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 Rosemont Center during CMS and state inspections, most recent first.
A resident with dementia, mood disturbance, depression, cognitive communication deficit, anxiety, and conduct disorder had been assessed as high risk for elopement, but no elopement prevention care plan was in place. The resident was able to activate a fire door alarm on an upper floor, exit via the stairs, and then pass through emergency fire doors near the main entrance across from the receptionist area, resulting in an elopement. This occurred despite the facility’s existing policy intended to prevent unsafe wandering in residents at risk for elopement.
Failure to Investigate Resident Abuse, Injury, and Unknown Substance Allegations: The facility did not complete thorough investigations for a resident with a new wound of unknown origin, two residents involved in a resident-to-resident assault with a trash can, and two residents involved in an allegation of self-medication and possible unknown substance ingestion. The record lacked required incident reports, witness statements, and documentation showing a complete investigation, and the DON confirmed the investigations were not completed.
Broken Sanitizing Sink Faucet in Main Kitchen: Staff were observed using the 3-compartment sink to wash pots and pans, but the sanitizing compartment tested below 50 ppm chlorine. The FSD stated the faucet was broken and continuously ran water into the sink, diluting the sanitizing solution, and that staff had to keep checking and adding sanitizer to compensate.
Failure to Provide Written Notice Before Room Change: A resident with anxiety, depression, CVA disease, dysphagia, and pain was moved to a new room with a new roommate, but the record did not show written notice was given to the resident or RP before the move, including the reason for the change. The room change form noted the move was for safety reasons and that the RP was notified the same day, and the DON acknowledged there was no evidence of advance written notice.
Failure to Provide Privacy During Resident Care: An aide was observed providing care to two residents while their roommate remained in the room, and the privacy curtain was only partially drawn at the foot of the bed each time, leaving the residents exposed. The DON confirmed the curtain was not fully drawn to provide full privacy during care.
Failure to promptly resolve a resident grievance about a room change request. A resident with schizoaffective disorder, anxiety, adjustment disorder, HTN, muscle weakness, and hyperlipidemia called the DON about another resident on the unit and requested to move to another floor. The DON notified the primary nurse and attempted to contact the guardian, but the record did not show prompt efforts to resolve the grievance, and the DON could not produce documentation of such efforts.
Failure to revise a resident’s care plan for aggressive behaviors. A resident with schizoaffective disorder, anxiety, and other diagnoses became very aggressive and hit another resident with a trash can after the other resident entered the room multiple times. The care plan only addressed agitation and use of a STOP sign at the door, but the resident refused to keep the sign in place and the DON confirmed it was repeatedly removed. There was no documented evidence that the care plan was updated with additional interventions to address the aggression toward wandering residents.
A nurse administered crushed medications mixed with water through a resident’s PEG tube without first checking tube placement, despite facility policy requiring confirmation of placement and gastric residual assessment before enteral medication administration. The resident had COPD and was receiving tube feeding, and the DON confirmed that tube placement must be checked before medications are given.
Failure to provide treatment/services to maintain ROM was identified for a resident with hemiplegia, muscle weakness, and limited ROM. OT recommended a left resting hand splint to maintain function and prevent decline, and the care plan directed staff to apply it after morning care and remove it at bedtime. However, the resident was observed without the splint on multiple occasions, reported staff did not apply it daily, and an LPN and CNA were unaware of the splint. The DON of Rehab confirmed the splint schedule, and OT later stated the resident could no longer tolerate the splint due to worsening contracture.
A facility failed to ensure that an LPN and a nurse aide had documented competency for resident care tasks. A resident with hemiplegia, muscle weakness, and limited ROM had an OT-recommended left resting hand splint included in the care plan and kardex, but the splint was not on during observation. The LPN and nurse aide both said they were unaware of the splint, and the nurse aide stated, "I don't know I'm agency staff."
Improper Food Storage in Main Kitchen: Surveyors observed food storage practices that did not follow the facility’s food storage policy in the main kitchen. Deli meats were found in open, unsealed plastic bags in the walk-in refrigerator, opened containers of chicken and beef broth base had no open date, and a box of cauliflower in the walk-in freezer was open to air.
An infection control deficiency occurred when staff did not follow EBP and hand hygiene requirements during resident care and medication administration. A nurse aide provided care to residents on EBP while wearing gloves but no gown, and an LPN administered medications and eye drops without sanitizing hands before or after glove use or between residents. One resident had a suprapubic catheter and was on EBP with orders for gown and glove use during high-contact care.
