Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roscoe Regional Rehab & Residential H C F during CMS and state inspections, most recent first.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
Residents seated together in the dining room were not served meals at the same time, with some residents waiting while others at the same table were already eating or finishing. Staff interviews confirmed that residents at the same table should have been served together, but the meal service process was not always followed.
Failure to Provide Ordered Wound Care and Heel Offloading: Two residents did not receive pressure ulcer care consistent with orders and consultant recommendations. One resident had a Stage 2 arm wound and a left buttock deep tissue injury, but there were no documented physician orders or treatment administration records showing the recommended wound treatments were given. Another resident had a physician order and care plan to offload both heels, yet observations showed only one heel protected or one heel left on the mattress, with staff confusion about the bilateral heel offloading requirement.
A resident with dementia and a prior hip fracture had repeated unwitnessed falls, and the record did not show documented frequent rounding, updated care plan interventions, or consistent supervision after the falls. Another resident with CHF, AFib, and anticoagulant use had two unwitnessed falls, but the care plan was not updated, neuro checks were not restarted per policy after the second fall, and there was no documented RN, NP, or MD post-fall assessment or PT evaluation.
Meal tickets and tray contents did not consistently match resident diets and stated food preferences. A resident who requested a vegetarian diet continued to receive meat items, while other residents received missing or incorrect items such as cranberry juice, soup, pureed tuna instead of pureed grilled cheese, tomato soup not present on the tray, and a baked potato instead of rice. Staff interviews confirmed the dietary preference was not documented in the resident’s assessment or care plan and that tray checks did not ensure the meal matched the ticket.
Improper food labeling and storage were observed in the kitchen and unit refrigerators. An open loaf of bread past its expiration date, unlabeled or undated resident foods, open dairy and dessert items without names or open dates, and personal food items were found in multiple refrigerators. Staff stated family sometimes placed disposal stickers on food, while the DOD said personal belongings should not be in the kitchen refrigerator and all opened food should be labeled with a date.
A resident with cerebral infarction, DM2, CKD, and moderate cognitive impairment reported missing clothing and a blanket, but the grievance was not formally documented or promptly resolved. The ADON/Unit Mgr searched for the blanket and offered a different one, yet no Grievance Report was completed, the DSW was not notified, the resident did not receive the investigation results, and the facility could not locate a resident property inventory form.
Missing Anticoagulant Care Plans: Two residents receiving Eliquis had no documented care plan interventions addressing bleeding risk. One resident had atrial fibrillation, upper-extremity impairments, and a right arm skin area noted on observation, while the other had severe cognitive impairment and deep vein disease. Records showed anticoagulant use on the MDS and MAR, but the care plans did not include measurable goals or interventions related to anticoagulation.
A resident with hemiplegia, dementia, and bladder incontinence was found lying in bed with a urine-soiled brief, clothing, and sheets, and urine odor and staining were also observed in the room. CNAs stated the resident refused cares earlier in the shift, but the refusal was not reported to nursing staff and the resident was left without timely toileting, dressing, or hygiene care. The ADON and DON stated staff should have reported the refusal and reattempted care, and that no behavior or rejection-of-care plan was in place.
A resident with hypothyroidism, severe cognitive impairment, and dependence on staff for ADLs did not have documented evidence that a prescribed daily levothyroxine dose was administered. The MAR for the month did not show the medication was given, despite the care plan directing endocrine meds per MD orders and facility policy requiring meds to be charted as administered. An LPN stated that if a med was not signed in the MAR, it likely was not given, and the DON stated meds were expected to be signed for after administration.
A resident was observed with a cup containing four pills on an overbed table during lunch while a CNA delivered the meal tray beside the medication cup. An LPN said they had given the resident morning meds earlier and should have watched the resident take them, but did not because the resident swallows one pill at a time and the nurse needed to finish med pass for the unit before lunch service.
