The Mansion at Rosemont

During a period on a Sunday, no staff members were present in the home who were certified in first aid, obstructed airway techniques, and CPR, and later only one certified staff member was present.

Three direct care staff members received less than the required 12 hours of annual training during the 2024 training year.

Direct care staff members did not receive training on several required topics, including medication self-administration, infection control, and resident needs assessment.

The home failed to report a medication error involving a missing prescription to the Department within 24 hours.

Two contractors were observed unsupervised in a resident room without required criminal background checks.

Direct care staff did not receive required training on meeting resident needs and safe management techniques for the 2023 training year.

A staff person did not receive required annual training in fire safety and resident rights for the 2023 training year.

Poisonous materials, including toothpaste, were left unlocked and accessible to residents due to a broken bathroom vanity lock.

A shower chair with feces on the seat was observed in a resident's shower.

A bottle of prescription strength shampoo was found unsecured under a resident's bathroom sink.

Medication records contained conflicting and undated instructions regarding the timing and application of medication.

A staff member was verbally and physically aggressive with a resident, refusing assistance and pushing them into a hot shower.

A staff member failed to treat a resident with dignity and respect by using aggressive language and refusing to assist with mobility.

No staff members were present in the home who were certified in first aid, obstructed airway techniques, and CPR during a period when 78 residents were present.

Multiple staff members did not receive required fire safety and emergency preparedness orientation on their first day of work.

Emergency telephone numbers for the nearest hospital and fire department were not posted by the telephone in the SDCU Kitchen.

The refrigerator temperature was recorded at 45 degrees Fahrenheit, which exceeds the required maximum of 40°F.

There was a large accumulation of lint across the lint trap of the dryer in the SDCU.

Directions for operating the locking mechanism were not conspicuously posted near the kitchen door or stair tower 6 in the SDCU.

Cameras were observed in hallways without signage identifying the areas as under surveillance.

Six unsupervised contractors were present in the home without criminal background checks on file.

The trash compactor was unclean with an infestation of gnats and flies due to insufficient cleaning staff.

A trash can was used to catch water dripping from a ceiling pipe, and the trash compactor area had an odor and pest infestation.

A ceiling tile was missing in the first floor dining room, and an underlying coolant pipe was leaking.

A bathroom faucet handle was not in good repair, resulting in no water flow when turned on.

The 200 Level Medication Cart was unlocked and the locking mechanism was not functioning properly, allowing drawers to be opened without a key.

Six loose pills were observed in several drawers of the 200 Level Medication Cart.

Discrepancies were found between glucometer readings and the resident glucose logs/files for multiple residents, including unrecorded readings and mismatched data.