A resident's request for medical records was delayed due to a miscommunication regarding payment, resulting in a failure to provide timely access as required by regulations. The facility's policy mandates access within 24 hours and copies within two business days, but the records were not sent until nearly two months later.
The facility did not meet the required nurse aide (NA) to resident ratios on six out of seven days reviewed. The day shift was understaffed from December 23 to December 25, failing to maintain one NA per 10 residents. The night shift was understaffed on December 20, 21, and from December 23 to December 26, not meeting the one NA per 15 residents ratio. This was confirmed by the Administrator.
The facility did not meet the required LPN to resident ratio of one LPN per 25 residents during the night shift for seven consecutive days. This deficiency was confirmed by the facility's administrator after a review of nursing time schedules.
The facility failed to create comprehensive care plans for several residents with complex medical needs, including those requiring oxygen therapy, seizure management, catheter care, splinting, and post-amputation care. These deficiencies were confirmed through staff interviews and record reviews, indicating a lack of timely and person-centered care planning.
A facility failed to protect a resident's privacy when a medication cart with an open laptop displaying resident information was left unattended. Additionally, a wall-mounted computer was found open, revealing resident details without staff supervision. These actions violated HIPAA regulations and compromised the confidentiality of resident health information.
The facility failed to notify residents and their representatives of transfers or discharges, as required by regulations. A resident was transferred to a hospital after a seizure, another due to suicidal ideations, and a third for unspecified reasons, without documented notification. The DON confirmed that discharge notification letters were not sent.
A resident who underwent a right below the knee amputation was readmitted to the facility, but the required significant change MDS assessment was not completed within the mandated timeframe. Despite receiving skilled therapy services and having specific physician orders, the facility failed to comply with federal regulations for resident assessments.
A facility failed to ensure a resident with limited ROM received appropriate treatment, as there was no documented evidence of the use of a prescribed splint. Despite recommendations from occupational therapy and a physician's order for a right upper extremity splint to be worn daily, records from March to October 2024 lacked documentation of its use. This deficiency was confirmed by the DON.
The facility failed to provide appropriate respiratory care for two residents. A resident with respiratory failure was given oxygen at 3 L/min instead of the ordered 2 L/min, and another resident with asthma received oxygen at 5 L/min instead of the ordered 2 L/min. These discrepancies were confirmed by an LPN.
A facility failed to maintain effective infection control during wound care for a resident. An LPN did not follow proper wound cleansing techniques and exited the resident's room wearing contaminated PPE, despite the room being marked for Enhanced Barrier Precaution.
A facility failed to maintain a safe and sanitary environment in a resident room, where two residents' areas were cluttered with personal items, snacks, and unauthorized power strips provided by the facility. The clutter included grocery bags, hygiene items, and respiratory equipment, obstructing access and creating potential hazards.
A resident with epilepsy experienced a seizure, but the physician was not notified during the morning shift as required by facility policy. The incident was only reported during the evening shift when the resident appeared unwell, leading to hospital transport. The lapse in communication was confirmed by the DON.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Facility staff failed to provide adequate supervision and accident prevention measures to protect a resident at high risk for elopement, resulting in an elopement incident. The facility’s policy on “Wandering, Unsafe Resident” was intended to prevent unsafe wandering for residents at risk of elopement, yet the resident, who had dementia with mood disturbance and agitation, depression, cognitive communication deficit, adjustment disorder with anxiety, and conduct disorder, was assessed on December 31, 2025, as being at high risk for elopement. Despite this high-risk status, the resident did not have an elopement prevention care plan in place prior to the incident. On February 12, 2026, at approximately 9:00 a.m., the resident, who resided on the second-floor unit, was able to press on the fire doors for more than 15 seconds, activating the alarm, and then used the stairs to leave the unit. The resident subsequently passed through emergency fire doors on the first floor located next to the entrance doors and across from the receptionist’s desk area. Review of the clinical record and facility investigation confirmed that an elopement prevention care plan for this resident was not developed until after this elopement event occurred.
