Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Axiom Healthcare Of Rosiclare during CMS and state inspections, most recent first.
The facility failed to maintain a full-time DON and did not have an RN on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency affected all 34 residents, with multiple dates lacking RN coverage. Staff interviews confirmed the absence of a DON since April 2024 and ongoing efforts to hire a full-time RN. Despite the lack of RN coverage, no residents currently require treatments that only RNs can perform.
A facility failed to complete a Level II PASRR for a resident diagnosed with a psychotic disorder. The resident was admitted with a diagnosis requiring a Level II screening, but the PASRR Level I outcome incorrectly stated no Level II was needed. The Business Office Manager was unaware of the oversight, and the administrator acknowledged the error, noting non-compliance with the facility's PASRR policy.
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by inadequate documentation and follow-up on gradual dose reduction (GDR) recommendations for two residents. One resident was prescribed multiple psychotropic medications without a documented rationale for declining a GDR, and there was a significant delay in addressing the pharmacist's recommendation. Another resident did not receive timely evaluations for GDRs, with a lapse in the required quarterly assessments. The facility lacked a specific GDR policy, contributing to these deficiencies.
Two residents with severe cognitive impairment and incontinence were not repositioned or provided with incontinence care as required by their care plans. Both residents remained in the day area for nearly three hours without being checked, leading to skin redness and soiled undergarments. The facility's policy on preventative skin care was not followed, resulting in a deficiency.
The facility failed to maintain an effective pest control program, leading to the presence of flies and roaches, potentially affecting all 40 residents. Observations revealed live roaches in the kitchen and multiple flies in the dining area. Residents reported seeing pests in their rooms, and staff confirmed the issue, noting that the exterminator had visited but the problem persisted. The facility's pest control policy requires monthly treatments, but these measures were insufficient to control the infestation.
The facility failed to adhere to food safety and sanitation standards, with uncovered and undated food in the refrigerator and unsanitary conditions in the kitchen, including pest issues and residue buildup. The absence of pest control services since December 2023 and inadequate cleaning practices contributed to these deficiencies, potentially affecting all 40 residents.
A high-risk resident in an LTC facility developed an unstageable pressure ulcer on the right heel due to the facility's failure to implement necessary interventions. Despite the resident's severe cognitive impairment and total dependence on staff, the care plan to float heels was not consistently followed. Observations showed the resident's heels were often flat on the bed, and the facility's wound tracking logs initially failed to document the new ulcer. The facility lacked a DON to oversee wound care, and the MDS Coordinator was unable to manage all responsibilities, contributing to the deficiency.
The facility failed to maintain an effective pest control program, affecting all 40 residents. Surveyors observed roaches and flies, and staff confirmed the absence of pest control services since December 2023. Residents and staff reported sightings of various pests, and the facility had not implemented internal measures to address the issue.
The facility failed to ensure privacy for female residents by not providing adequate curtains for commode stalls in the women's bathroom. Observations showed that only one of three stalls was fully covered, while the others were either partially covered or lacked curtains entirely. Interviews with staff and residents indicated that this issue had persisted for months, violating residents' rights to dignity and respect.
A resident in an LTC facility was consistently woken up early by staff to assist the day shift, despite their preference to sleep in. The facility's care plan did not address the resident's waking time preferences, and the resident's family had previously raised concerns. Staff interviews and the resident's own statements confirmed the early waking practice, which contradicted the facility's policy on resident rights.
A facility failed to report an alleged abuse incident to the State Survey Agency. A family member reported seeing a nurse yelling at and pushing a resident, but the facility's investigation could not substantiate the claim due to a lack of specific identification. The resident involved had a severe cognitive deficit and hearing issues, requiring specific communication strategies. Despite the facility's policy, the administrator did not report the incident, citing the absence of a specific resident name.
A facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with severe cognitive deficits and hearing impairment. The incident was reported by a visitor who observed a nurse allegedly yelling at and pushing the resident. The facility's administrator did not initiate a new investigation, believing it to be the same as a previous unsubstantiated incident, and did not follow the facility's comprehensive investigation policy.
