit were protected from LPN-A, who was allowed to continue working on the Lexington unit after causing an injury to R1's right arm. The facility administrator was notified of the IJ on 1/21/21, at 4:30 p.m. […]

• Immediate jeopardy, isolatedF689Jun 10, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 10, 2023

  Based on observation, interview and document review, the facility failed to follow manufacturer directions while using mechanical full body lifts, by not opening the stabilizing legs fully, for 3 of 3 residents (R1, R6 and R7). This resulted in an immediate jeopardy for R1 when the lift tipped over while R1 was being transferred, fracturing both femurs, and for R6 and R7 when staff were observed transferring them (both R6 and R7) not following the manufactures instructions. The immediate jeopardy began on 12/28/22, when R1 was transferred incorrectly using a full body mechanical lift, the lift tipped over and R1's legs were fractured. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 1/9/22, at 5:40 p.m. […]

• Actual harm, isolatedF756Jan 26, 2023

  Based on interview and record review, the facility failed to ensure the consultant pharmacist performed a complete medical record review for prescribed Clozaril an antipsychotic medication for one of one residents (R1) reviewed for antipsychotic medications. The antipsychotic medication required strict monitoring of an absolute neutrophil count and dispensing from the Risk Evaluation and Mitigation Strategy to reorder and administer the medication as prescribed. R1 suffered physical withdrawal symptom and psychosocial decompensation. Findings include: U.S. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2026

  Based 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.Findings include:During observation and interview on 8/5/26 at 9:33 a.m., cook (C-A) prepared carrots without wearing a beard restraint. C-A acknowledged knowing a beard restraint was required, stated management had previously instructed him to wear one, and acknowledged having been previously counseled for not wearing a beard restraint.During an interview on 8/5/26 at 9:52 a.m., the assistant director of culinary services (ADCS) stated dietary staff are expected to wear hairnets or beard restraints whenever preparing food. […]