Failure to Investigate Resident Abuse, Injury, and Unknown Substance Allegations
Penalty
Summary
The facility failed to conduct a complete and thorough investigation to rule out abuse or neglect for four residents reviewed. Facility policy required all reports of resident abuse, neglect, mistreatment, and injuries of unknown source to be thoroughly investigated, including interviews with witnesses and staff members on all shifts who had contact with the resident during the alleged incident period. The policy also required resident-to-resident altercations to be investigated and reported to the nursing supervisor, DON, administrator, and applicable regulatory agencies. For one resident, the clinical record showed a skin issue identified during a weekly shower on the sacrum with sanguineous drainage. A wound consultation the next day documented a re-consultation for wound care services and treatment for an unstageable pressure ulcer on the left buttock. The DON stated there was no investigation or incident report available for the new wound and no statement from the LPN who documented the skin check assessment, which had left the location and description blank. For two residents involved in resident-to-resident altercations, the record documented one resident repeatedly going into another resident’s room, the other resident becoming upset and throwing a trash can at him, and later a nurse observing the same resident hitting the other resident with a trash can. The injured resident stated he did not know why he was hit. The DON confirmed the facility did not complete an investigation for these resident-to-resident abuse allegations and there was no evidence of a complete and thorough investigation to prevent further incidents during the investigation. For another pair of residents, one resident’s record documented that an OT reported the resident was self-medicating in another resident’s room, a pill was found on the other resident’s end table, and the other resident later told staff she had given the medication for a headache. The clinical record did not show evidence of a complete and thorough investigation to prevent further ingestion of unknown substances during the investigation, and the DON confirmed no investigation was completed for the allegation involving unknown substances in the residents’ possession that may have been ingested.
Broken Sanitizing Sink Faucet in Main Kitchen
Penalty
Summary
The facility failed to ensure kitchen equipment was maintained in safe and operating condition in the main kitchen. During review of the facility’s undated pot and pan washing policy, it was noted that pots and pans are to be washed in the first sink, rinsed in the second sink, and sanitized in the third sink using warm water and bleach or sanitizer to provide no less than 50 PPM chlorine for one minute. During an initial tour of the main kitchen, a dietary aide was observed using the 3-compartment sink to wash pots and pans, and the Food Service Director tested the sanitizing sink with a chlorine test strip that measured less than 50 ppm chlorine. Observation of the sanitizing sink showed the faucet had a constant stream of water pouring into the sink, and the Food Service Director stated the faucet was broken and could not be turned off, causing the sanitizing solution to be diluted. In a later interview, the Food Service Director stated the sink faucet had been broken since the end of the previous month and that staff needed to frequently check the sanitizing solution and add extra sanitizer as needed to compensate for the broken faucet diluting the solution.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to ensure that written notification was provided before a resident's room change for 1 of 17 residents reviewed. Resident R1 had diagnoses including anxiety, depression, cerebral vascular disease, dysphagia, and unspecified pain, and a Quarterly MDS dated December 13, 2024 indicated the resident was cognitively intact. A nursing note dated December 9, 2025 documented that the resident was transferred from the 2nd floor to room C with scheduled medications and belongings, and that the resident was alert and oriented, without signs or symptoms of distress, and adjusting to the new room and roommate. The facility's room change notification form indicated the move was for safety reasons and that written notification was provided to the resident's responsible party on the same date as the room change. However, the clinical record did not show evidence of written notification to the resident and/or responsible party before the move, including an explanation of why the move was needed. During discussion with the DON, it was acknowledged that there was no evidence that the resident or responsible party received written notice, including the reason for the change, prior to the room or roommate change.
Failure to Provide Privacy During Resident Care
Penalty
Summary
The facility failed to provide personal privacy during care for two residents, R3 and R46. During an observation of the first-floor unit, Nurse Aide E4 was providing care to Resident R3 while the resident’s roommate remained in Bed-B next to the window, and the privacy curtain was drawn only partially at the foot of the bed, leaving Resident R3 exposed to the roommate. The DON, E2, observed the situation and confirmed that E4 did not fully draw the curtain to provide full privacy during care. A later observation on the same unit showed Nurse Aide E4 providing care to Resident R46 under similar conditions, with the roommate in Bed-B next to the window and the privacy curtain again drawn only partially at the foot of the bed, exposing Resident R46 to the roommate. The DON again confirmed that E4 did not fully draw the curtain to provide full privacy during care.