The facility failed to provide timely incontinence care for two residents with moderate cognitive impairments. One resident was left in saturated clothing for an extended period, despite staff claims of having provided care. Another resident was observed with wet clothing and a wet chair cushion, indicating a lack of timely assistance. The facility's administrator acknowledged the expectation for timely care to prevent skin issues, highlighting a failure to adhere to care plans.
A resident with severe cognitive deficits and a high risk of falls did not have the prescribed body pillow in place to prevent rolling out of bed, as observed on multiple occasions. Despite the care plan's directive and previous incidents, staff failed to ensure the intervention was consistently implemented, citing the pillow was in the laundry. The facility's fall prevention policy was not adequately followed, leading to a lapse in safety measures.
A resident with moderate cognitive impairment and multiple diagnoses did not receive incontinence care per current standards. A CNA failed to wash near the labia during perineal care and did not perform proper hand hygiene after removing gloves. The facility's policy requires washing the pubic area, including the labia, and washing hands after glove removal.
Failure to Maintain RN Coverage and Director of Nursing
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) and did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through observation, interviews, and record reviews. The facility's nursing schedules revealed multiple dates where there was no RN coverage, affecting the care of all 34 residents residing in the facility. The absence of a DON has been ongoing since April 29, 2024, and the facility has been actively trying to hire a full-time RN to address this issue. Interviews with facility staff, including the Administrator, Regional Manager, Assistant Director of Nursing, and a Licensed Practical Nurse (LPN), confirmed the lack of RN coverage and the absence of a DON. The Assistant Director of Nursing, who is an LPN, stated that there has not been a DON since she started working at the facility in June 2024. Additionally, the LPN mentioned that there are many days without an RN on shift, although currently, no residents require treatments that only RNs can perform, such as intravenous antibiotics. The facility's personnel policy emphasizes compliance with federal, state, and local laws, but the current staffing situation does not meet these standards.
Failure to Complete PASRR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident diagnosed with a mental disorder. The resident, identified as R27, was initially admitted to the facility on January 23, 2023, and had a current admission date of May 10, 2024, with a diagnosis of psychotic disorder with delusions. Despite this diagnosis, the PASRR Level I Screen Outcome dated May 7, 2024, indicated that no Level II screening was required, stating there was no evidence of a PASRR condition of an intellectual/developmental disability or serious behavioral health condition. However, the resident was prescribed Zyprexa for altered mental status, which was not reflected in the PASRR Level I determination. The Business Office Manager, responsible for ensuring PASRR screenings, was unaware of why a Level II screening was not completed for R27, as the admission occurred before her employment. The facility's administrator acknowledged the error and noted that the staff did not follow the facility's PASRR policy, which requires a Level II screening referral if the Level I screen indicates a mental disorder. The facility's policy, dated November 13, 2018, outlines the procedure for conducting Level I screens and referring for Level II screenings when necessary, which was not adhered to in this case.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically in the cases of two residents, R5 and R24. R5 was prescribed multiple psychotropic medications, including sertraline, without a documented patient-specific rationale for declining a recommended gradual dose reduction (GDR). The physician, V6, did not provide the required rationale for why a GDR was clinically contraindicated, and there was a significant delay in addressing the pharmacist's recommendation, as the consultation report was not signed until over two months later. For R24, the facility did not conduct timely evaluations for GDRs of Risperidone, as required by CMS guidelines. Although a GDR was accepted by the physician in August 2023, there was no subsequent pharmacy consultation report available for August 2024, when the next GDR was due. The facility only provided a new consultation report during the survey in November 2024, indicating a lapse in the required quarterly evaluations. The facility lacked a specific GDR policy, and the administrator was unaware of whether the new owners had implemented one. This lack of policy and adherence to regulatory guidelines contributed to the failure to ensure residents were free from unnecessary medications, as evidenced by the delayed and incomplete documentation and follow-up on GDR recommendations.
