Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roselawn Manor during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility failed to ensure at least 8 hours of consecutive RN coverage per day. Review of the nursing staff schedule showed no documentation of the required RN coverage on two days, and the Administrator verified the gap during interview. The facility census was 40.
Facility Assessment lacked documentation showing the number of qualified staff needed to meet resident needs. Review of the assessment found no support for how staffing needs were determined, and the Administrator confirmed the assessment did not include this information for the 40-resident census.
Failure to Follow EBP, Glucometer Sanitization, and Legionella Water Management Requirements: An LPN provided PEG tube care for a resident identified for EBP without wearing a gown, despite signage requiring gown and gloves for high-contact care. In separate observations, LPNs performed accuchecks on two residents and returned the glucometer to the cart without sanitizing it after each use, stating they only cleaned it at the start or end of the shift. Facility records also showed required water flushing and monitoring were not completed in inactive or unused areas under the Water Management Plan.
Medications were left at the bedside for a resident with moderate cognitive impairment who was dependent on staff for med administration. During observation, a clear plastic cup containing five meds was found on the over-the-bed table with no staff present, and an LPN verified the meds had been left there. The resident had orders for supplements, a stool softener, a beta blocker, and eye drops, and the facility policy stated the resident is always observed after administration to ensure the dose was completely ingested.
Kitchen sanitation and food storage practices were not maintained in accordance with professional standards. Open cans with black residue were found stored under the sink, the stove had black residue and food debris, and the dishwasher contained a thick black substance with a spoon embedded in it. Staff reported the dishwasher had been leaking for two months, and maintenance noted prior attempts to fix the leak and a planned replacement of the high-pressure line.
Delayed Medicare Non-Coverage Notice: A resident receiving skilled services under Medicare Part A had a NOMNC signed by the POA after the last covered day. The resident was cognitively intact and required assistance with bathing, bed mobility, transfers, and supervision with eating and toilet hygiene. The Administrator confirmed the notice should have been given at least 2 days before Medicare-covered services ended, but it was not provided timely.
IDT members did not attend a resident's care conferences as required by policy. A resident with Parkinson's disease, dementia, CKD stage III, a G-tube, essential tremor, and moderate ID was severely cognitively impaired and dependent for all ADLs. Care conference records showed attendance was limited to nursing and the Social Service designee at some meetings, and only the Social Service designee at another, while the resident's representative reported only the Social Service designee was present.
Failure to provide and document resident activities: A resident with Parkinson’s disease, dementia, CKD stage III, a G-tube, essential tremor, and moderate ID had severe cognitive impairment and was dependent on staff for all ADLs. The resident’s preferences included music, group activities, and religious programs, and the care plan called for regular invitations to exercise, music, Bingo, socials, and religious services. However, the record contained no activity participation documentation, and the AD stated that while staff provided 1:1 activities and the resident sometimes attended group activities, participation was not documented as required by policy.
A resident with bilateral UE contractures had orders for a left palm protector and right hand roll to be applied in the morning and removed at lunch, with skin checks. POC entries were repeatedly marked response not required, and multiple observations showed the resident in bed without the splints applied; a CNA confirmed they had not been placed on yet, and the DON verified there was no documentation of refusal or a noncompliant care plan.
Failure to address significant weight loss: A resident with anemia, anxiety, arthritis, and depressive disorder had a mechanical soft diet and no supplement orders, yet experienced a marked weight drop after a prior gain. Staff documentation noted the loss, but the DON confirmed there was no record that the change was discussed at the weekly Nutrition Risk meeting or that a cause was identified; the resident stated he was not eating the food and had recently lost his teeth.
Tube Feeding Not Labeled, Dated, or Timed: A resident with a gastrostomy and multiple serious diagnoses was observed receiving Nutren 2.0 at 45 ml/hr, but the tube feeding bag was not labeled, dated, or timed when it was hanging and running. An MDS staff member verified the issue, and the facility competency record required the nurse to label the container and spike set with the resident name, date, and time hung.
Medication administration failed to follow a physician order for one resident with HTN and Parkinson's disease. The resident was ordered metoprolol ER 25 mg daily with instructions to hold if BP was below 110 mmHg, yet the MAR showed the medication was given when BP readings were 108/60 and 88/46. The DON verified two doses were administered outside the ordered parameters, and facility policy stated physician orders are checked for the correct dosage scheduled.