Facility assessment did not show whether enough qualified staff were available on nights to meet resident needs. The facility reported minimum night staffing of 1 CNA to 80 residents, with mandatory OT used to maintain staffing, while residents and families reported delayed call bell response, long waits for care, and unsafe staffing concerns. Surveyors also noted a strong urine odor in a unit dining room and hallway, and the facility identified many incontinent residents and residents who wandered.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate staffing and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Residents at Shared Tables Were Not Served Meals Together
Penalty
Summary
The facility did not ensure that residents were treated in a manner and environment that maintained or enhanced dignity and respect during dining for four residents observed in the main dining room. During lunch observations, residents seated at the same table were not served together, and some residents were left waiting while others at the same table were already eating or finishing their meals. On one observation, three residents were seated together and one resident was finishing lunch, another had already been served but was not eating, and a third resident was still waiting to be served. On another observation, one resident at a table with two others repeatedly called out for food for about ten minutes before being served. At another table, one resident was almost done eating while the other resident had not yet received food and was served only when the first resident finished. At a third table, one resident had food while the other waited to be served for at least ten minutes or more. The Dining Room Service Policy last reviewed 11/2019 had no documented evidence of serving instructions by table, and staff interviews confirmed that residents sitting at the same table should have been served at the same time, but this was not always followed.
Failure to Provide Ordered Wound Care and Heel Offloading
Penalty
Summary
Pressure ulcer care was not provided consistent with professional standards for two residents reviewed for skin integrity. For one resident with a history of wounds, including congestive heart failure, type 2 diabetes, and lymphedema, a wound consultant documented a Stage 2 pressure wound on the right arm and later a deep tissue injury on the left buttock. The consultant notes included treatment recommendations of Skin Prep for the right arm wound and xeroform gauze for the left buttock injury, but there was no documented physician order for either treatment and no documented evidence that the treatments were administered in the treatment record. The resident’s July 2025 treatment record did not show administration of treatment for the right arm blister, and the August 2025 treatment record did not show administration of the recommended treatment for the left buttock deep tissue injury before 08/27/2025. During interviews, the RN Unit Manager stated there was no documented treatment order for either wound and therefore no treatment was documented as given. The RN Unit Manager also stated treatment orders should have been entered by nursing staff, and the DON stated the RN Manager was responsible for entering new treatment orders as recommended during wound rounds. For another resident with congestive heart failure, type 2 diabetes with mild non proliferative diabetic retinopathy, and lymphedema, the physician ordered bilateral heel offloading every shift. The resident’s MDS documented moderate cognitive impairment, bilateral lower extremity impairment, dependence for bed mobility, and risk for pressure ulcers/injuries. Despite the order and care plan intervention to float heels in bed, observations showed the resident in bed with only one heel boot in place or one heel not offloaded. Staff interviews reflected confusion about whether the order applied to one heel or both heels, and one CNA stated they were unaware of a task for bilateral heel offloading even though the electronic record indicated heels should always be offloaded.
Inadequate Supervision and Post-Fall Monitoring
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for residents who had repeated falls. For one resident with diagnoses including dementia and a right hip fracture, the record showed a history of falls, dependence on staff for transfers and toileting, and use of narcotic pain medication. After an unwitnessed fall in the room, the resident was found on the floor without footwear and away from the bed, complained of back pain, and was documented as having frequent rounds and safety precautions, but there was no documented evidence that frequent rounding or other adequate interventions were implemented to prevent another fall two days later. After the second fall, the resident was found on the bathroom floor with a hematoma above the eyebrow and severe right leg pain, and was sent to the hospital. The investigation documented that the resident had been noncompliant with the care plan and had transferred without assistance. The record also showed later falls and observations of unsafe environmental conditions, including the resident lying in bed with the curtain fully closed, a gym mat not positioned at bedside, a wheelchair placed close to the bed, and a coaxial cable creating a tripping hazard. Interviews with nursing staff and management indicated that the resident did not receive special or increased supervision after the falls, that rounding was not documented, and that staff could not confirm whether increased monitoring had been implemented. For another resident with diagnoses including transient ischemic attack, congestive heart failure, atrial fibrillation, and anticoagulant use, two unwitnessed falls occurred on consecutive days. The first fall was documented with neurological checks initiated, but after the second fall there was no documentation that the care plan was updated with new interventions, no documented in-person or telehealth assessment by an RN, NP, or physician, and no documented post-fall evaluation by Physical Therapy. Facility policy required neurological checks after unwitnessed falls, yet the neurological checks were not restarted after the second fall and continued only through the original monitoring period. Interviews with the DON, LPN, ADON, Administrator, and Medical Director confirmed that the resident was assessed by phone rather than in person and that the expected post-fall documentation and monitoring were not completed as required.
