Roosevelt Park Nursing and Rehabilitation Communit

Inspectors wroteBased on interview and record review, the facility failed to ensure that they had Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 1 of 30 days (3/8/26) reviewed for RN coverage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 34 residents, resulting in the increased likelihood for cross-contamination, equipment failure and harborage conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policies and procedures for enhanced barrier precautions (EBP), hand hygiene, and monitoring for infection control practices for 2 (R14 and R24) of 2 residents reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's desire for showers for 1 of 1 resident (R6) reviewed for choices.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure licensed nurses followed professional standards of practice related to medication storage, medication administration, medication administration documentation, and treatment documentation for 4 residents (R2, R14, R110 & R111) out of 24 residents reviewed for professional standards. Findings Include: R14Review of a Face Sheet reflected R14 admitted to the facility with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, epilepsy, dysphagia following cerebral infarction (difficulty swallowing after a stroke), gastrostomy (feeding tube) and contractures. During an observation on 6/3/26 at 8:50 AM, Certified Nurse Aide (CNA) C and CNA D entered R14's room to assess his need for a brief change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities for 1 (R14) of 1 resident reviewed for activities.

Inspectors wroteThis citation refers to Intake 2806247 in addition to the recertification survey. Based on observation, interview, and record review, the facility failed to prevent accidents and/or maintain an environment that was free from accident hazards for 2 of 4 residents (R2 and R14) reviewed for accidents and/or accident hazards, for the bathrooms in 6 of 9 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER]/21, room [ROOM NUMBER]/24, room [ROOM NUMBER]/29, room [ROOM NUMBER], room [ROOM NUMBER]/33) reviewed for water temperatures, and 1 of 2 shower rooms (West Shower Room) reviewed for accident hazards.

Inspectors wroteBased on interview and record review, the facility failed to have regular hospice visits documented and/or communication for 1 (R36) of one resident reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to ensure vaccinations were offered and up to date according to the Centers for Disease Control (CDC) for 5 Residents (R6, R7, R31, R44, and R45) of 5 residents reviewed for vaccinations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that equipment was being maintained in proper working order, potentially affecting all residents that use the hot water, and eat food provided by the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to submit and ensure an accurate and timely Minimum Data Set (MDS) for 1 Resident (R11) of 4 residents reviewed for Resident Assessments.

Inspectors wroteBased on interview and record review, the facility failed to address Pre-admission Screening/Annual Resident Review (PASARR) in a timely manner for 1 Resident (R35) out of 17 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide daily care for one (R14) of one resident reviewed for cares of a dependent resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated for 1 (R20) and the oxygen concentrator filter was clean for 1 (R14), of 2 residents reviewed for respiratory devices.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely notify necessary parties, provide support and follow-up for 1 Resident (R27) out of 3 Residents having a psychosocial adjustment difficulty causing delay in care, services and the potential for further psychosocial, mental, and potential physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications in 1 of 1 medication carts inspected (West Medication Cart).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 17 sampled residents (R9).

Inspectors wroteBased on interview and record review, the facility failed to post complete and accurate Daily Staffing sheets for 3 of 30 sheets reviewed (3/3/26, 3/7/26, and 3/22/26).

Inspectors wroteThis citation pertains to intake # 2614154Based on interview and record review, the facility failed to prevent misappropriation of residents narcotic medication for 2 residents (Resident #1 and #2) and monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 4 residents (Resident #2, #3, #4, and #6) out of 7 residents reviewed for the misappropriation of narcotics, resulting in the diversion of narcotic medications and the potential for ongoing diversion of narcotic medications.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to prevent, recognize, and control the onset and spread of infection among staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain call light placement within reach of two (Resident #26 and Resident #27) of two residents reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 13 residents (Resident #21, #24, #20, and #136), reviewed for the provision of nursing services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet resident needs for 3 of 13 residents (Resident #3, #5, and #10) and residents participating in resident council, reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to 1.) administer controlled medications and 2.) accurately document the administration of controlled drugs for 4 of 13 residents (Resident #14, #83, #7, and #20) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to offer evening snacks for two (Resident #17 and Resident #5) of two residents, and to those residents that attend the monthly resident council meetings.

Inspectors wroteBased on observation and interview, the facility failed to maintain and clean a safe environment for all resident's that visited or utilized the activity room.