Failure to Assist with Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with repositioning and incontinence care for two residents, R5 and R15, who were dependent on staff for these activities of daily living. R5, who has severe cognitive impairment and is always incontinent of bowel and bladder, was observed sitting in a geriatric recliner in the day area for nearly three hours without being repositioned or receiving incontinence care. Despite the care plan indicating the need for repositioning and peri care every two hours, R5 remained in the same position, leading to noted redness in the peri area and thighs when care was eventually provided. Similarly, R15, who also has severe cognitive impairment and requires substantial assistance for toileting and dressing, was observed in a wheelchair in the day area for the same duration without being repositioned or receiving incontinence care. R15's care plan also required checks every two hours and assistance with toileting, which was not adhered to, as evidenced by the presence of urine in the disposable undergarment when care was finally given. Both residents' care plans and the facility's policy on preventative skin care were not followed, resulting in a deficiency in the care provided.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches, which could potentially affect all 40 residents. During the survey, live roaches were observed under the three-compartment sink and in the dry food storage area, while multiple flies were seen in the food preparation area. The Dietary Manager acknowledged the issue, stating that the exterminator had visited and was expected to return soon. However, the presence of pests persisted, as evidenced by multiple observations of flies in the dining room over two days. Residents also reported issues with pests. An alert and oriented resident mentioned having seen flies frequently, with one observed flying around her head and over her bed table. Another resident reported seeing roaches in his room and stated he would stomp on them when seen. Staff members, including cooks and dietary aides, confirmed the presence of roaches and flies, indicating that they had informed the Maintenance Director, who had been spraying. The Maintenance Director and Administrator both acknowledged the pest problem, with the Administrator noting that the pest control company was aware of the infestation and had indicated it could take six months to a year to eradicate the roaches. The facility's pest control policy requires monthly preventative treatments, with additional treatments as needed, but it appears these measures were insufficient to control the pest issue effectively.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and maintain a sanitary environment in the kitchen, which has the potential to affect all 40 residents residing in the facility. During the survey, it was observed that fruit in the refrigerator was left uncovered and undated, contrary to the facility's policy requiring all food to be covered and dated. Additionally, a roach was seen crawling in the kitchen, and the Dietary Manager acknowledged an increase in roaches due to the absence of pest control services since December 2023. The Administrator confirmed that pest control services had been called but had not yet arrived. Further observations revealed unsanitary conditions in the kitchen, including a trash bag with dirty linens on the floor, a scaly and rust-colored residue on the ice machine, and a soiled wet blanket on the floor due to a backed-up drain. The kitchen floors and walls were dirty, with greasy and black residues observed in various areas. The Maintenance Director and a Dietary Aid acknowledged the presence of these residues and stated that cleaning efforts were underway, although a deep clean had not yet been completed. The facility's policies on kitchen sanitation and refrigerator storage were not being followed, contributing to the unsanitary conditions.
