Pennsylvania Department of Health
ROSEMONT CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 49 surveys for this facility. Please select a date to view the survey results.

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ROSEMONT CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on September 8, 2025, it was determined that Rosemont Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004 Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility. Findings include: 1. Document review on September 8, 2025, between 9:00 a.m. and 1:00 p.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. The facility updated and reviewed the EP plan. NHA and Maintenance Director were reeducated on the requirement to review and update the EP plan every 2 years.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID #181402

Component 01

Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on September 8, 2025, it was determined that Rosemont Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type III (200), unprotected, ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100 Based on observation and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility. Findings Include: 1. Document review on September 18, 2025 between 9:00 am and 1:00pm, revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the Life Safety Code Survey. The Life Safety Code Floor Plans shall include the following: a. Smoke Barrier Walls (outside wall to outside wall); b. Fire Barrier Walls (2-hour walls); c. Horizontal Exits; d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan; e. Required Exits should be clearly noted; f. Shafts Walls In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES): Zone dimensions (length and width) Resident Room numbers and number of residents in each room Nurses station locations to include number of nurses at each location Directional arrows for emergency movement routes Each room use must be identified (dining, soiled linen, housekeeping, office, etc.) Identify where FSES deficiency exists on floor plans. Exit interview with the Administrator and Maintenance Director on September 18, 2025, at 1:15 pm, confirmed the facility was unable to provide portable floor plans with the required information.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. The facility will obtain floor plans that meet the requirement. NHA/Maintenance Director were reeducated the requirement for very detailed portable floor plans

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161 Based on document review and interview, it was determined the facility failed to maintain the building construction fire resistance rating, affecting the entire facility. Findings Include: Document review on September 8, 2025 between 9:00 a.m. and 1:00 p.m., revealed the building has been classified as a three-story, unprotected ordinary construction, that is fully sprinklered. The story height exceeds the maximum allowance by two stories. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed the construction type.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Rosemont Center would like the Department of Health and Human Services Life Safety Divisions assistants with reapplying for another FSES for two-story type III (200) and a TLW, for an unprotected ordinary construction which is fully sprinklered, the story height exceeds the maximum allowance for this construction type one story.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain the fire alarm system, affecting one of two reports. Findings Include: 1. Document review on September 8, 2025, between 9:00 a.m. and 1:00 p.m., revealed the facility could not produce the Semi-Annual Visual Inspection, which was due in March 2025. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. NHA/Maintenance Director were reeducated on the requirement of having 2 yearly fire alarm inspections. NHA/Designee will audit fire alarm inspections semi-annually to ensure inspections are done timely. Results will be shared at QAPI until substantial compliance is met

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting the entire facility. Findings include: 1. Document review on September 8, 2025, between 9:00 am and 1:00pm,, revealed the sprinkler inspection report dated July 22, 2025, listed the following sprinkler system deficiencies: a. Pendants and uprights dated 50 + yrs b. Dry sidewalls dated 2008 c. Valve leaking on water motor gong during inspection d. Pendants in lobby installed with non- listed escutcheon e. Pendants too low in lobby f. Water motor gong did not operate The facility could not provide documentation the sprinkler system deficiencies listed above were corrected. 1. Document review on September 8, 2025, between 9:00 a.m. and 1:00 p.m., revealed the sprinkler inspection report dated July 22, 2025 listed the following sprinkler system deficiencies: a. Pendants and uprights dated 50 + yrs b. Dry sidewalls dated 2008 c. Valve leaking on water motor gong during inspection d. Pendants in lobby installed with non- listed escutcheon e. Pendants too low in lobby f. Water motor gong did not operate The facility could not provide documentation the sprinkler system deficiencies listed above were corrected. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed repair documentation for the deficiencies was not available.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Follow up work was scheduled based on the 7/22/25 sprinkler inspection. NHA/ Maintenance Director was reeducated on the requirements to follow up on sprinkler inspections. NHA/Designee will audit sprinkler inspections quarterly to ensure all recommendations from inspections were followed up. Results will be shared at QAPI until substantial compliance is met

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible, affecting one of five smoke zones in the facility. Findings Include: 1. Observation on September 8, 2025, at 11:22 a.m., revealed in the ground floor kitchen, a wall mounted fire extinguisher was blocked by a wall mounted tray rack and portable tray serving cart. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m. confirmed access to the portable fire extinguisher was obstructed.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Tray rack was immediately removed from near the fire extinguisher.
NHA/Designee audited all fire extinguishers to ensure none were blocked. NHA/Maintenance Director and Dietary Department were reeducated on not having anything near wall hanging fire extinguishers. NHA/Designee will audit around wall hanging fire extinguishers weekly x4 and then monthly x3. Results will be shared at QAPI until substantial compliance is met.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed maintain and inspect the emergency generator, affecting the entire facility. Findings include: 1. Document Review on September 8, 2025, between 9:00 a.m. and 1:00 p.m., revealed the facility failed to provide documentation of the following tests and inspections: a. Annual 90 min Load Bank; b. Generator preventative maintenance indicating there was no evidence of wet stacking. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 90-minute Load Bank test and wet stacking was scheduled. Maintenance Director was reeducated on the requirement of having a yearly 90-minute load bank test and wet stacking test on the generator. Test results will be reviewed by Regional Maintenance Director

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to maintain electrical components, affecting one of five smoke zones. Findings include: 1. Observation on September 8, 2025, at 10:10 a.m., revealed extension cords plugged into an multiplier, inside the ground floor storage room. Exit interview with the Administrator and Maintenance Director on September 8, 2025, at 1:15 p.m., confirmed the electrical deficiency.

Plan of Correction - To be completed: 10/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Electrical plugs were immediately plugged directly into the wall. NHA/Designee audited all rooms to ensure no extension cords or multipliers are being used. Maintenance Director was reeducated on not using extension cords or multipliers. NHA/Designee will audit 5 random rooms weekly x4 and then monthly x3. Results will be shared at QAPI until substantial compliance is met.

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