Inspectors wroteResident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Infarction (stroke), epilepsy, chronic pain syndrome, dysphagia (difficulty swallowing). Review of R10's Care Plan revealed: Problem Start Date: 06/10/2024 (R10) is unable to follow structured activity .Goal-(R10) will appear comfortable and satisfied with their daily facility activities/routine. (R10's) preferences will be honored to extent possible. Encourage (R10) to get up in his wheelchair daily and attend activities of interest . Approach Start Date: 06/10/2024 Assist (R10) with locating favorite TV show or channel as needed. Per sister (R10) will watch whatever is on the TV. He does enjoy sports mainly baseball and Westens (sic) . Approach Start Date: [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor and ensure residents were free from adverse drug reactions (extrapyramidal symptoms) for 2 of 13 residents (Resident #12 and #5) reviewed for psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt nursing care and services were provided to assist 1 of 13 residents (Residents #10) reviewed for Activities of Daily Living (ADL) care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice, for 1 resident (Resident #10) out of 13 residents reviewed for the development of pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent the worsening of a contractures for 1 of 13 residents (Resident #10) reviewed for position, mobility, and splint use.

Inspectors wroteBased on interview and record review, the facility failed to perform a root cause analysis and implement meaningful interventions/preventative measures following a fall for 1 of 13 residents (Resident #10) reviewed for accidents and hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow safety guidelines for two (Resident #83 and Resident #10) of two residents reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that sufficient pain management was provided for 1 of 13 residents (Resident #10) reviewed for pain management.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program for 1(Resident #138) of 7 residents reviewed for antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure the influenza vaccine and pneumococcal vaccines were offered and administered for 3 of 5 residents (Resident #15, #10, and #24), reviewed for immunizations.

Inspectors wroteThis citation pertains to intakes #'s: MI00149655 and MI00149651 Based on interview and record review, the facility failed to 1.) prevent misappropriation of residents narcotic medication and drug diversion for 4 residents (Resident #8, #7, #3, and #4) and 2.) monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 3 residents (Resident #3, #4, and #5) out of 7 residents reviewed for the misappropriation of narcotics.

Inspectors wroteThis citation refers to MI00147558. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 4 residents (R2 and R4), resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During an initial tour of the kitchen, starting at 9:03 AM on 7/1/24, it was observed that the top portion of the door seals of the two door Traulson freezer were found with an increased accumulation of crumb and dirt debris and shown to Dietary Supervisor (DS) G. During a revisit to the kitchen, at 8:02 AM on 7/2/24, it was observed that the top portion of the door seals of the two door Traulson freezer were found with an increased accumulation of crumb and dirt debris. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. [...]

Inspectors wroteThis citation has two Deficient Practice Statements (DPS) DPS 1: Based on interview and record review, the facility failed to 1) Implement a system to prevent, recognize, and control the onset and spread of infection among residents for 3 residents (Resident #33, Resident #37, and Resident #21) and 2) Investigate, document surveillance of, and implement preventative measures to address an outbreak of a respiratory illness among staff and residents.

Inspectors wroteBased on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 3 out of 3 residents reviewed ( Resident #10, Resident #4, and Resident #18) and several reported unmet needs at the Resident Council Meetings, when staff did not assist a resident to get out of bed throughout the day, did not consistently offer and pass out evening snacks or fresh water on each shift, and by not answering call lights in a timely manner.

Inspectors wroteDuring a tour of the facility, at 11:35 AM on 7/1/24, it was found that the hot water from the central spa hand sink was found to reach 123.9F when tested with a rapid read thermometer. An interview with Maintenance Director (MD) E, at 11:40 AM on 7/1/24, found that he takes hot water temperatures in the morning and there is multiple hot water systems in the building. One servicing the west end, one for the east end, and one for the kitchen. When asked what hot water system supplies the Central spa room, MD E stated it was the west end water heater. Observation of the water heater for the west end of the building, at 11:46 AM on 7/1/24, found that the water heater goes through a mixing valve before supplying care areas on the floor. At this time, the thermometer showed outgoing water at 120F and MD E adjusted the mixing valve to help lower the temperature. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for two residents (Resident #10 and Resident #25) receiving hydration and nutrition through a feeding tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) Properly store medications in 1 of 2 medication carts and in 1 of 2 medication storage rooms and 2.) Ensure that a resident's medications were securely stored in a medication cart for one resident (Resident #18).

Inspectors wroteBased on interview and record review the facility failed to offer additional food preferences, and alternative or optional food choices for two residents (Resident #4 and Resident #18) of six residents interviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the activated medical and financial Durable Power of Attorney (DPOA) was accurately recorded in the medical record for 1 of 6 residents (Resident #24) reviewed for advance directives, resulting in the potential for inappropriate delegation of resident rights to a person not formally authorized to make decisions on behalf of the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide Advance Beneficiary Notices (ABN) and the Notice of Medicare Non-Coverage (NOMNC) for 3 Residents (Resident #12, Resident #19, Resident #40) of 3 residents reviewed for notifications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required an antibiotic were prescribed the appropriate antibiotic for 3 of 6 residents (Resident #142, Resident #143, and Resident #144) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program.