Failure to Prevent Pressure Ulcer Development in High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of new pressure ulcers for a resident identified as high risk. The resident, who was severely cognitively impaired and totally dependent on staff for activities of daily living, developed an unstageable pressure ulcer on the right heel. Despite having a care plan that included floating the heels while in bed, this intervention was not consistently implemented, as observed during multiple instances where the resident's heels were flat on the bed. The resident's medical history included conditions such as dementia, diabetes mellitus, and decreased mobility, which increased the risk for pressure ulcers. The facility's records indicated that the resident was on a standard mattress instead of a specialized air loss mattress, which was recommended for high-risk individuals. The facility's staff, including CNAs and an LPN, were aware of the need to float the resident's heels but failed to do so consistently. Additionally, the facility's wound tracking logs did not initially document the pressure ulcer on the right heel, indicating a lack of timely identification and monitoring. The facility's staff, including the MDS Coordinator/Infection Preventionist, acknowledged the oversight in wound care and prevention. The physician expected the facility to follow orders for wound care and prevention, including the use of specialized mattresses and floating the heels. However, the facility did not have a Director of Nursing to oversee wound care, and the MDS Coordinator was unable to fulfill all the responsibilities due to limited availability. This lack of oversight and adherence to care plans contributed to the development of the unstageable pressure ulcer on the resident's right heel.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which has the potential to affect all 40 residents residing there. On multiple occasions, surveyors observed pests such as roaches and flies within the facility. The Dietary Manager acknowledged the absence of pest control services and noted an increase in roach sightings. The Maintenance Director provided an outdated pest control summary and was unable to confirm any recent pest control visits, citing a possible company bankruptcy as a reason for the lapse in service. Additionally, the Administrator confirmed that no pest control services had been conducted since December 2023 and expressed concerns about using chemicals suggested by the pest control company. Residents and staff reported sightings of roaches, spiders, water bugs, ants, and flies throughout the facility. A family member was observed swatting flies away from a resident's food, and several CNAs confirmed the presence of flies and roaches. Despite having a policy that mandates monthly pest control treatments, the facility had not implemented any internal measures to mitigate the pest issue. The Administrator mentioned that the pest control company had been contacted but had not yet visited the facility as scheduled.
Privacy Violation in Women's Bathroom
Penalty
Summary
The facility failed to protect the privacy of its female residents by not providing adequate curtains or doors to cover the commode stall areas in the women's common bathroom. During the survey, it was observed that out of three commode stalls, only one had a curtain fully covering it, while the second stall had a curtain that was missing hooks and could only partially cover the entrance. The third stall had no curtain at all. Interviews with staff and residents revealed that the curtains had been missing or inadequate for an extended period, with some staff indicating that the issue had persisted since they began working at the facility. Residents expressed uncertainty about the absence of curtains, and staff members provided inconsistent explanations, suggesting that the curtains were either in the laundry or had been missing for months. The facility's administrator acknowledged the issue and mentioned plans to replace the curtains. The lack of privacy in the bathroom area was a clear violation of the residents' rights to dignity and respect, as outlined in the facility's resident rights policy.
Failure to Honor Resident's Right to Choose Waking Time
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing them to choose their waking time. A resident, identified as R12, was consistently woken up early by the midnight shift staff to assist the day shift, despite the resident's preference to sleep in. This practice was confirmed by multiple staff members and the resident's family member, who had previously raised concerns during a care plan meeting. The facility's care plan for R12 did not address the resident's preferences regarding waking times, and the resident's assessment indicated it was somewhat important for them to choose their own bedtime, but did not document their preferred waking time. Interviews with staff and the resident's roommate revealed that R12 was routinely woken up at 5:00 AM, even though the resident expressed a desire not to be up that early. The facility's administrator claimed that R12 only got up early when they wanted to, but this was contradicted by the resident's own statements and observations from others. The facility's policy on resident rights, provided to the surveyor, stated that residents have the right to choose their schedules, including sleeping and waking times, which was not upheld in this case.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency for a resident reviewed for abuse. The incident involved a newly admitted resident's family member who reported witnessing a nurse yelling at a resident and pushing them down the hall. The facility's investigation could not substantiate the claim as the family member could not identify the staff member or the resident involved. The administrator did not report the allegation to the State Survey Agency, citing the lack of a specific resident name as the reason. The resident in question, who was potentially involved in the incident, had a severe cognitive deficit and was hard of hearing, which required staff to speak loudly for communication. The resident's care plan included specific communication strategies to address these needs. Despite the facility's policy requiring the reporting of suspected mistreatment to the State Survey Agency within 24 hours, the administrator did not report the incident due to the absence of a specific resident name, leading to a deficiency in the facility's abuse prevention program.