Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Roane General Hospital during CMS and state inspections, most recent first.
Failure to Process Resident Grievances Promptly: Multiple resident complaints were voiced in Resident Council meetings about missing belongings, CNA behavior, room conditions, safety issues, and equipment repairs, but they were not handled as grievances. The DON stated there had been no grievances for the year despite ongoing concerns from residents, including missing blankets, clothing, underwear, delayed call light response, and other unresolved issues.
Late completion of Quarterly MDS assessments was identified for two residents reviewed during survey. The MDSs were submitted after the 14-day completion window, and the MDS Coordinator verified the late submission during interview.
A facility failed to document physician actions or clinical rationales for multiple pharmacy GDR recommendations involving antidepressant and anxiolytic medications. The DON agreed that the physician did not provide the required documentation for several residents. In another case, an LPN and the VPNS identified an irregularity in a Buspirone order when the resident was receiving a single 7.5 mg tablet in bubble packs despite the order specifying 0.25 of a 30 mg tablet.
Infection prevention and control deficiencies were observed throughout the facility. At the nurses' station, staff had personal drinks and one nurse was eating despite policy prohibiting food and drink there. An EBP sign for a resident was blocked by a decoration, an LPN handled meds with ungloved hands and without a barrier during pass, the soiled laundry room venting system was not working and a fan blew air toward the clean laundry room, and the back shower room had cracked tiles and uncleanable material around pipes.
PASARR Diagnosis Mismatch: A resident’s PASARR did not match the medical record, care plan, and medication profile. The resident had diagnoses including anxiety, major depressive disorder, chronic paranoid schizophrenia, and bipolar disorder, but the PASARR listed schizophrenia-related findings and dementia instead of anxiety, major depressive disorder, or bipolar disorder. The MDS Coordinator stated she did not know why the documents did not match and agreed they should.
A resident had monthly weights ordered and showed significant weight gains, but there was no documentation that the DON or staff notified the physician of either increase. The resident’s care plan directed staff to monitor weights and report significant weight changes to the physician, and the DON confirmed the care plan was not implemented as written.
A resident’s care plan was not revised to reflect current diagnoses and medications. The record showed anxiety, major depressive disorder, chronic paranoid schizophrenia, and bipolar disorder, but the care plan did not include all listed conditions and omitted Lamotrigine from the medication-related care plan despite active orders for Xanax, Lamotrigine, Citalopram, Rexulti, and Zyprexa. The MDS coordinator confirmed the care plan had not been updated.
Failure to Notify Physician of Significant Weight Gain: A resident had monthly weights ordered and showed significant weight gains on two occasions, but there was no documentation that the DON or staff notified the physician of either change. The resident’s care plan directed staff to monitor weights and report significant weight changes to the physician, and the DON confirmed the notifications were not made.
A resident had two current medication orders without documented medical indications in the problem list: furosemide 40 mg daily and citalopram 20 mg daily. During record review, the omission was confirmed by the DON, who agreed it should have been identified during the pharmacy MRR.
A resident was not offered the option to receive or decline the COVID-19 vaccine and was not provided with documented education about the vaccine. A review of immunization records found no COVID education, offer, consent, or declination documentation, and the IP confirmed that no such records were available.
A resident’s alleged neglect concern involved being assisted to a wheelchair without the physician-ordered Hoyer lift. The complaint was investigated, but the DON confirmed it was not reported to the appropriate agencies within the required time frame, stating the event occurred over a weekend and was not reported. She also stated that neglect concerns should be reported to APS, OHFLAC, and the State or regional LTC Ombudsman within 24 hours.
Incomplete investigation of resident bruising and dependent resident assessment: An LPN reported visible bruising on a resident’s left underarm and upper arm, and the facility’s investigation remained inconclusive about how the injury occurred. Staff interviews noted concerns about improper transfer techniques and that the resident should always have been transferred with a full body lift, but the DON confirmed that no other dependent residents were interviewed or assessed for injury after the incident was reported.
