The Villas at Roseville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Mar 5, 2025

  Based on interview and document review, the facility failed to ensure residents received the medications ordered by the provider for 1 out of 3 residents (R1) reviewed for significant medication errors, which resulted in hospitalization in the intensive care unit (ICU). This resulted in an immediate jeopardy (IJ) for R1 when the facility omitted her apixaban (medication that decreases clotting ability of blood) for six days, for a total of 12 doses, R1 had a stroke and was sent to the hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 2/18/25 at 4:00 p.m., when R1 missed her first dose of apixaban (Eliquis). […]

• Immediate jeopardy, isolatedF578Dec 14, 2023

  Based on interview and document review, the facility failed to ensure resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 3 residents (R13) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R13 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R13's Provider Orders for Life-Sustaining Treatment (POLST) identified R13 had an active order to administer CPR, however, the physician orders indicated R13 was do-not-resuscitate (DNR). The administrator was notified of the IJ on [DATE], at 3:15 p.m. […]

• No harm, potential for more than minimal, widespreadF801Apr 30, 2026

  Based on interview and document review, 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 of 2020, which had the potential to affect all 54 residents who resided in the facility. Findings include: Qualifications for the Culinary Services Director (CSD) was requested however was not received. During the initial kitchen tour on 4/27/26 at 10:45 a.m., CSD stated she worked full time at the facility and there was also a registered dietician (RD) who worked one day a week but was available by phone for questions whenever needed. […]

• No harm, potential for more than minimal, patternF761Sep 1, 2021

  Based on observation, interview and document review, the facility failed to properly secure medications in 1 of 1 treatment cart observed for medication storage. Findings include: During an observation on 8/31/21, at 8:20 a.m. the treatment cart was unlocked and unattended by staff. The cart was located outside of the medication room in the hallway across from the nurse's station and at the intersection of the three resident rooms hallways. During the observation, multiple residents walked passed as they returned to their rooms from breakfast and to go outside. At 9:30 a.m. the cart remained unlocked until registered nurse (RN)-A walked and locked the treatment cart. During observation on 9/1/21, at 8:48 a.m. the treatment cart was unlocked and unattended. […]

• No harm, potential for more than minimal, patternF880Sep 1, 2021

  Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) guidance and Minnesota Department of Health (MDH) Covid recommendations were followed for eye protection being used by facility staff while in resident care areas. In addition failed to ensure proper sanitizing of re-useable equipment reviewed for infection control. Findings include: Minnesota Department of Health (MDH) COVID-19 PPE Grid for Congregate Care Settings dated 6/30/21, in accordance with the CDC, indicated health care workers with face to face contact with residents. On 8/30/21, at 2:16 p.m. […]