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident identified as R3. The incident was initially reported by a visitor, V21, who observed a nurse allegedly yelling at a resident and pushing them down the hall. The facility's administrator, V1, was informed of this allegation but did not initiate a new investigation, believing it to be the same as a previous incident documented on 5/24/24. The previous investigation concluded that the claim could not be substantiated, as the nurse involved stated that the resident, R3, was hard of hearing and required loud communication. The facility's investigation into the initial allegation was inadequate, as it did not include interviews with all potential witnesses or the resident involved. The administrator did not interview other staff members or residents who might have witnessed the incident, nor did she start a new investigation when the surveyor reported the allegation on 6/3/24. The facility's policy on abuse prevention requires a comprehensive investigation process, which was not followed in this case. Resident R3, who was involved in the incident, has a severe cognitive deficit, as indicated by a BIMS score of 01, and a history of falls with injuries. The resident's care plan includes specific communication strategies due to their hearing impairment and cognitive issues. Despite these documented needs, the facility did not adequately address the allegation of abuse, failing to ensure the resident's right to be free from mistreatment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R12 and R16, as observed by surveyors. R12, who has a moderate cognitive impairment and is dependent on staff for toileting, was not checked or changed for an extended period after being up since 5:00 AM. Despite staff claims of having changed R12 after breakfast, observations indicated that R12's incontinence brief and clothing were saturated with urine by the time care was eventually provided. This discrepancy in care timing suggests a failure to adhere to the resident's care plan, which includes scheduled toileting and assistance as needed. Similarly, R16, who also has a moderate cognitive impairment and requires supervision for toileting, was observed with wet clothing and a wet chair cushion, indicating a lack of timely assistance. Despite being redirected by staff, R16 was not provided with immediate care, and her condition remained unchanged for a significant period. The facility's administrator acknowledged the expectation for residents to receive timely care to prevent skin breakdown and infections, highlighting a failure to follow the care plan that mandates assistance with toileting and regular checks.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and follow interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who has severe cognitive deficits and a history of falls with injuries, was admitted with diagnoses including left hip nailing, dementia, osteoarthritis, depression, and anemia. The resident's care plan included the use of a body pillow for comfort and positioning to prevent rolling out of bed, an intervention that was not consistently implemented. Observations on multiple occasions revealed the absence of the body pillow in the resident's bed, despite the care plan's directive and previous incidents of the resident rolling out of bed. The facility's fall prevention policy outlines procedures for assessing residents after falls and implementing new interventions, yet these were not adequately followed in this case. Staff were aware of the missing body pillow, with explanations given that it was in the laundry, but no immediate alternative was provided until prompted by the surveyor. The facility administrator acknowledged the oversight and the need for a backup pillow, indicating a lapse in ensuring the resident's safety measures were consistently in place as per the care plan and facility policy.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide incontinence care according to current standards of practice for a resident with moderate cognitive impairment and multiple diagnoses, including intractable seizures, debility, depression, and anxiety. The resident was dependent on staff for toileting, as documented in the Minimum Data Set. During an observation, a Certified Nursing Assistant (CNA) did not perform perineal care correctly. The CNA used a washcloth with no rinse peri wash to clean the resident's pubic area and inner thighs but failed to wash near the labia, which is a required step according to the facility's Perineal Cleansing policy. Additionally, the CNA did not follow proper hand hygiene protocols. After completing the incontinence care, the CNA removed their gloves and donned a new pair without washing their hands, which is against the facility's policy. The facility's Perineal Cleansing policy specifies that gloves should be removed and hands washed with soap and water or a cleansing gel after providing care. The facility administrator confirmed that the expectation was for incontinence care to be provided per current standards of practice.
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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 Rosiclare
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salem Springlake Health & Rehabilitation Center | 12 mi | — | 7 | 0 |
| Crittenden County Health & Rehabilitation Center | 16.3 mi | — | 7 | 0 |
| Carrier Mills Nsg & Rehab Ctr | 24.1 mi | — | 10 | 0 |
| Axiom Healthcare Of Harrisburg | 24.4 mi | — | 4 | 0 |
| Saline Care Nursing & Rehab | 24.6 mi | — | 0 | 0 |
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