Rosemont Center

Inspectors wroteBased on review of employee personnel records and staff interview it was determined that the facility failed to complete annual performance review at least once every twelve months for three out of three nurse aides reviewed (Employee E13, Employee E14, and Employee E15). Findings Included: Review of facility documentation and employee personnel files revealed the following nurse aides did not have (a completed) an up-to-date annual performance review: Employee E13, Employee E14, and Employee E15. Interview on July 30, 2026, at 2:30 p.m. with Nursing Home Administrator, Employee E1, confirmed the facility failed to complete annual performance reviews for the following employees Employee 13, Employee 14, and Employee 15. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.19 (2) Personnel records.

Inspectors wroteBased on observations, review of policy, review of clinical record and review of facility provided documentation, it was determined facility did not ensure to provide adequate supervision to prevent elopement for one of three residents reviewed (Resident R1)

Inspectors wroteBased on staff interviews and review of clinical records, it was determined that the facility failed to conduct a complete and thorough investigation to rule out abuse/neglect for 4 of 17 residents reviewed (Resident R1, R2, R23 and R51). Findings Include: Review of facility policy Abuse Prevention Program reviewed November 30, 2022, revealed all reports of resident abuse, neglect, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. The individual conducting the investigation will include, but not be limited to, interview any witnesses to the incident and interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews it was determined that the facility failed to ensure kitchen equipment was maintained in safe and operating condition (Main Kitchen). Findings Include:Review of undated facility policy Pot and Pan Washing revealed proper pot and pan washing procedures reduce the possibility of food contamination. Review of facility policy revealed pots and pants will be washed in the first sink, rinsed in the second sink, and sanitized in the third sink. Pots and pans are sanitized using warm water and bleach or sanitizer to provide no less than 50 PPM chlorine in solution for one minute. An initial tour of the main kitchen was conducted on September 2, 2025, at 9:00 a.m. with Food Service Director, Employee E6. During a tour of the kitchen, a dietary aide was observed to be utilizing the 3-compartment sink to wash pots and pants. [...]

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that written notification was received prior to a resident's room change for 1 out of 17 residents reviewed (Resident R1). Review of Resident R1's September 2025 physician orders revealed the diagnoses of anxiety (intense, excessive and persistent worry and fear about everyday situations); depression (a mood disorder that may be described as feelings of sadness, loss, or anger that interfere with a person's everyday activities); cerebral vascular disease (a group of disorders that affect blood flow to the brain, leading to conditions such as stroke, aneurysms, and vascular malformations); dysphagia (difficulty swallowing) and unspecified pain. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide personal privacy during care for two of 17 residents reviewed (Resident R3, and R46). Findings Include: Observation of the first-floor unit conducted September 2, 2025, at 10:56AM revealed that Nurse Aide, Employee E4, was providing care for Resident R3. Further observation revealed that Resident R3's roommate was in Bed-B, next to the window. Further, the privacy curtain for Resident R3 was drawn only partially at foot of the bed, exposing Resident R3 to his/her roommate. Interview with the Director of Nursing (DON), Employee E2, conducted at the time of the observation confirmed that Nurse Aide, Employee E4, did not fully draw the curtain to provide Resident R3 with full privacy during care. [...]

Inspectors wroteBased on staff interviews, and review of clinical records, it was determined that that facility failed to ensure that prompt efforts were made to resolve a resident's grievance regarding a room change request for 1 out of 17 residents reviewed (Resident R51).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to revise a care plan related to aggressive behaviors for one of 17 residents reviewed. (Resident R51)

Inspectors wroteBased on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that proper feeding tube placement was established prior to administering medication through a feeding tube for one of two residents observed (Resident RF27).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the failed to provide treatment/services to maintain or improve range of motion/mobility for one of four residents reviewed for limited range of motion (Resident R12). Findings Include:Review of facility policy Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to promote optimal safety and independence. Review of Resident R12's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was cognitively intact and had diagnoses of hemiplegia (affecting left non-dominant side), muscle weakness, and need for assistance with personal care. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of personnel files, review of clinical records, observations, and staff interviews it was determined that the facility failed to assure that nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet the residents' needs for two of five nursing staff reviewed (Employee E5 and E9). Findings Include:Review of facility policy Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to promote optimal safety and independence. Review of facility's job description for nurse aides revealed that nurse aide staff are responsible for reviewing care plans and daily assignments and perform nursing care as outlined. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to store and prepare food in accordance with standards of food service safety (Main Kitchen). Findings Include:Review of undated facility policy Food Storage revealed leftover food is stored in covered containers or wrapped carefully and securely. Observations during an initial tour of the main kitchen on September 2, 2025, at 9:00 a.m. with Food Service Director, Employee E6, revealed the following:Observations of the walk-in refrigerator revealed deli meats in open plastic bags, not sealed. Further observations revealed opened containers of chicken and beef broth base, with no open date. Observations in the walk-in freezer revealed a box of cauliflower open to air, not sealed. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement an effective infection control program related to medication administration and the use of personal protective equipment (PPE) in enhanced barrier precautions 4 of 17 residents reviewed (Resident R27, R47, R14, R59). Findings Include:Review of facility policy on Enhanced Barrier Precaution (EBP) dated April 1, 2024, revealed that it is the policy of the facility to follow state and federal guidelines to minimize the spread of Multidrug Resistant Organism (MDRO's) by implementing effective personal protective equipment (PPE) usage. The policy is intended to provide guidance for PPE use as well as room restriction for preventing transmission of MDRO's. Under section Key Points #2. EBP is indicated for residents with the following: [...]