Meal Tickets and Tray Contents Did Not Match Resident Diets and Preferences
Penalty
Summary
The facility did not ensure that resident meal tickets and trays matched the residents’ ordered diets and stated food preferences for multiple residents during dining observations. Resident #65, who had diagnoses including unspecified fracture of the left femur, asthma, and GERD, was cognitively intact and independent in eating, but stated the facility did not honor a requested vegetarian diet. The resident reported telling staff, including CNAs, nurses, and dietary, that they did not eat meat products, yet the dietary assessment and care plan did not document a vegetarian preference, and meal tickets continued to reflect meat items such as turkey sandwich, pork with gravy, bacon, cheeseburger, and turkey with stuffing. Staff interviews confirmed the resident was known to avoid meat, that the dietician worked off-site, and that the dietary preference had not been entered into the resident’s dietary assessment or care plan as a vegetarian diet. During dining observations, other residents also received meals that did not match their meal tickets. Resident #19’s dinner ticket listed cranberry juice, but it was not received, and soup was served even though no soup was listed. Resident #29’s ticket documented pureed grilled cheese, but the resident received pureed tuna salad instead. Resident #44’s lunch ticket listed tomato soup on multiple occasions, but tomato soup was not observed on the tray. Resident #33 received a baked potato rather than rice as listed on the meal ticket. A CNA stated that the kitchen was responsible for ensuring the tickets were correct and that staff checked consistency and ordered diet, but not whether the tray contents matched the ticket exactly. The facility policy stated that the dietitian or designee was responsible for interviewing residents and/or families to obtain preferences and documenting them on the nutritional assessment. The Director of Dietary stated there were difficulties with the meal ticket system and that meal tickets should match tray contents and be checked by staff serving the meal. The record review and observations showed that the facility did not consistently follow the documented menus or meal tickets for the affected residents during the survey period.
Improper Food Labeling and Storage in Kitchen and Unit Refrigerators
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety in the main kitchen and on the North and South unit refrigerators. During observations with the Director of Dietary, an open loaf of bread with an expiration date of 05/24/2025 was found in the walk-in refrigerator, two open bottles of honey consistency cranberry juice had 6/4 written on them, and a personal lunch bag was observed in the stand alone prep refrigerator. The facility policy required opened items to be labeled and dated and discarded after three days, and non-potentially hazardous foods to be labeled and dated and discarded after five days once opened. In the North Unit Refrigerator, a brown paper bag labeled with a resident name contained a small hard plastic cup with a soiled napkin pushed over noodles and broccoli, a black disposable food container had a resident name but no date, two open cream cheese spreads had no name or open date, a yellow pudding had no name or open date, and a Kentucky Fried Chicken takeout cup with an exposed straw and frozen pink/red substance had no name or date. In the South Unit Refrigerator, ice cream and sherbet containers had no name or date, five resident-labeled containers had disposal dates of 08/30/2025 and 08/31/2025 but no date showing when the food was received or prepared, and other items included an open container of ham lunch meat, an open bag of crab meat, an open bottle of juice, and a clear container with a yellow substance and an unclear date. Staff stated family may place disposal stickers on food, believed food stayed in the refrigerator for three days, and the Director of Dietary stated staff should not place personal belongings in the kitchen refrigerator and that all food should be labeled when opened with a date.