Failure to Process Resident Grievances Promptly
Penalty
Summary
The facility failed to follow its grievance process by not making prompt efforts to resolve resident complaints and by not keeping residents notified of progress toward resolution. Record review of Resident Council minutes for the prior six months showed multiple complaints brought to the Activity Director, including missing personal belongings, CNA actions and attitudes, room conditions, safety concerns, and furniture repairs. The Director of Nursing stated there had been no grievances for 2025, even though the minutes documented repeated resident complaints involving missing clothing, underwear, blankets, water pitchers not being filled or checked, call lights not being answered in a timely manner, and other concerns. During a Resident Council meeting, ten residents present confirmed that not all of the listed concerns had been addressed, especially missing items. The documented issues included Resident #19 missing clothing and underwear, Resident #2 not getting blood sugar checks in the morning and wanting a wheelchair checked, Resident #23 and Resident #3 reporting missing blankets and water pitchers not being filled or checked, Resident #123 reporting a bed that would not rise, and other complaints about room repairs, television problems, and staff behavior. On 09/23/25, the DON confirmed that these instances should have been filed as grievances and addressed in a timely manner so documentation would be available.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments in a timely manner for two of six residents reviewed during the long-term survey process. For Resident #1, the Quarterly Minimum Data Set (MDS) assessment was completed late, with the assessment completion date more than 14 days after the assessment reference date, and the assessment was submitted on 09/04/25. For Resident #7, the Quarterly MDS assessment dated 08/08/25 was also completed late, with the assessment completion date more than 14 days after the assessment reference date, and the assessment was submitted on 09/04/25. During interview on 09/24/25 at 1:55 PM, the MDS Coordinator verified that the submission date was past the 14-day assessment completion date.
Pharmacy Review and Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews and gradual dose reduction (GDR) recommendations were documented with physician actions or clinical rationales when no action was taken. For Resident #3, a pharmacy recommendation dated 04/18/25 stated the resident was due for a GDR assessment for Bupropion and Escitalopram, both ordered for depression, but the physician did not consider a GDR and did not document a clinical rationale for not doing so. For Resident #18, a pharmacy recommendation dated 11/28/25 stated the resident was due for a GDR assessment for Duloxetine, the first of two recommended GDR assessments within the first year of the order, but the physician did not accept the recommendation or provide a rationale for not completing the GDR. For Resident #4, a pharmacy recommendation dated 05/25/25 stated the resident was due for a GDR assessment for Citalopram, which was ordered for anxiety and depression, but the physician declined the recommendation without documenting a clinical rationale. During interview, the DON agreed the physician had not signed or provided documentation of clinical contraindications for Residents #18, #4, and #3. In addition, Resident #27’s medication order for Buspirone 7.5 mg PO BID, written on 03/22/25, specified administration of 0.25 tablet of a 30 mg tablet, but review of the medication cart showed bubble packs containing single 7.5 mg tablets in each pouch; the LPN stated the resident was dispensed a single tablet during the morning medication pass, and the VPNS confirmed there was an irregularity in the medication order that needed revision to reflect accurate dispensing.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. During observation at the nurses' station, three nurses had personal drinks at the station and one nurse was eating there, despite the facility infection control policy stating there was to be no food or drink at the nurses' station. The Director of Nursing later confirmed that nurses were not to have food or drink at the station. Enhanced Barrier Precautions were not followed for a resident whose door had an EBP sign that was blocked by a large pumpkin decoration, preventing the sign from being visible to anyone entering the room. During medication pass, an LPN removed pills from a bubble pack into an ungloved hand, placed them in a medication cup, then picked up a pill that fell on the medication cart without gloves and placed it in the cup. In addition, the soiled laundry room venting system was non-functional, a fan was blowing toward the clean laundry room door, and cracked shower room floor tiles and uncleanable material covering pipes next to the commode were observed in the back shower room.
PASARR Diagnosis Mismatch
Penalty
Summary
The facility failed to submit the correct admitting diagnosis on a Preadmission Screening and Resident Review (PASARR) for one resident. Record review showed the resident had diagnoses of generalized anxiety disorder, major depressive disorder, chronic paranoid schizophrenia, and bipolar disorder, while the latest PASARR dated 05/18/21 listed schizophrenia disorder, hallucinations, delusional, disoriented, seriously impaired judgment, and dementia. The PASARR did not reflect anxiety, major depressive disorder, or bipolar disorder, even though the care plan included anxiety, major depressive disorder, and schizophrenia, and did not include dementia or bipolar disorder. The resident was also ordered Xanax for anxiety, Lamictal, Citalopram, Rexulti, and Zyprexa, and the MDS Coordinator stated she did not know why the two documents did not match and agreed they should.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to implement the care plan for Resident #1’s nutritional status related to weights. Record review showed an order for monthly weights, and the resident had a 14% weight gain on 05/10/25 and an 11% weight gain on 05/14/25. According to the DON, there was no documentation that the Physician was notified of either significant weight gain. The facility policy for Long Term Care Significant Weight Change states that the Physician and MPOA will be notified of a significant weight change. Review of the resident’s care plan created 07/24/25 for nutritional status showed the approach was for staff to monitor weights and report significant weight changes to the physician, and the DON confirmed on 09/23/25 that the facility did not implement the care plan as written.