A resident with Hemophilus meningitis and pneumonia had impaired cognition and was receiving quetiapine. Pharmacy recommended an AIMS evaluation due to the antipsychotic use, but the medical record showed no AIMS was completed, and the DON verified this during interview.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to ensure at least eight hours of consecutive RN coverage per day for seven days. Review of the nursing staff schedule from 05/19/26 to 05/25/26 showed no documentation supporting eight hours of consecutive RN coverage on 05/23/26 and 05/24/26. During an interview on 05/28/26 at 11:00 A.M., the Administrator verified that the facility did not have eight hours of consecutive RN coverage on those two days. The facility census was 40.
Facility Assessment Lacked Staffing Determination
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet residents’ needs during day-to-day operations and emergencies. Review of the Facility Assessment dated [DATE], reviewed on 03/12/26, showed no documentation supporting that the facility determined the number of qualified staff needed to provide care for residents. During an interview on 05/27/26 at 2:43 P.M., the Administrator confirmed the Facility Assessment did not contain documentation supporting the facility’s determination of the number of staff needed to provide care for the residents. The facility census was 40.
Failure to Follow EBP, Glucometer Sanitization, and Legionella Water Management Requirements
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed for a resident with an indwelling medical device. Resident #48 was admitted with diagnoses including acute on chronic respiratory failure with hypoxia, malignant neoplasm of the tonsil, tracheostomy status, and gastrostomy status. The care plan identified the resident as potentially requiring EBP and included interventions related to education and monitoring. During observation of medication administration, an LPN provided care and medications through the resident’s PEG tube without wearing a gown, even though signage on the bathroom door indicated the resident was in EBP and required staff to wear gown and gloves for high-contact care. The LPN later returned to the room with supplies to unclog the PEG tube and continued care with mask and gloves only, and the LPN confirmed she did not wear a gown because none was available in the room. The facility also failed to ensure glucometers were sanitized after accuchecks. During observation, an LPN checked blood sugars for two residents and returned the glucometer to the medication cart without sanitizing it after each use. The LPNs stated they used one glucometer for all residents on their respective halls and sanitized it only once at the start of the shift or at the end of the shift when cleaning the cart. In addition, review of the facility’s legionella records showed that monitoring and routine pipe flushing were not completed in portions of the building that were inactive or not in regular use, and the Project Manager confirmed the required water flushes had not been completed in accordance with the Water Management Plan.
Medications Left at Bedside
Penalty
Summary
Medications were left at the bedside for a resident who had moderate cognitive impairment and was dependent on staff for medication administration. The resident had diagnoses including epilepsy, nonrheumatic aortic valve stenosis, hypertension, and cognitive communication deficit. Active physician orders included bee pollen, docusate sodium, Theragran-M, calcium, metoprolol tartrate, sodium chloride ophthalmic solution, and artificial tears ophthalmic solution. During observation of the resident's room, a clear plastic medication cup containing five medications was found on the over-the-bed table with no staff present in the room. The resident stated the nurse was usually there and that she was thirsty, and said she should probably take her medications. An LPN later verified that the resident's medications had been left at the bedside and identified the medications in the cup as Theragran-M, calcium 600 mg, bee pollen 500 mg, metoprolol 50 mg, and Colace 100 mg. The facility policy stated the resident is always observed after administration to ensure the dose was completely ingested.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen stored, prepared, distributed, and served food in accordance with professional standards for food service safety. During observation of the kitchen, one six pound eleven ounce can of crushed pineapple, approximately half full, and one seven pound empty chocolate pudding can were found stored under the three-compartment sink with the lids left open and positioned upright. Both cans had black residue on the interior and exterior surfaces, and the findings were verified with the dietary staff member present. Further observation of the kitchen revealed black, loose residue and crumbled food debris around the gas burners of the stove, along with multiple dried streaks of an unidentified substance on the right side of the stove. In the back corner of the dishwasher, an area approximately eleven inches by eleven inches contained a thick black substance, and a spoon was found with its spoon head protruding from the substance and black residue adhered to the handle. The dietary staff member reported the dishwasher had been leaking for two months, and maintenance staff stated the leak had been thought to be fixed earlier with a clamp and that a plumbing contractor would later replace the high-pressure line. Facility policy stated the kitchen floors should be wet mopped after each meal service and the stove top cleaned daily with a diluted cleaner disinfectant.