Failure to Promptly Address Missing Personal Property Grievance
Penalty
Summary
Resident #42’s grievance regarding missing personal property was not acted on promptly and the resident did not receive the results of the investigation or replacement of the missing items. Resident #42 had diagnoses including cerebral infarction, type 2 diabetes mellitus, and chronic kidney disease, and the admission MDS dated 08/04/2025 documented moderate cognitive impairment and a need for partial moderate assistance with dressing. During an interview, the resident stated that shirts, pants, and a blanket were missing, that the items had been labeled with the resident’s name, and that the concern had been reported to the Social Worker and the Assistant DON/Unit Manager more than a week earlier. The Assistant DON/Unit Manager stated the resident reported a missing red blanket, but not missing clothing, and that they contacted laundry and staff from the south wing where the resident had previously been located. A search was conducted, but the blanket was not found, and the resident was offered a different blanket. The Assistant DON/Unit Manager stated they did not complete a Grievance Report or report the matter to the Director of Social Work. The facility was also unable to locate a Resident Inventory form for Resident #42 in the electronic record, and staff gave conflicting statements about who was responsible for completing inventory documentation. The Director of Social Work stated they were not aware of, and did not receive, a Grievance/Missing Item Report for the resident’s missing items.
Missing Anticoagulant Care Plans
Penalty
Summary
The facility did not ensure the development and implementation of comprehensive person-centered care plans with measurable objectives and time frames for two residents who were receiving anticoagulant therapy. Resident #28 had diagnoses including atrial fibrillation, neoplasm of bone, soft tissue, and skin, and heart failure, and had an order for Eliquis 2.5 mg by mouth twice a day for atrial fibrillation. The resident also had orders to apply protective sleeves to both arms and to cleanse and dress the right forearm with normal saline, xeroform, ABD pad, and kling. During observation on 08/25/2025, Resident #28 had an area of bright red uncovered skin to the right arm above the protective sleeve. The 5/23/25 Quarterly MDS and 8/8/25 Annual MDS documented anticoagulant use and impairments to both upper extremities, but the 7/22/25 care plan did not include documented interventions to address bleeding risk related to Eliquis. Resident #5 had diagnoses including schizoaffective disorder, deep vein disease, and major depressive disorder, and a Quarterly MDS dated 8/1/25 documented severe cognitive impairment and anticoagulant use. A physician order dated 2/10/24 directed Eliquis 5 mg twice a day for deep vein disease, and the MAR from 07/01/2025 through 08/28/2025 documented the medication was administered as ordered. The record review and staff interviews showed there was no anticoagulant care plan in place for Resident #5, and the Assistant DON/Unit Manager stated they were aware of this and that the care plan would be updated. The facility policy stated care plans were to include relevant focuses, etiologies, goals, and interventions, with review by the interdisciplinary team at required intervals.
Failure to Provide ADL Care and Address Refused Hygiene
Penalty
Summary
The facility did not ensure necessary assistance and care were provided to support activities of daily living for one resident who was reviewed for ADLs. The resident had diagnoses including hemiplegia and hemiparesis following a non-traumatic subarachnoid hemorrhage affecting the right dominant side, type 2 diabetes mellitus, and dementia with mood disturbance. The resident’s assessment documented moderate cognitive impairment, and care plans identified touching assistance for toilet transfers, moderate assistance with toileting, and verbal cues/encouragement for dressing. Another care plan documented frequent bladder incontinence with toileting upon request, and the resident had no rejection of care or behavior care plans in place. During observations, the resident was found lying in bed with a urine-soiled adult brief, pants, and bed sheets, and at another time there was a strong smell of urine in the room with a large urine stain on the bed sheets. A CNA stated the resident had refused cares earlier in the shift and had not had the brief changed since the prior night shift, while another CNA stated the resident refused cares that morning but the refusal was not reported to nursing staff. The ADON/Unit Manager and DON stated the CNAs should have reported the refusal and reattempted care, and the ADON/Unit Manager stated the resident did not have a behavior or rejection of cares care plan in place even though it should have been.
