Rosewood Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Schuylkill Haven, Pennsylvania.
- Location
- 401 University Drive, Schuylkill Haven, Pennsylvania 17972
- CMS Provider Number
- 395416
- Inspections on file
- 22
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rosewood Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not maintain a qualified full-time social worker position after both prior social workers left their employment in late December, leaving the facility without full-time social services coverage. Residents reported that there had been no full-time social worker since the end of the year, and one resident stated she needed social services for a legal matter. The current social worker reported she started in early January, had only worked a few full days, and was not full-time at the time of the survey, resulting in noncompliance with state social services requirements.
The facility failed to ensure call bells were accessible for two residents, leading to a deficiency in accommodating their needs. One resident, dependent on staff for ADLs, had a call bell tied out of reach, while another resident, requiring moderate assistance, had a call bell draped out of reach. These observations occurred over several days, indicating a failure to follow care plan interventions.
A resident with hypertension and atrial fibrillation received metoprolol and amiodarone despite physician's orders to withhold these medications if the systolic blood pressure (SBP) was below 110 mmHg. The medications were administered twice when the resident's SBP was below the specified threshold, as confirmed by the DON.
The facility failed to store food in a sanitary manner, with issues such as undated food items, dried substances in storage areas, and improper refrigerator temperatures. Observations revealed unsanitary conditions in the dietary department and a nursing unit pantry, with the Dietary Manager and Administrator confirming the deficiencies.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day over a 21-day period. Nursing schedules showed care hours ranging from 2.98 to 3.14 per resident, confirmed by the Administrator.
Failure to Maintain a Full-Time Social Worker Position
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having more than 120 beds. During an interview, Resident 1 reported that there had not been a full-time social worker since the end of the previous year, and in a resident group interview, another resident similarly stated that there had been no full-time social worker since December 2025. At that same group interview, a resident reported needing social services related to a legal matter. Review of employee files showed that one of the facility’s two social workers left on December 23, 2025, and the other left on December 31, 2025. The current social worker stated that she began working on January 7, 2026, had only worked four full days since starting, and was not employed full-time at the time of the interview. These findings demonstrate that the facility did not have a full-time social worker in place during the period reviewed, in violation of 28 Pa. Code: 201.14(a) and 211.16(a).
Inaccessible Call Bells for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were accessible for two residents, leading to a deficiency in meeting the reasonable accommodation of resident needs and preferences. Resident 7, who had diagnoses including dysarthria, hemiplegia, hemiparesis, and anxiety, was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, and personal hygiene. Despite a care plan intervention requiring staff to check that the call bell was within reach, observations on multiple occasions over several days revealed that Resident 7's call bell was tied to the light string of an adjacent bed, out of reach. Similarly, Resident 92, who had diagnoses including anxiety, bradycardia, and fibromyalgia, required partial to moderate assistance from staff for ADLs. The care plan for Resident 92 also included an intervention for staff to ensure the call bell was within reach and to encourage its use for assistance. However, observations showed that Resident 92's call bell was draped over a box on the wall behind the bed, out of reach, during multiple checks over several days. These observations indicate a failure to provide reasonable accommodation for the residents' needs, as outlined in their care plans.
Plan Of Correction
1. Residents 7 and 92 had their call bells placed within reach. 2. To identify other residents who have the potential to be affected, the DON/designee completed an audit of all resident rooms to ensure call bells are within reach. 3. To prevent this from reoccurring, DON/designee completed education with the nursing staff and all facility staff on ensuring call bells are within reach when exiting a resident room. Education for all staff is ongoing. 4. To monitor and maintain ongoing compliance, the DON/designee will audit call bell placement in 10 resident rooms weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with hypertension and atrial fibrillation. The physician's orders required the administration of metoprolol and amiodarone once daily, with the stipulation that these medications should not be given if the resident's systolic blood pressure (SBP) was below 110 mmHg. However, a review of the medication administration records revealed that staff administered these medications twice in February 2025 when the resident's SBP was below the specified threshold. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. Resident 93 did not sustain any adverse effects from receiving the medication. Physician was made aware of resident 93 receiving medication outside of parameters. 2. To identify other residents who have the potential to be affected, the DON/designee completed an audit of residents prescribed medications with parameters. 3. To prevent this from recurring, the DON/designee completed education with licensed nurses on checking and following parameters prior to medication administration. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 10 residents with medication parameters to ensure accuracy of medication administration weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner in both the dietary department and one of the nursing unit pantries. During a kitchen tour, it was observed that the soap dispenser lever at the handwashing sink was covered with thick dried food debris. Additionally, a measuring cup with a dried, flaky substance was found in the cooks' utensil drawer, stored alongside clean utensils. In the thickened liquid cooler, an opened package of sliced cheese and a large opened bulk container of grape jelly were not dated, and a dried pink substance was found inside the length of the door. In the walk-in cooler, two areas of dried white substance were found on the floor under shelves storing meat and milk cartons, and a large opened bulk container of grape jelly was dated but not legible. The Dietary Manager confirmed that these items should have been dated and legible. In the Nursing unit 3A pantry, the refrigerator was found to have temperatures above the required 41 degrees Fahrenheit, with readings of 47, 48, and 46 degrees Fahrenheit on consecutive observations. The refrigerator contained eight milk and three yogurt containers during these observations. The Administrator confirmed that the refrigerator was used for resident foods, indicating a failure to maintain proper food storage temperatures as per the facility's policy.
Plan Of Correction
1. The noted areas in the kitchen were cleaned and undated food was discarded. The items from the unit 3A refrigerator were discarded. Refrigerator temperature settings were changed to a cooler level. Refrigerators replaced on three units. 2. There were no other instances identified during the survey. 3. To prevent this from reoccurring, the NHA/designee completed education with the dietary manager and kitchen staff on kitchen cleanliness and dating food items. The environmental services manager and staff were educated on checking refrigerator temperatures, discarding food items if temperatures are elevated, and to notify the NHA of reoccurring elevated temperatures. 4. To monitor and maintain compliance, the NHA/designee will complete kitchen audits to check for dated open items and kitchen cleanliness weekly x 4, biweekly x 2, and monthly x 1. To monitor and maintain compliance, the NHA/designee will complete food pantry refrigerator temperature audits to check for proper refrigerator temperatures weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. This deficiency was identified through a review of nursing schedules over a 21-day period from January 23 to February 12, 2025. During this time, the facility consistently provided less than the required hours of care, with daily averages ranging from 2.98 to 3.14 hours per resident. The Administrator confirmed the shortfall in nursing care hours during an interview on February 14, 2025.
Plan Of Correction
1. The staffing minimum required nursing care hours ("HPPD") is unable to be corrected for the selected dates. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee will continue to work with Nursing Supervisors and the Staffing Coordinator to ensure the HPPD is at 3.20 or the state staffing minimum. Bonuses, position advertising, staffing flexibility, and agency use are measures used to secure staffing. Staffing will be based on current census and supervisors, or scheduler will contact other staff or agencies to cover call offs. 4. To monitor and maintain ongoing compliance, the DON/designee will audit schedules and HPPD weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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