Roselawn Manor

In the surveyor’s words

From the most serious findings on record at Roselawn Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727May 28, 2026

  Based on facility staffing review and staff interview, the facility failed to ensure at least eight hours of consecutive Registered Nurse (RN) coverage per day for seven days. This had the potential to affect all residents who reside in the facility. The facility census was 40.Findings include:Review of the nursing staff schedule from 05/19/26 to 05/25/26 revealed no documentation to support the facility had eight hours of consecutive RN coverage on 05/23/26 and 05/24/26.Interview on 05/28/26 at 11:00 A.M., the Administrator verified the facility did not have eight hours of consecutive RN coverage on 05/23/26 and 05/24/26.

• No harm, potential for more than minimal, widespreadF838May 28, 2026

  Based on facility document review and staff interview, the facility failed to ensure the Facility Assessment included the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the residents' needs. This had the potential to affect all the residents. The facility census was 40.Findings include:Review of the Facility assessment dated [DATE], which was reviewed on 03/12/26 revealed no documentation to support the facility determined the number of qualified staff needed to provide care for the residents. During an interview on 05/27/26 at 2:43 P.M., the Administrator confirmed the Facility Assessment did not contain documentation to support the facility determining the number of staff that would be needed to provide care for the residents.

• No harm, potential for more than minimal, widespreadF880May 28, 2026

  Based on record review, observation, staff interview, and policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed. This affected one (#48) of four residents reviewed for EBP. The facility failed to ensure glucometers were sanitized following accuchecks. This had the potential to affect seven (#8, #9, #11, #20, #28, #32, and #41) who the facility identified as receiving accuchecks testing on the E and D-halls. The facility also failed to ensure the measures to prevent the growth of Legionella were completed. This had the potential to affect all residents who reside in the facility. […]

• No harm, potential for more than minimal, patternF761May 28, 2026

  Based on record review, observation, staff interview, and policy review the facility failed to ensure medications were not left at the bedside. This affected one (#33) of four residents observed during med pass. The facility identified 10 residents (#9, #14, #16, #22, #27, #31, #32, #33, #38 and #41) who were independently mobile whether ambulatory or wheelchair on D-hall. The facility census was 40. Findings include: Review of medical record for Resident #33 revealed an admission date of 11/15/24 with diagnoses including but not limited to epilepsy, nonrheumatic aortic (valve) stenosis, hypertension, and cognitive communication deficit.Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF812May 28, 2026

  Based on observation, staff interview and facility policy, the facility failed to ensure the kitchen stored, prepared, distributed and served food in accordance with professional standards for food service safety. This had the potential to affect 36 out of 40 residents who received food from the kitchen. Four Residents (#23, 26,37, and 48) do not receive food from the kitchen. The facility census was 40.Findings include:Observation of the kitchen on 05/26/26 at 7:47 A.M., with [NAME] #265, revealed one six pound eleven ounce can of crushed pineapple, approximately half full, and one seven pound empty chocolate pudding can being stored under the three compartment sink with the lids left open and positioned upright. Both cans contained black residue on the interior and exterior surfaces. […]