Pennsylvania Department of Health
 ROSEMONT CENTER
Patient Care Inspection Results

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ROSEMONT CENTER
Inspection Results For:

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ROSEMONT CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an Abbreviated Survey in response to two complaints, completed on February 26, 2026, it was determined that Rosemont Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations: Based on observations, review of policy, review of clinical record and review of facility provided documentation, it was determined facility did not ensure to provide adequate supervision to prevent elopement for one of three residents reviewed (Resident R1) Findings include: Review of facility policy 'Wandering, Unsafe Resident,' revised August 2014, indicated its purpose is to "prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." Review of Resident R1's clinical record revealed a medical diagnosis of dementia with mood disturbance and agitation, depression, cognitive communication deficit, adjustment disorder with anxiety, conduct disorder. Review of elopement assessment completed on December 31, 2025, at 3:15 pm, revealed Resident R1 was at high risk for elopement. Review of facility provided investigation report, completed on February 13, 2026, revealed that on February 12, 2026, at 9:00 am, R1 was residing on second floor unit and managed to escape by taking stairs after pressing of fire doors for more than 15 seconds (which activated alarm). Further review of investigation report revealed that Resident R1 also managed to walk through emergency fire doors on first floor which is right next to entrance doors and is located across from receptionist's desk area. Review of Resident R1's care plan revealed that the facility did not develop a care plan to prevent elopement until February 12, 2026; after the elopement incident. 28 Pa Code 201.18(b.1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 04/06/2026

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. R1 care plan was updated after elopement. DON/Designee will audit all residents who are at risk of elopement to ensure they have a care plan to prevent elopement. DON/Designee to educate Nurses and IDT on ensuring all residents with high elopement risk have a care plan to prevent elopement. DON/Designee will audit residents at high risk for elopement for preventative care plan weekly x4 and then monthly x3. Results will be shared at QA until substantial compliance is met.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations: Based on a review of facility staffing data, it was determined that the facility did not ensure a minimum of one nurse aide (NA) per 10 residents on day shift, one NA per 11 residents on evening shift and one NA per 15 residents on night shift for four of 16 shifts reviewed (February 21, 2026 through February 26, 2026) According to Pennsylvania state regulations, effective July 1, 2024, a minimum of one NA per 10 residents during day, and one NA per 11 residents during evening shift, and one NA per 15 residents during night shift is required. Review of facility's nursing staff ratios from February 21, 2026, through February 26, 2026, revealed that facility did not meet ratio's as follows: February 21 night shift February 23 day shift February 24 evening/night shift The above findings were discussed with facility's administration on February 26, 2026, at 2:00 pm.
 Plan of Correction - To be completed: 04/06/2026

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 evening and overnights 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 x2 weeks to ensure nursing assistants are staffed at the proper ratio. Results will be shared at QAPI until substantial compliance is met.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations: Based on a review of facility staffing data, it was determined that the facility did not ensure a minimum of one licensed practical nurse (LPN) per 40 residents on night shift for four of 16 shifts reviewed (February 21, 2026 through February 26, 2026) According to Pennsylvania state regulations, effective July 1, 2024, a minimum of one LPN per 40 residents during night shift is required. Review of facility's nursing staff ratios from February 21, 2026, through February 26, 2026, revealed that facility did not meet ratio's as follows: February 21 night shift February 22 night shift February 24 night shift February 25 night shift The above findings were discussed with facility's administration on February 26, 2026, at 2:00 pm.
 Plan of Correction - To be completed: 04/06/2026

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 overnight shift. 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 x2 weeks to ensure LPN's are staffed at the proper ratio. Results will be shared at QAPI until substantial compliance is met.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations: Based on review of facility staffing data sheets, it was determined that the facility did not ensure to provide a minimum of 3.2 hours of direct resident care for each resident in a 24 period for four out of five sampled days ( 2/21/2026, 2/22/2026, 2/23/2026, 2/24/2026) Review of facility nursing staffing sheets for the week of February 21, 2026 through February 26, 2026, revealed the following days where the staffing hours of direct resident care fell below the required 3.2 hours. February 21 2.95 February 22 3.18 February 23 2.88 February 24 3.10 The above findings were discussed with facility's administration on February 26, 2026 at 2:00 pm.
 Plan of Correction - To be completed: 04/06/2026

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 minimum nursing hours are being met. 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 x2 weeks to ensure minimum staffing hours are met. Results will be reviewed at QAPI until substantial compliance is met.

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