Care Plan Not Updated to Match Current Diagnoses and Medications
Penalty
Summary
The facility failed to update the care plan to reflect current medications and diagnoses for five of five residents reviewed for unnecessary medications. For Resident #4, the medical record listed generalized anxiety disorder, major depressive disorder, chronic paranoid schizophrenia, and bipolar disorder, but the care plan only reflected anxiety, major depressive disorder, and schizophrenia; dementia or bipolar were not care planned. The resident was ordered Xanax 0.5 mg three times daily for anxiety disorder, Lamotrigine 100 mg twice daily for schizophrenia, Citalopram 20 mg daily, Rexulti for schizophrenia, and Zyprexa 5 mg for schizophrenia, yet the care plan did not include Lamotrigine. When the MDS Coordinator was asked about the care plan on 09/23/25 at 01:45 PM, she agreed that it had not been revised.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to follow its policy to notify the physician regarding significant weight changes for Resident #1. Record review showed an order for monthly weights, and the resident had a 14% weight gain on 05/10/25 and an 11% weight gain on 05/14/25. The Director of Nursing confirmed on 09/23/25 that there was no documentation that the physician was notified of either weight gain. The facility policy for Long Term Care Significant Weight Change stated that the physician and Medical Power of Attorney would be notified of a significant weight change. The resident’s care plan for nutritional status, created on 07/24/25, directed staff to monitor weights and report significant weight changes to the physician, and the DON later confirmed that the facility did not notify the physician of either weight gain.
Missing Medication Indications in Resident Record
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure that every resident's medication regimen was managed safely and effectively with medical indications included. During record review for unnecessary medications, Resident #48 was found to have two currently ordered medications without a documented indication in the problem list: Furosemide 40 mg daily, ordered 11/04/22, and Citalopram hydrochloride 20 mg daily, ordered 09/12/23. The omission of indications for these medications was confirmed with the DON, who agreed that the issue should have been identified during the pharmacy medication regimen review.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that Resident #10 was offered the option to receive or decline the COVID-19 vaccine and was not provided appropriate education about the vaccine. During a review of immunization records, surveyors found no records of COVID education or documentation that the COVID vaccine had been offered to Resident #10. The Infection Preventionist stated during interview that there were no records, consents, or declinations for the COVID vaccine for Resident #10.
Failure to Timely Report Alleged Neglect Concern
Penalty
Summary
The facility failed to timely report an alleged neglect-related complaint involving Resident #21 after a concern was identified during a Facility Reported Incident investigation. The complaint stated that Resident #21 was assisted to a wheelchair without the physician-ordered Hoyer lift. Record review showed the complaint was investigated, but it was not reported to the appropriate agencies within the required time frame. During interview, the DON confirmed the complaint was not reported timely and stated the incident occurred over a weekend and did not get reported. She also stated that concerns and grievances about neglect in resident care should be reported to APS, OHFLAC, and the State or regional LTC Ombudsman within 24 hours.
Incomplete Investigation of Resident Bruising and Dependent Resident Assessment
Penalty
Summary
The facility failed to conduct a thorough investigation into a Facility Reported Incident involving Resident #38 after an LPN reported visible bruising on the left underarm and left upper arm. The investigative record noted a purple bruise extending from the mid-clavicular left chest to the proximal upper left arm and toward the elbow, with normal range of motion and physician notification. Staff interviews were completed with caregivers who worked during the days surrounding the incident, but the investigation remained inconclusive as to how the bruising occurred. The record also noted that multiple staff reported improper transfer techniques and that Resident #38 should always have been transferred using a full body lift, while some staff stated it was easier to pivot the resident instead of using the ordered lift. The facility also failed to interview and assess all dependent residents to confirm they had not suffered harm or injury after the incident was reported. During the investigation, the DON confirmed that staff members had been questioned about Resident #38’s care, but no other dependent residents were interviewed or assessed for injury soon after the incident. The report further states that the roommate was incapacitated and unable to provide insight into the injury, and several staff members involved in the resident’s care were unavailable for interview at the time of the later review.
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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.
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Nursing homes near Spencer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miletree Center | 0.3 mi | ★★★★★ | 10 | 0 |
| Elizabeth Care Center | 16.7 mi | ★★★★★ | 11 | 0 |
| Minnie Hamilton Health Care | 16.7 mi | ★★★★★ | 23 | 0 |
| Mountain View Care Center | 19.1 mi | ★★★★★ | 7 | 0 |
| Clay Healthcare Center | 22.4 mi | ★★★★★ | 0 | 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.