Delayed Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided timely to Resident #17. The resident was admitted with diagnoses including traumatic subdural hemorrhage, CVA, hypertension, and epilepsy, later discharged to the hospital and then readmitted to the facility. Review of the end of PPS MDS assessment showed the resident was cognitively intact and required partial/moderate assistance with bathing, bed mobility, and transfers, with supervision for eating and toilet hygiene. The MDS also showed the resident’s last day of Medicare Part A coverage was 12/23/25. Review of the resident’s NOMNC showed Medicare’s last covered day was 12/23/25, but the form was signed on 12/24/25 by the resident’s power of attorney. During interview, the Administrator verified the resident received skilled services under Medicare Part A from 11/09/25 until 12/23/25 and confirmed the NOMNC should have been provided to the resident or representative at least two days before Medicare Part A services ended. Facility policy stated the NOMNC must be issued no later than two days before services are terminated.
IDT Members Did Not Attend Care Conferences
Penalty
Summary
The facility failed to ensure interdisciplinary team (IDT) members attended care conferences as required by facility policy for one resident reviewed for care conferences. Resident #26 was admitted on 11/16/18 with diagnoses including Parkinson's disease, dementia, chronic kidney stage III, gastrostomy tube, essential tremor, and moderate intellectual disabilities. The quarterly MDS assessment documented severe cognitive impairment and dependence on staff for all activities of daily living. Care conference documentation showed conferences were held on 10/10/25, 01/02/26, and 04/04/26, but the staff attendees were limited to nursing and the Social Service designee on two occasions, and only the Social Service designee on the third. The resident's representative stated she attended one care conference in the past year and only the Social Service designee was present. The Resident Service Coordinator verified the attendance records and confirmed the facility staff who attended those conferences. The facility policy required the care plan to be prepared by an IDT including the attending physician, RN, state tested nursing assistant with responsibility for the resident, food and nutrition staff, and other appropriate staff and disciplines as determined by the resident's needs, with participation of the resident, family, or representative to the extent practicable.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide activities to meet the physical, mental, and psychosocial needs of Resident #26 and failed to document the resident’s participation in activities as required by policy. Resident #26 was admitted on 11/16/18 with diagnoses including Parkinson’s disease, dementia, chronic kidney stage III, gastrostomy tube, essential tremor, and moderate intellectual disabilities. The quarterly MDS showed severe cognitive impairment and dependence on staff for all ADLs. The Resident Preference Evaluation dated 06/25/25 stated it was important to the resident to listen to music, do things with groups of people, and participate in religious activities. The activity care plan dated 11/28/18 stated the resident enjoyed being active in the care community daily, including attending activities and sitting in the lounge with others, and identified interventions such as inviting the resident to exercise classes, music programs, Bingo, parties, socials, and religious programs. Review of the medical record revealed no documentation of activity participation. Observations on 05/26/26 and 05/27/26 showed Resident #26 sitting in a specialty chair in the common area in front of the television. On 05/27/26, no other residents were observed sitting in the common area. The Activity Director stated on 05/28/26 that activity staff provided one-on-one activities with Resident #26 two times per week, including listening to music, hand massages, or grooming, and that the resident did attend group activities at times, but the activity department did not document the resident’s participation in group or individual activities. The facility policy stated that records maintained by the Activity Coordinator include activity assessment, individual participation documentation, calendar of events, activity progress notes, and overall plan of care-activities.
