Rosemont Center

In the surveyor’s words

From the most serious findings on record at Rosemont Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 26, 2021

  Based on clinical record review, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that adequate nursing staffing was maintained resulting in the neglect of six of 27 residents as evidenced by nursing care, medications and treatments not being administered to Residents R1, R4, R11, R38, R56 and R65. This failure placed all 27 residents on the Second Floor Nursing Unit in an Immediate Jeopardy situation during one of three nursing shifts (11:00 p.m.- 7:00 a.m.) on December 25, 2020. […]

• Immediate jeopardy, patternF689Jun 26, 2021

  Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for two of 2 nursing units observed (First Floor and Second Floor Nursing Units). This failure placed residents on the First and Second Floor Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy title, Safety of Water Temperatures, dated November 14, 2020, revealed that, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. […]

• Immediate jeopardy, patternF725Jun 26, 2021

  Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety on one of two nursing units (Second Floor Nursing Unit) during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020. Residents on the Second Floor Nursing Unit did not receive medications and treatments; the security of a medication cart was compromised; and non-licensed nursing staff were not appropriately supervised and monitored by a licensed nurse. This failure placed all 27 residents who resided on the Second Floor of the facility in an Immediate Jeopardy situation. […]

• Immediate jeopardy, isolatedF600Sep 1, 2022

  Based on observations, review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of six residents reviewed (Resident R1). This deficiency was identified as an Immediate Jeopardy of past non-compliance for Resident R1 who was struck by a nurse aide. Findings include: Review of facility policy, Abuse Prevention Program dated revised December 2016, revealed that, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. […]

• Actual harm, isolatedF689May 24, 2023

  Based on staff interviews, review of clinical records, and facility documentation, it was determined that the facility failed to provide adequate supervision in the form of one to one as order by the physician and as indicated in the resident's plan of care for Resident R39. This failure resulted in actual harm to Resident R39 who sustained a fall, a laceration to the forehead, requiring transfer to the hospital and sutures for one of 20 residents reviewed. (Resident R39). Findings include: Review of the May 2023 physician orders for Resident R39 included the diagnoses of colon cancer; cerebral infarction (a stroke); schizophrenia (a mental disorder characterized by having false beliefs about people, places and things, seeing, hearing, feeling and smelling something that does not does… […]