Missing Documentation for Ordered Thyroid Medication
Penalty
Summary
The facility did not ensure that Resident #85 received treatment and care in accordance with professional standards of practice when a physician’s order for Levothyroxine Sodium Tablet 125 mcg by mouth daily was not documented as administered on 12/30/2023. Resident #85 had diagnoses including Adult Failure to Thrive, Hypertension, and Hypothyroidism, and the Five-Day MDS documented severe cognitive impairment with dependence on staff for activities of daily living. The care plan directed administration of endocrine medications per physician orders. The facility’s Medication Administration Record for December 2023 did not show that the levothyroxine dose was given on 12/30/2023, and the policy required medications to be charted as administered in the electronic MAR. An LPN stated that if a medication was not signed in the MAR, it likely had not been administered, and the DON stated that when medication was administered, it was expected to be signed for to confirm administration.
Unsecured Medications Left at Resident Bedside
Penalty
Summary
The facility did not ensure that all drugs and biologicals were stored in locked compartments, as observed during dining on the North Unit. Resident #44 was seen in a wheelchair in their bedroom with a small clear cup containing four pills—three tablets and one capsule—on the overbed table in front of them while a CNA delivered a lunch tray and placed it next to the medication cup. When interviewed, the LPN identified as the medication nurse for Resident #44 stated they had delivered the resident’s morning medications at approximately 11:00 AM and should have watched the resident take them, but the resident swallows one pill at a time and the nurse needed to complete morning medications for the unit before lunch service. The LPN observed the cup of pills on the resident’s overbed table and stated they would contact the MD to review the resident’s orders. The medications identified were metformin, calcium plus vitamin D, omega, and fish oil.
Facility Assessment Did Not Address Adequate Night Shift Staffing
Penalty
Summary
The facility did not update its facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends. The November 2024 assessment documented a maximum capacity of 85 residents and 2 respite residents with an average census of 75, but it did not indicate whether sufficient qualified staff were available on the night shift to meet resident needs. The facility reported that direct care staffing on nights consisted of 2 CNA staff, with critical staffing at 1 CNA to 80 residents, and that mandatory overtime was used to maintain these minimum numbers. The facility also stated that it attempted to provide additional staff, up to 10 per day on the evening shift and 5 per night shift. Survey findings showed resident care needs that were significant on the units. The facility provided a list showing 42 of 77 residents were incontinent, including 20 incontinent residents on the North Unit and 22 of 37 residents on the South Unit, and identified 8 residents who wandered. Residents and family members reported concerns about low staffing, long waits for call bell response, and delays in receiving care. During the Resident Council Meeting, a resident stated that call bells were not answered timely at night and that they sometimes waited from midnight until 3:00 AM for help with being changed. During observation, a strong urine odor was noted in the dining room and hallway. On the night shift, staffing included one LPN and one CNA on the North Unit, and the RN supervisor, one CNA, and one float CNA on the South Unit; a CNA stated they were mandated until 3:00 AM and were limited to brief changes and answering call lights.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roscoe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Achieve Rehab And Nursing Facility | 13.8 mi | ★★★★★ | 10 | 0 |
| Sullivan County Adult Care Center | 15.1 mi | ★★★★★ | 10 | 1 |
| Mountainside Residential Care Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Delhi Rehabilitation And Nursing Center | 20.9 mi | ★★★★★ | 0 | 0 |
| Ellen Memorial Rehabilitation And Healthcare Cente | 31.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Roscoe Regional Rehab & Residential H C F.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.