Failure to Promptly Resolve Resident Grievance About Room Change
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a resident grievance regarding a room change request for one resident. The resident had diagnoses including schizoaffective disorder, anxiety, adjustment disorder, hypertension, muscle weakness, and hyperlipidemia. Review of the facility policy showed that grievances or complaints could be submitted orally or in writing and that actions on such issues were to be responded to in writing with a rationale for the response. A nursing note written by the DON documented that the DON received a call from the resident about another resident on the 2nd floor nursing unit and, as a result, the resident requested to move to the 1st floor. The note stated that the resident continued to be a risk to a resident's safety on the 1st floor, the primary nurse was notified, monitoring for the concern was initiated, and an attempt to notify the resident's guardian was unsuccessful with a message left for a return call. Review of the clinical record and facility documentation did not show evidence that the facility made prompt efforts to resolve the grievance, and during interview the DON could not produce documentation showing that prompt efforts were made to address the room change request.
Failure to Revise Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to revise Resident R51’s care plan to address aggressive behaviors after the resident became physically aggressive toward another resident. Resident R51 had diagnoses including schizoaffective disorder, anxiety, adjustment disorder, hypertension, muscle weakness, and hyperlipidemia, and a quarterly MDS dated May 2, 2025 indicated the resident was cognitively intact. The resident’s care plan had previously addressed agitation and later included a focus area stating the resident was known not to use the STOP sign at the door, with the only intervention being placement of a magnetic stop sign across the door. On May 22, 2025, staff documented that Resident R51 was very aggressive, was difficult to redirect, and threw a trash can at Resident R23 after Resident R23 entered the room multiple times. A nursing note also documented that a licensed nurse observed Resident R51 hitting Resident R23 with a trash can, and that Resident R23 stated he did not know why he was hit. The DON confirmed in interview that Resident R51 refused to keep the stop sign in front of the door and kept removing it. The record contained no documented evidence that the care plan was revised to include additional interventions to help decrease Resident R51’s aggressive behaviors toward residents who wandered into the room.
Failure to Verify PEG Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper feeding tube placement was established before administering medications through a PEG tube for one resident. Facility policy on administering medications through an enteral tube required confirmation of tube placement and checking gastric residual volume before flushing the tubing and giving medications. The resident had diagnoses including chronic obstructive pulmonary disease and was assessed in the MDS as receiving tube feeding. During a medication administration observation, the nurse crushed the resident’s medications, mixed them with water, and administered them through the PEG tube without checking for placement. The nurse confirmed at the time of the observation that the PEG tube placement was not checked. The DON stated that feeding tube placement must be checked and confirmed prior to administering medications.
Failure to Provide Ordered Splinting for ROM Maintenance
Penalty
Summary
Failure to provide treatment and services to maintain or improve range of motion and mobility was identified for one resident with left-sided hemiplegia, muscle weakness, and need for assistance with personal care. The resident’s MDS documented impairment of functional limitation in range of motion on one side to the upper and lower extremities. An OT discharge summary recommended a splint to maintain the resident’s level of performance and prevent decline, and the care plan directed that the resident wear a left resting hand splint after morning care and remove it before bedtime care, as tolerated, to maintain left hand and arm ROM and prevent contractures. During observation, the resident was not wearing the left-hand splint and reported that staff did not apply it daily. A nurse and a nurse aide stated they were unaware of the splint. The DON of Rehab confirmed the splint should have been applied every morning and removed every night. On a later observation, the resident again was not wearing the splint and reported that therapy had attempted to apply it but could not get it on. The DON of Rehab reported difficulty applying the splint, and the OT later confirmed that the resident was no longer able to tolerate the splint because of worsening contracture and that the splint required the resident to be able to lay the fingers flat, which the resident could no longer do.
Staff Competency and Splint Care Not Followed
Penalty
Summary
The facility failed to assure that nursing staff had the competencies and skill sets needed to provide care for residents' needs for two of five nursing staff reviewed, Employee E5 and Employee E9. Facility policy stated residents would receive restorative nursing care as needed to promote optimal safety and independence, and job descriptions for nurse aides and LPNs required them to review care plans, follow assignments, and provide care according to facility policies and treatment orders. Review of personnel files showed no evidence that either Employee E5 or Employee E9 had skills competency evaluations to verify competency in hands-on skills and techniques needed to care for residents. Resident R12 was cognitively intact and had diagnoses including hemiplegia affecting the left non-dominant side, muscle weakness, and need for assistance with personal care. The resident's MDS also showed impairment of functional limitation in range of motion on one side to the upper and lower extremities. OT recommended a splint to maintain performance and prevent decline, and the care plan directed that the resident wear a left resting hand splint after morning care and remove it before bedtime care. The nursing kardex assigned the nurse aide to apply the splint after morning care and remove it before nighttime care. On observation, Resident R12 was not wearing the left-hand splint and stated staff does not apply it daily. Employee E5 stated being unaware of the splint, and Employee E9 also stated being unaware of the splint and said, "I don't know I'm agency staff."