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 18 resident records reviewed (Residents R17, R41, R44, R48, R49, and R59).

Inspectors wroteBased on observation, clinical record review, and review of facility documentation and staff interview, it was determined that the facility failed to ensure that the resident's rights to privacy and confidentiality of his/her medical records was maintained for one of 24 residents observed (Resident R28).

Inspectors wroteBased on review of clinical record review, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that resident/resident representative were notified of resident's discharge/transfer for three of three residents reviewed (Resident R11, R41, R42)

Inspectors wroteBased on a review of clinical records, review of the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of twenty-four residents reviewed who had a below the knee amputation (Resident R59).

Inspectors wroteBased on observations, review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure a resident with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of 24 residents reviewed for limited range of motion (Resident R49).

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of 18 residents reviewed (Residents R17, R38).

Inspectors wroteBased on observation, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with wound treatment for one out of one resident observed and disinfecting of medical equipment (R44).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment in one resident room on the 1st floor. (room [ROOM NUMBER])

Inspectors wroteBased on staff interviews and the review of the clinical record, it was determined that the facility failed to ensure that the physician was notified of a change in the resident's medical status for one out of four residents reviewed (Resident R1).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to psychotropic medications and behavior management for one of 14 residents reviewed (Resident R27).

Inspectors wroteBased on observations, reviews of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted central catheter (PICC) line in accordance with professional standards of practice for one of 30 residents reviewed (Resident R354).

Inspectors wroteBased on the review of clinical records, facility documentation, observations, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly). Two of two employee records reviewed. (Employee E4 and E5). Findings Include: Observation of a PICC line medication administration for Resident R354 on January 30, 2024, at 12:16 p.m. with the extension tube and the cap for both lumens were missing which exposed the PICC line. Employee E4 was preparing medication to be administered via PICC line. [...]

Inspectors wroteBased on the review of Quality Improvement Program (QUAPI) plan, facility documentation, and interview with staff, it was determined that the facility failed to demonstrate and maintain an effective Quality Improvement Program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators.

Inspectors wroteBased on a review of facility documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less than 12 hours annually for five of five nurse aide staff training information reviewed (E6. E7, E8, E9 and E10). Findings Include: Review of the nurse aide annual training information provided during the survey revealed that there were no training logs/tracking to review for nurse aides E6. E7, E8, E9 and E10 Review of the nurse aide training/in-service information provided during the survey revealed that nurse aides training logs did not contain evidence that the training met the twelve hours of annual training requirement. An interview with the Director of Nursing on February 1, 2024, at 11:00 a.m. [...]

Inspectors wroteBased on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide written notice, including reason for transfer before a resident's room was change for two of four residents reviewed (Residents R1 and R2). Findings Include: A review of facility policy titled, Room Change/Roommate Assignment revised May 2017, indicated that prior to changing a room or roommate assignment all parties involved in the change/assignment, residents and their representatives will be given a notice in advance of such change. Advance notice of room change will include why the change is being made. Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 4, 2023, revealed Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility failed to provide wound treatment related to a resident's wound for one of two residents reviewed. (Resident R1)

Inspectors wroteBased on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure a care plan was updated with the correct positioning device for 1 resident (Resident R3) and not updated for colostomy care for one resident for 2 out of 15 residents reviewed (Resident R3 and Resident R49).

Inspectors wroteBased on observations, review of facility policy, staff interviews and the review of clinical records, it was determined that the facility failed to ensure that resident received appropriate care and services related to activities of daily living for 2 out of 15 records reviewed (Resident R3 and Resident R34).

Inspectors wroteBased on observations, staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a resident's restorative nursing care program was implemented for 2 out of 15 residents reviewed (Resident R15).

Inspectors wroteBased on the review of facility policies, clinical records, observations and interview with resident and staff, it was determined that the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of 18 residents reviewed. (Resident R49). Findings Include: Review of facility policy Pain Assessment and Management, dated March 2020, revealed that During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions. b. Characteristics of pain: (1) Location of pain; (2) Intensity of pain (as measured on a standardized pain scale); [...]