Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rosary Care Center during CMS and state inspections, most recent first.
The facility failed to ensure proper hand hygiene and food safety during meal service, affecting all residents except one. Staff members were observed handling food with contaminated gloves and failing to change gloves or perform hand hygiene after touching various surfaces. A hair was found in the food, and contaminated food was not discarded. These actions violated the facility's food safety policy.
The facility failed to administer medications as ordered, affecting four residents. An LPN confirmed that a resident did not receive Lamotrigine due to unavailability. Another resident missed Januvia for the same reason. A third resident did not receive Seroquel for three days, and a fourth missed galantamine hydrobromide ER for two days post-admission. The DON confirmed these deficiencies, citing pharmacy delivery issues.
The facility failed to adhere to its Enhanced Barrier Precautions policy by allowing staff to remove and dispose of soiled PPE in the hallway outside residents' rooms, instead of inside the rooms as required. This practice was confirmed by staff and had the potential to affect all residents on the second floor who were on EBP.
A facility failed to notify a resident's family of a change in condition requiring a medication change. The resident, with multiple health issues, had a UTI and was prescribed antibiotics, but there was no documentation of family notification. An LPN confirmed the lack of documentation, violating the facility's policy to notify within 24 hours.
The facility failed to ensure proper self-administration of medications for two residents, leading to deficiencies in medication management. One resident had inconsistencies in documentation and assessment, with medications improperly organized and no record of administration. Another resident experienced issues with medication delivery and lacked documentation of self-medication assessments. The facility did not adhere to its policy on self-administration, resulting in a lack of oversight and documentation.
The facility experienced a medication error rate of 6.25%, exceeding the acceptable threshold of 5%. Two residents did not receive their prescribed medications due to unavailability. An LPN confirmed that Lamotrigine for seizures and Januvia for diabetes were not administered as they were not available in the facility. The facility's policy requires medications to be administered as ordered and within 60 minutes of the scheduled time.
Failure in Hand Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and food safety practices during meal service, which had the potential to affect all residents except one who did not consume food orally. During an observation, a staff member was seen taking food temperatures while wearing disposable gloves and touching various surfaces, including a thermometer, serving utensils, and paperwork, before handling ready-to-eat pork chops. This staff member also discovered a hair in the pork chops but did not discard or replace the contaminated food. Another staff member, the Dietary Director, was observed plating meal trays while wearing gloves and touching multiple surfaces before handling a dinner roll without changing gloves or performing hand hygiene. Additionally, a Dietary Aide was observed disassembling a hamburger, placing the patty in a microwave, and then reassembling the burger without changing gloves after handling the microwave. This was confirmed during an interview with the aide. The facility's policy on food safety requirements, which includes preventing cross-contamination and physical contamination of food, was not adhered to by the staff, leading to these deficiencies.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician and within prescribed time frames, affecting four residents. For Resident #12, Lamotrigine, an anticonvulsant medication, was not available in the facility or in the contingency box supply, leading to a missed dose. Similarly, Resident #40 did not receive Januvia, an anti-diabetic medication, as it was not available in the medication cart or contingency storage. Both instances were confirmed by the respective LPNs involved. Resident #36 did not receive Seroquel, an antipsychotic medication, for three consecutive days due to the facility awaiting delivery from the pharmacy. This was confirmed by the Director of Nursing (DON). Additionally, Resident #66 did not receive galantamine hydrobromide ER, an anti-dementia medication, for two days after admission because it was on order. The DON confirmed the delay and noted that the facility used one pharmacy, which was responsible for delivering the medications.