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to store and prepare food in accordance with standards of food service safety in the main kitchen. Review of the undated facility policy on Food Storage stated that leftover food is to be stored in covered containers or wrapped carefully and securely. During an initial tour of the main kitchen with the Food Service Director and Employee E6, surveyors observed deli meats in the walk-in refrigerator stored in open plastic bags that were not sealed. They also observed opened containers of chicken and beef broth base with no open date. In the walk-in freezer, a box of cauliflower was observed open to air and not sealed.
Infection Control and PPE Use Not Followed During Care and Medication Administration
Penalty
Summary
The facility failed to implement an effective infection control program related to medication administration and the use of PPE under Enhanced Barrier Precautions (EBP). Facility policy dated April 1, 2024 stated that EBP requires PPE use to minimize the spread of MDROs, including gown and glove use for residents with wounds or indwelling medical devices. During observation of a resident on EBP, a nurse aide was providing care while wearing gloves but not a gown, and the DON confirmed the resident was on EBP and that gown and gloves were required. A similar observation later showed the same nurse aide providing care to another resident on EBP while wearing gloves but not a gown, and the DON again confirmed that gown and gloves were required. During medication administration observation, an LPN administered eye drops and other medications for multiple residents without sanitizing hands before putting on gloves, after removing gloves, or between medication administrations. For one resident with a suprapubic catheter on EBP, the nurse did not sanitize hands before or after preparing medications, before or after administering medications via feeding tube, or before and after administering artificial tears to both eyes. The resident’s care plan identified EBP related to the indwelling medical device and directed staff to wear gloves and gowns for high-contact care. Additional observation showed a nurse aide emptying the resident’s catheter bag at bedside without wearing a gown.
Delayed Access to Medical Records for a Resident
Penalty
Summary
The facility failed to comply with the requirement to provide timely access to medical records for a resident, as outlined in 42 CFR Part 483.10(g)(2)(i)(ii)(3). The deficiency was identified during an abbreviated survey conducted in response to complaints. The facility's policy states that residents have the right to access their personal and medical records within 24 hours of a request, excluding weekends and holidays, and to obtain copies within two business days. However, the facility did not meet these timelines for Resident R1, who requested a copy of their medical records. The delay occurred because the Medical Records Department was unaware that payment for the records had been received, as the check was made out to the facility rather than directly to the department. This oversight led to a delay in processing the request. The facility administrator confirmed that the records were not released immediately, and the social worker did not send an electronic copy of the records to the resident until nearly two months after the initial request. This failure to provide timely access to medical records resulted in a deficiency under the resident rights regulations.
Plan Of Correction
I hereby acknowledge the CMS 2567-A, issued to ROSEMONT CENTER for the survey ending 12/26/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Resident R1 was sent the requested medical records. NHA/Designee will audit medical record requests for the last 30 days to ensure timely release of records. RDO will reeducate administrative staff on the regulation of releasing records timely. NHA/Designee will audit the release of medical records from requests weekly x 3 and then monthly x 3. Results will be shared at QAPI monthly until substantial compliance is met.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified by the regulation effective July 1, 2024. During the review period from December 20, 2024, to December 26, 2024, the facility did not meet the required staffing levels on six out of seven days. Specifically, the facility was understaffed on the day shift from December 23 to December 25, 2024, where the ratio of one NA per 10 residents was not maintained. Additionally, the night shift was understaffed on December 20, 21, and from December 23 to December 26, 2024, failing to meet the ratio of one NA per 15 residents. This deficiency was confirmed by Employee E1, the Administrator, on December 26, 2024, at approximately 12:45 p.m.
