The Villas at Roseville: Mental Health Care Failure - MN
The resident, identified in inspection records only as R4, was cognitively intact. She had asked for female caregivers. Her provider had ordered psychiatry to see her "next week," with social work directed to contact her case manager to expedite a transfer to a setting that could better support her mental health. Her anxiety had increased. Her psychiatric medications needed review.
None of it happened.
When inspectors interviewed R4 on April 27, she said her PTSD, anxiety, and depression made her feel she wasn't heard or understood by staff. She used an iPad to speak with a grief therapist. She had not been offered any additional therapy or mental health support.
The registered nurse inspectors spoke with on April 30 said provider orders were meant to be followed and that referrals mattered so all caregivers could provide cohesive care. She said she was unaware R4 had a psychiatry referral at all.
The social services director said the same thing. The order wasn't completed, she told inspectors, because social services was unaware it existed.
The director of nursing said staff were expected to enter provider orders into the medical record as soon as possible and that outside psychiatric appointments were to be arranged per those orders. When asked why R4's order was missed, the director of nursing said she wasn't sure, and that it was unknown whether R4 had accepted or declined the additional services. She said she would look into it.
No further information was provided to inspectors.
R4's care plan, updated April 21, noted she was at risk for altered behavior related to trauma and required a psychiatry referral. The care plan existed. The order existed. The need was documented in multiple places by multiple people. What didn't exist was anyone who knew all three things at the same time.
R4 told inspectors she felt unheard. The records confirmed it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At Roseville from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 19, 2026 · Our methodology
THE VILLAS AT ROSEVILLE in ROSEVILLE, MN was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records only as R4, was cognitively intact.
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.