Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Roselawn Gardens Nursing & Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment engaged in a sexual act, discovered by a CNA during a period of low staffing. Both residents had documented behavioral issues and care plans addressing their needs, but the incident occurred despite these interventions, indicating a failure to protect residents from sexual abuse.
The facility failed to ensure that several residents received the pneumococcal vaccine or were given the opportunity to consent to or refuse the vaccine. A resident signed a consent form, but there was no evidence of vaccine administration. For other residents, there was no documentation of vaccine eligibility assessment, education, consent, declination, or administration, as confirmed by the DON. This affected five out of 13 residents reviewed for immunizations.
A facility failed to implement non-pharmacological interventions and proper medication parameters for a resident with chronic pain syndrome. Despite being prescribed both Acetaminophen and Oxycodone, the resident was frequently given Oxycodone without being offered Acetaminophen first, and non-pharmacological interventions were not documented. An LPN was unaware of medication administration parameters, and the facility's pain management policy was not followed.
A resident with diabetes received an incorrect insulin dose due to an LPN's failure to prime the insulin pen as per the manufacturer's instructions and facility policy. The resident's blood sugar level required a specific dose, but the lack of priming could have resulted in an inaccurate administration.
An LPN failed to properly clean and disinfect a glucometer between resident use, affecting two residents and potentially impacting others in the facility. The LPN admitted to not knowing the facility's policy and used an alcohol wipe instead of the required bleach product disinfecting wipe, contrary to the facility's cleaning policy.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents with severe cognitive impairment from resident-to-resident sexual abuse. On the date of the incident, a CNA discovered one resident in his wheelchair with his pants down while another resident was performing oral sex on him. Both residents had a history of dementia and behavioral issues, with one identified as a registered sex offender and the other exhibiting increased sexual behaviors. Staffing was notably low at the time, with only one nurse and two aides present for 42 residents due to several staff call-offs. The CNA who discovered the incident reported separating the residents immediately. Medical records and care plans for both residents indicated severe cognitive impairment and outlined interventions such as medication management, redirection, and supervision. Despite these measures, the incident occurred, and interviews with staff confirmed the sexual act between the two cognitively impaired residents. The facility's policy prohibits abuse, neglect, and exploitation, but the event demonstrated a failure to ensure residents were free from sexual abuse by others in the facility.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that several residents received the pneumococcal vaccine or were given the opportunity to consent to or refuse the vaccine. Resident #31 had signed a consent form to receive the pneumococcal vaccine, but there was no documented evidence in either the electronic medical record (EMR) or the hard chart that the vaccine was administered. The Director of Nursing (DON) confirmed this oversight during an interview. For Residents #34, #36, #38, and #39, there was no documented evidence of pneumococcal vaccine eligibility assessment, education, consent, declination, or administration. The facility's policy stated that all residents should be assessed for vaccine eligibility within five working days of admission and offered the vaccine series within 30 days unless medically contraindicated or already vaccinated. However, these steps were not documented for these residents, as confirmed by the DON during interviews. The facility's failure to document vaccine-related processes affected five out of 13 residents reviewed for immunizations, with a total facility census of 40. The lack of documentation and adherence to the facility's policy on pneumococcal vaccination led to the deficiency, as the residents were not properly assessed, educated, or given the opportunity to consent or refuse the vaccine.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions and parameters were in place to effectively manage pain for a resident with chronic pain syndrome. The resident, who was cognitively intact and had diagnoses including chronic kidney disease, hepatitis, schizophrenia, chronic pain syndrome, and cirrhosis, was prescribed both Acetaminophen and Oxycodone for pain management. However, the resident was consistently administered Oxycodone without being offered Acetaminophen first, and there was no evidence of non-pharmacological interventions being attempted prior to administering the narcotic medication. The Medication Administration Record (MAR) for January and February showed frequent administration of Oxycodone for varying pain levels, while Acetaminophen was rarely given. An interview with an LPN revealed a lack of knowledge about parameters for determining which medication to administer, and the facility's policy on pain management, which included non-pharmacological interventions and titrating medication doses, was not followed. This deficiency affected the resident's pain management and highlighted a failure in adhering to the facility's pain management policy.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident's medications were administered according to the physician's orders, resulting in a significant medication error. Resident #38, who has a medical history including type two diabetes mellitus, paranoid schizophrenia, and essential hypertension, was observed receiving insulin injections. The resident had two insulin orders: a fixed dose of four units before meals and at bedtime, and a sliding scale dose based on blood sugar levels. On the day of the observation, the resident's blood sugar was 194, requiring an additional two units per the sliding scale, totaling six units to be administered. During the medication administration, the LPN did not prime the insulin pen as required by the manufacturer's instructions and the facility's policy. The insulin pen should have been primed by dialing and wasting two units to remove air from the needle before setting the dose. The LPN confirmed the failure to prime the pen, which could lead to the resident receiving an incorrect dose of insulin. The facility's policy and the manufacturer's instructions both emphasize the importance of priming to ensure accurate dosing.
Improper Disinfection of Glucometer Between Resident Use
Penalty
Summary
The facility failed to properly clean and disinfect the blood glucose monitor (BGM/glucometer) between resident use, affecting two residents directly observed during medication administration and potentially impacting seven additional residents in the 300 hall with orders for blood sugar monitoring. During an observation, an LPN performed a fingerstick blood sugar (FSBS) test on one resident and then placed the glucometer on the medication cart without cleaning it. The same glucometer was later used on another resident without proper disinfection. The LPN admitted to not knowing the facility policy on cleaning and disinfecting the glucometer and used an alcohol wipe, which was not in accordance with the facility's policy. The facility's Environmental and Equipment Cleaning Policy, last revised in August 2019, required glucometers to be cleaned after each resident use with a bleach product disinfecting wipe and allowed to air dry before the next use. Alcohol was not considered an acceptable disinfectant for glucometers. Interviews with the LPN and the Regional Nurse confirmed the lack of adherence to the policy, as the LPN used a dry cloth and alcohol wipes instead of the required germicidal wipes. This oversight in following the established cleaning protocol led to the deficiency noted by the surveyors.
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
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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 Alliance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Alliance Ctr For Rehab & Nc Inc | 0.2 mi | ★★★★★ | 0 | 0 |
| Mccrea Manor Nsng And Rehab Ctr Llc | 2.1 mi | ★★★★★ | 15 | 0 |
| Canterbury Villa Of Alliance | 3.1 mi | ★★★★★ | 3 | 0 |
| Bel Air Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Green Meadows Skilled Nursing And Rehab | 5.8 mi | ★★★★★ | 6 | 0 |
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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.