Plan Of Correction
Preparation and/or execution of his plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Nursing schedules were reviewed to ensure the proper nursing assistant ratio on the day and overnight shifts. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct Nursing Assistant ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure nursing assistants are being staffed at the proper ratio. Results will be shared at QA monthly until substantial compliance is met.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum number of Licensed Practical Nurses (LPNs) per resident during the night shift. Specifically, the facility did not meet the required ratio of one LPN per 25 residents for seven consecutive days, from December 20, 2024, through December 26, 2024. This deficiency was identified through a review of nursing time schedules, which revealed the shortfall in staffing levels. The issue was confirmed by the facility's administrator, Employee E1, on December 26, 2024, at approximately 12:45 p.m.
Plan Of Correction
Preparation and/or execution of his plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Nursing schedules were reviewed to ensure the proper LPN ratio on the evening shifts. NHA/designee will reeducate the scheduler, Nurse Supervisors, and Nursing Management on the correct LPN ratios. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA monthly until substantial compliance is met.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, as identified during a review of clinical records and staff interviews. Resident R17, diagnosed with acute and chronic respiratory failure with hypoxia, was observed receiving oxygen therapy without a corresponding care plan for oxygen administration. This deficiency was confirmed by a licensed nurse, indicating a lack of timely care planning for the resident's oxygen needs. Resident R41, who has epilepsy and is on Keppra to prevent seizures, experienced seizure activity, prompting a physician to order blood work. However, there was no evidence of a care plan addressing the resident's epilepsy diagnosis. The Director of Nursing confirmed the absence of a care plan for this condition. Similarly, Resident R44, with a diagnosis of rhabdomyolysis and an order for urinary catheter management, was found to have no care plan for the catheter's administration, as confirmed by licensed staff. Additional deficiencies were noted for Resident R48, who had a urinary catheter but no care plan for its use, and Resident R49, who required splinting and range of motion exercises but lacked a corresponding care plan. Resident R59, with a recent below-the-knee amputation, also did not have a care plan addressing this significant medical condition. These omissions were confirmed through interviews with the Director of Nursing, highlighting a systemic issue in care planning for residents with complex medical needs.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, specifically for one resident, identified as Resident R28. During an observation on the second-floor unit, a medication cart was found unattended in the hallway, with a laptop computer open and displaying resident information visible to passersby. This lapse in security allowed unauthorized individuals to potentially view sensitive health information, violating the resident's rights to privacy and confidentiality. Additionally, during a medication administration observation, a computer mounted on the wall was left open, revealing names of residents and clinical documentation without any staff member present to monitor it. A registered nurse, identified as Employee E6, explained that these computers are used by aides to document resident information. This incident further highlights the facility's failure to ensure that protected health information is secured and only accessible to authorized personnel, as required by HIPAA regulations.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to ensure timely notification to residents, their representatives, and the ombudsman regarding transfers or discharges, including their appeal rights. This deficiency was identified for three residents during a review of clinical records and facility documentation, as well as interviews with staff. The facility was unable to produce a policy on notifying residents and their representatives about transfers or discharges. Resident R11 was transferred to a local hospital after a seizure episode resulting in a fall, but there was no documented evidence of notification to the resident or their representative. Similarly, Resident R41, who was admitted with epilepsy, depression, anxiety, and a history of suicide attempts, was sent to the hospital for evaluation after expressing suicidal ideations, yet no notification was documented. Resident R42 was also transferred to a hospital without documented notification to the resident or their representative. Interviews with the Director of Nursing (DON) confirmed that the facility did not send written notifications to the residents or their representatives regarding their transfers to the hospital. The DON admitted that discharge notification letters were not sent to the residents or their families. This lack of communication and documentation was a violation of the facility's responsibility to inform residents and their representatives about transfers or discharges, as required by regulations.
Failure to Conduct Significant Change MDS Assessment for Amputee Resident
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who underwent a right below the knee amputation (RBKA). The resident, identified as R59, was readmitted to the facility from a local hospital with a diagnosis of RBKA related to osteomyelitis of the right foot. Despite the significant change in the resident's condition, which included a new diagnosis of acquired absence of the right leg below the knee, the facility did not complete the required significant change MDS assessment within the mandated timeframe. The resident's clinical record showed that they were receiving skilled physical and occupational therapy services and had specific physician orders for wound care and non-weight bearing status on the right lower extremity. An interview with the Regional Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident's status post BKA should have triggered a significant change MDS assessment. However, the assessment was not completed as required, indicating a deficiency in the facility's compliance with federal regulations for resident assessments.