Improper PPE Disposal in Hallway
Penalty
Summary
The facility failed to properly implement its Enhanced Barrier Precautions (EBP) policy, which led to a deficiency in the handling and disposal of soiled personal protective equipment (PPE). Observations revealed that a Certified Nursing Aide (CNA) removed PPE in the doorway of a resident's room and disposed of it in a trash can located in the hallway, contrary to the facility's policy. This practice was confirmed by the CNA, who stated that the process was to remove PPE in the doorway and place it in a trash can outside the room. Similarly, a Licensed Practical Nurse (LPN) confirmed that trash cans for soiled PPE were kept in the hallway outside residents' rooms, which was not in accordance with the facility's policy. The facility's policy, dated April 1, 2024, required that trash cans for discarding PPE be positioned inside the resident's room. However, it was observed that trash cans were initially placed outside the rooms of residents on EBP until a review of the policy prompted a change. Interviews with staff confirmed that the facility had not been following its own policy, as trash cans were kept outside the rooms until the policy was reviewed and corrected. This failure to adhere to the established policy had the potential to affect all 23 residents on the second floor who were on EBP.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family of a resident when there was a change in the resident's condition that required a medication change. This deficiency was identified through a review of the electronic medical record, staff interviews, and the facility's policy on change in condition. The resident in question was admitted with multiple diagnoses, including chronic respiratory failure, hypertension, chronic kidney disease, heart failure, and other significant health issues. The resident's medical record showed a urine culture indicating a urinary tract infection (UTI), for which a physician ordered an antibiotic treatment. However, there was no documented evidence that the resident's family was informed about the positive UTI test or the initiation of the antibiotic treatment. An interview with an LPN confirmed that the medical record lacked documentation of family notification regarding the resident's change in condition and treatment. The facility's policy, revised in February 2021, mandates that the resident, their attending physician, and the resident's representative be notified within 24 hours of any changes in the resident's medical or mental condition. This policy was not adhered to in the case of the resident, leading to the identified deficiency.
Deficiencies in Self-Medication Management
Penalty
Summary
The facility failed to ensure proper self-administration of medications for two residents, leading to deficiencies in medication management. Resident #18, who has a history of transient cerebral ischemic attack, atrial fibrillation, and other conditions, was found to have inconsistencies in the documentation and assessment of self-medication. The resident's medication administration plan required a self-administration assessment every 90 days, but the medical record lacked evidence of these assessments and a physician's order for self-medication. During an observation, medications were found improperly organized in a daily container, and there was no documentation of when the medications were administered. Interviews with nursing staff revealed a lack of awareness and documentation regarding the resident's medication regimen. Resident #38, diagnosed with paraplegia, spina bifida, and other conditions, also experienced issues with self-medication management. The resident's plan of care included quarterly self-medication assessments, but the medical record did not contain evidence of these assessments or a physician's order for self-administration. The resident reported not receiving the medication Methenamine for four days, and it was confirmed that the medication had not been delivered to the facility despite being ordered. Nursing staff were unaware of the need for medication refills unless requested by the resident, and there was no documentation of medication consumption. The facility's policy on self-administration of medications requires documentation in the medical record and periodic reassessment of the resident's ability to self-administer medications. However, the facility failed to adhere to this policy, resulting in a lack of oversight and documentation for residents approved for self-medication. The Director of Nursing confirmed the list of residents approved for self-administration, but the facility did not maintain adequate records to ensure compliance with physician orders and policy requirements.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, resulting in a medication error rate of 6.25%, which is above the acceptable threshold of 5%. This deficiency was identified through observations, medical record reviews, staff interviews, and policy reviews. Two medication errors were observed out of 32 opportunities for medication administration, affecting two residents. The first incident involved a resident who did not receive their prescribed dose of Lamotrigine 200 mg for seizures because the medication was not available in the facility or in the contingency box supply. The medication was scheduled to be administered twice daily, but the dose was omitted due to unavailability. The second incident involved another resident who did not receive their prescribed dose of Januvia 50 mg for Diabetes Mellitus because the medication was not available in the medication cart or the facility's contingency medication storage. The medication was scheduled to be administered once daily, but the dose was not administered due to its unavailability. Both incidents were verified through interviews with the respective LPNs involved, who confirmed the unavailability of the medications and the subsequent omission of the doses. The facility's policy on medication administration requires that medications be administered in accordance with written orders and within 60 minutes of the scheduled time, which was not adhered to in these cases.
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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 Sylvania
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franciscan Care Ctr Sylvania | 1.4 mi | ★★★★★ | 27 | 1 |
| Kingston Health Center Of Sylvania | 1.5 mi | ★★★★★ | 37 | 0 |
| Divine Rehabilitation And Nursing At Sylvania | 2.2 mi | ★★★★★ | 0 | 0 |
| Arbors At Sylvania | 2.3 mi | ★★★★★ | 1 | 0 |
| Lakes Of Sylvania, The | 2.8 mi | ★★★★★ | 9 | 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 June 2026) and official state health department websites.