The Estates at Roseville: Skin Injury Undocumented - MN
No note explaining why a dressing was placed. No call to the provider for orders. No alert to the nurse manager. The director of nursing learned about the redness on the resident's coccyx only when federal inspectors came asking.
The resident is identified in inspection records only as R2. The redness was documented on the admission skin assessment form, which is exactly where it was supposed to be documented. That part worked. What followed did not.
The director of nursing told inspectors on September 26 that when a nurse finds a wound or area of concern during an admission skin check, the expectation is clear: look for dressing change orders, contact the provider if orders are needed, and if a dressing goes on under standing orders, write a note explaining why. Then tell the nurse manager. Then tell the provider.
None of that happened with R2.
The director of nursing said she had not been informed about the redness at all. When inspectors pressed on what the documentation showed, she acknowledged it: there were no notes, no provider orders, nothing beyond the initial notation on the admission form. "Based only on the documentation," she told inspectors, "it was difficult to determine if the area of redness was from pressure or moisture related."
That distinction matters. Pressure injuries and moisture-related skin damage look similar in early stages and require different interventions. Without a proper assessment, a clinical note, and a provider in the loop, the facility had no way to know which it was dealing with, or whether it was getting worse.
The director of nursing said redness caught early is easier to treat. She said pressure injuries can develop quickly depending on how well a resident can reposition themselves. She listed the risk factors: advanced age, frail skin, limited mobility. She said early identification was important so the area could receive proper skin care.
She said all of this to inspectors while confirming that none of it had happened for R2.
The facility's own skin assessment and wound management policy, updated in February 2025, required staff to notify the nurse manager, the wound nurse, the provider, and the resident's representative any time there was a new significant change in skin integrity or a pressure ulcer. The redness on R2's coccyx was documented on admission. Whether anyone beyond the admitting nurse ever knew about it before inspectors arrived is not reflected anywhere in the record.
The inspection, conducted as a complaint investigation, cited the facility at a level of harm described as minimal harm or potential for actual harm. A small number of residents were identified as affected.
What the record leaves open is what happened to R2's skin after admission. The inspection narrative does not say whether the redness resolved, whether it worsened, or whether a provider ever did get involved. The documentation gap that inspectors found means the facility's own records cannot answer that question either.
The director of nursing told inspectors it was important to assess areas of redness and alert the provider so orders could be obtained to prevent the area from turning into something bigger.
The record shows that for R2, that did not happen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Estates At Roseville LLC from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 29, 2026 · Our methodology
THE ESTATES AT ROSEVILLE LLC in ROSEVILLE, MN was cited for violations during a health inspection on November 20, 2025.
No note explaining why a dressing was placed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.