Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
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.
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.
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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 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 | — | 29 | 0 |
| Beaumont At Bryn Mawr | 1 mi | — | 0 | 0 |
| Bryn Mawr Village | 1.1 mi | — | 23 | 0 |
| Quadrangle | 2.1 mi | — | 0 | 0 |
| Waverly Heights | 2.9 mi | — | 5 | 0 |
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