Failure to Document Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM), specifically in ensuring the use of a splint as recommended by occupational therapy and ordered by the physician. The resident, identified as R49, had a discharge recommendation from occupational therapy for the use of a splint/brace and active and passive range of motion exercises. A physician's order specified the use of a right upper extremity resting hand splint to be worn after lunch daily, with the resident allowed to remove it independently. However, a review of the resident's treatment administration record from March to October 2024 showed no documented evidence that the splint was donned and doffed as required. This lack of documentation was confirmed by the Director of Nursing during an interview, indicating a failure to follow through with the prescribed treatment and services to maintain or improve the resident's ROM.
Inappropriate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. Resident R17, diagnosed with acute and chronic respiratory failure with hypoxia, was ordered to receive oxygen at 2 liters per minute via nasal cannula continuously. However, on October 10, 2024, it was observed that the resident was administered oxygen at 3 liters per minute, contrary to the physician's order. This discrepancy was confirmed by a licensed nurse, Employee E5. Similarly, Resident R38, diagnosed with asthma, was ordered to receive oxygen at 2 liters per minute via nasal cannula as needed. On October 8, 2024, it was observed that the resident was administered oxygen at 5 liters per minute, which was not in accordance with the physician's order. This was also confirmed by the same licensed nurse, Employee E5.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program during wound treatment for a resident. A Licensed Practical Nurse (LPN) was observed administering wound care to a resident with a physician's order for specific wound care procedures. The LPN transported the entire treatment cart into the resident's room, which was marked for Enhanced Barrier Precaution. During the wound cleansing process, the LPN did not follow the proper technique of cleansing from the center to the outer side of the wound. Additionally, the LPN exited the resident's room wearing contaminated Personal Protective Equipment (PPE), specifically a gown. These actions were confirmed during the observation with the LPN.
Cluttered Resident Rooms and Unauthorized Power Strips
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in a resident room on the first floor, specifically in room 105. Observations revealed that Resident R1's area was cluttered with open and closed boxes, random items such as spices, hygiene products, snacks, and clothing, as well as grocery bags containing snacks and other items. A power strip outlet was found amidst the clutter, powering a nebulizer and Bi-pap respiratory machines. The resident reported that the facility provided the power strip. The tray table was also cluttered with breakfast items, a fan, headphones, and a full urinal. In the same room, Resident R2's bed was positioned away from the headboard wall, with a chair and bariatric wheelchair blocking access to the closet. The resident's area was similarly cluttered with Walmart bags containing snacks, plastic boxes, and a nebulizer placed on top of an electric mixer. The dresser was covered with hygiene items, leaving no space for the nebulizer treatment machine. The floor was cluttered with power strips, grocery bags containing oranges, clothing, and snacks. Resident R2 confirmed ownership of the items and mentioned ordering them online. The maintenance director confirmed these observations and made some adjustments, but the administrator was unaware of the power strips' origin.
Failure to Notify Physician of Resident's Seizure
Penalty
Summary
The facility failed to notify the physician of a change in a resident's medical status, specifically for a resident diagnosed with epilepsy who experienced a seizure. According to the facility's policy, any significant change in a resident's condition, such as a seizure, should prompt immediate notification to the attending physician. However, on the morning shift, a licensed nurse, Employee E4, was informed by a CNA that the resident had a seizure lasting at least one minute. Despite this, Employee E4 did not notify the physician or any supervisory nursing staff about the incident during her shift. Later, during the evening shift, another employee, Employee E5, noticed the resident did not look well during dinner and reported this to Employee E4. It was only at this point that the physician was notified, and the resident was subsequently transported to the hospital. The resident was admitted with a diagnosis of a breakthrough seizure, indicating a significant lapse in communication and adherence to the facility's policy regarding changes in a resident's condition. The Director of Nursing confirmed that there was no notification of the seizure during the morning shift until the evening when the resident was sent to the hospital.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,837 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rosemont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bryn Mawr Extended Care Center | 0.9 mi | ★★★★★ | 30 | 0 |
| Beaumont At Bryn Mawr | 1 mi | ★★★★★ | 0 | 0 |
| Bryn Mawr Village | 1.1 mi | ★★★★★ | 23 | 0 |
| Quadrangle | 2.1 mi | ★★★★★ | 1 | 0 |
| Waverly Heights | 2.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rosemont Center.
100% money-back within 48 hours.
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.