Failure to Apply Ordered Hand Splints
Penalty
Summary
The facility failed to ensure splints were applied per physician order for a resident with contractures of the right hand, left hand, right elbow, and left elbow. The physician ordered a left blue palm protector and a right hand small tan hand roll, or washcloth if needed, to be applied in the morning at breakfast time and removed at lunch time for about four hours with skin monitoring. The care plan also directed staff to assist with bilateral hand splints after morning care or hand hygiene, remove them at the end of first shift or as tolerated, and perform skin checks before application and after removal. Review of the Point of Care aide documentation for the prior 30 days showed multiple entries marked as response not required for the hand splint task. Observations on 05/27/26 and 05/28/26 showed the resident in bed with no hand splints applied at several times throughout the morning and early afternoon. On 05/27/26, the CNA stated the resident had not yet been seen and that splints are usually applied when the resident is gotten ready in the morning. On 05/28/26, the CNA verified the splints had not been applied yet that day. The DON stated the resident had an order for a washcloth or calcium alginate because the hand gets moist at times, and verified the POC should not have been documented as response not required or not applicable, and there was no noncompliant care plan or documentation showing the resident refused the hand splints.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to address a resident’s significant weight loss. Resident #05 was admitted with diagnoses including anemia, anxiety, arthritis, and depressive disorder, and was cognitively intact but dependent on staff for several activities of daily living. The resident was on a mechanical soft diet with thin liquids and had no physician orders for meal supplements or changes in diuretics. The weight record showed a gain to 293.0 pounds, followed by a drop to 270.8 pounds and then 263.0 pounds within a short period of time. A nutrition note documented that the resident had been reviewed and that the resident continued to have good intake, but also noted the recent significant weight loss. The resident told the surveyor that he had lost a lot of weight because he did not eat the food and that his diet had been changed to mechanical soft after all of his teeth were pulled. The corporate dietician stated that residents with significant weight changes should be reweighed within a day or two and discussed at the weekly Nutrition Risk Meeting. The DON stated the facility did not have documentation showing the resident’s significant weight loss was discussed at the weekly Nutrition Risk Meeting to determine possible causes or needed interventions, and verified there had been no diuretic changes in March or April that would explain the loss. The facility policy required monthly weights, more frequent monitoring when indicated, reweighing within a reasonable time frame for a 5% significant weight change, and assessment by the Nutrition at Risk committee for possible causes.
Tube Feeding Not Labeled, Dated, or Timed
Penalty
Summary
The facility failed to ensure enteral nutrition was labeled, dated, and timed for one resident receiving tube feeding. Resident #48 was admitted on 01/02/26 and had diagnoses including acute/chronic respiratory failure with hypoxia, malignant neoplasm of the tonsil, tracheostomy status, and gastrostomy status. Physician orders included Nutren 2.0 at 45 ml per hour every shift, changing the syringe daily, and documenting total intake of enteral feed and water flushes three times daily. During observation on 05/27/26 at 8:26 A.M., the resident was resting in bed with Nutren tube feeding hanging on the pole and running at 45 ml per hour, but the Nutren bag was not labeled, dated, or timed as to when it was hung. The MDS staff member verified during interview at 8:38 A.M. that the tube feed was not labeled, dated, or timed. The skills demonstration/evaluation record for feeding tube closed system stated that the nurse labels the container and spike set with the resident name, date, and time hung.
Medication Administered Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure staff followed physician orders for medication administration for one resident out of five reviewed for medication errors. Resident #21, admitted on 11/14/23 with diagnoses including displaced simple supracondylar fracture of the right humerus, hypertension, subsequent encounter for fracture with routine healing, and Parkinson's disease, had a physician order dated 03/19/24 for metoprolol succinate ER 25 mg daily for essential hypertension, with instructions to hold the medication if blood pressure was less than 110 mmHg. Review of the MAR showed that on 04/11/26 the resident's blood pressure was 108/60 mmHg and metoprolol was administered, and on 05/14/26 the blood pressure was 88/46 mmHg and metoprolol was again administered. The resident's quarterly MDS showed cognitive impairment with a BIMS score of 08. During interview, the DON verified the resident received two doses of metoprolol outside the physician ordered parameters. Facility policy stated physician orders are checked for the correct dosage scheduled.
Failure to Follow Pharmacy Recommendation for AIMS Monitoring
Penalty
Summary
The facility failed to ensure pharmacy recommendations were acted upon for one resident reviewed for pharmacy recommendations. Resident #01 was admitted with diagnoses of Hemophilus meningitis and pneumonia, had impaired cognition with a BIMS score of 09, and was receiving an antipsychotic medication. The care plan identified altered neurological status related to Hemophilus meningitis and risk for high falls related to psychoactive drug use. A pharmacy recommendation dated 03/30/26 called for an AIMS evaluation because the resident was receiving quetiapine, but review of the medical record showed no AIMS evaluation was completed. During interview on 05/27/26, the DON verified that no AIMS evaluations were completed for Resident #01.
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 147 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 Spencerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows Of Delphos The | 8.2 mi | ★★★★★ | 1 | 0 |
| Vancrest Of Delphos | 9.7 mi | ★★★★★ | 1 | 0 |
| Springs Of Lima The | 9.9 mi | ★★★★★ | 0 | 0 |
| Shawnee Manor | 10.6 mi | ★★★★★ | 1 | 0 |
| Otterbein-cridersville | 11.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Roselawn Manor.
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 October 2026) and official state health department websites.