Roosevelt Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, staff interviews, and clinical record reviews, it was determined that the facility failed to administer medications in accordance with physician orders for two of two residents reviewed. (Residents R1, R4)

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with the Enhanced Barrier Precautions for one of one resident treatment reviewed (Resident R3).

Inspectors wroteBased on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the emergency care of residents with tracheostomy tube (opening in the trachea to help air and oxygen reach the lungs) for four of four employee records reviewed (Employee E8, E9, E10, E11). Findings Include: Review of facility policy titled Emergency Tracheostomy Tube Change and Decannulation dated September 2020, revealed An emergency tracheostomy tube change can become necessary for a variety of reasons. An experienced clinician should be able to quickly assess and identify the need for such procedure. Implementation includes: 1. If current trach is blocked, remove the inner cannula first. If still occluded, deflate the tracheal cuff and removed obstructed tube. 2. [...]

Inspectors wroteBased on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors.

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure to document the Code Status for one of 35 residents reviewed (Resident R4). Findings Include:Review of Facility Policy on Advance Directives, dated September 2022, revealed; Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by state law. [...]

Inspectors wroteBased on interview with resident, and review of facility provided documentation, it was determined that facility did not ensure to provide evidence that all alleged violation was thoroughly investigated related to incident during smoke break between two residents (Resident R53, R232)

Inspectors wroteBased on observations, review with resident and staff, and review of clinical record, it was determined that facility did not ensure to develop and implement a resident centered care plan resulting in falls for one of 36 residents reviewed (Resident R144)

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to develop a comprehensive, person-centered care plan related to enhanced barrier precautions for 1 of 3 residents reviewed (Resident R250).

Inspectors wroteBased on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (ADL) (shaving and nail care) for two of 4 sampled residents. (Residents 246, R155)

Inspectors wroteBased on observations, review of facility provided documentation, and interview with staff, it was determined that facility did not ensure resident's environment was free from accident, and hazard for one of 36 residents reviewed (Resident R15)

Inspectors wroteBased on review of facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to implement ordered treatment and services related to incontinence management for two out of 35 residents reviewed (Resident R125, R223). Findings Include:Review of clinical literature indicates that a catheter is a flexible medical tube inserted into the body to drain or deliver fluids, most commonly used to remove urine from the bladder when a person cannot void (urinate or empty the bladder) naturally. A Foley catheter and a suprapubic catheter are both types of urinary catheters but differ in placement and use: [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to implement interventions consistent with resident assessed needs for one of two residents reviewed for nutrition (Resident R3). Findings Include:Review of Resident R3's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 20, 2026, revealed the resident was deemed cognitively intact, had diagnoses of muscle weakness and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and had an unhealed pressure ulcer (localized injury to the skin and/or underlying tissue). [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure medication regimen reviews were timely addressed by the physician for three of five residents reviewed (Resident R3 and R5). Findings Include:Review of facility policy Medication Regimen Reviews revealed medication regimen reviews (MRR) are conducted at least monthly by a licensed pharmacist. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, errors, and other irregularities. Review of Resident R3's Medication Regimen Review Recommendation to Prescriber dated December 22, 2025, revealed the following recommendation [Resident R3] currently receiving abilify (antipsychotic medication_. [...]

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for 1 of the three residents reviewed. (Resident R250).

Inspectors wroteBased on observation, review of facility policy, clinical record review and interview with staff and residents, it was determined that the facility did not maintain complete and accurate medical records for one of 12 records reviewed (R1)Findings Include: Review of clinical record revealed that resident R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to, low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis. The resident died in the facility on [DATE]. Review of physician orders for resident R1 revealed an order for OxyCODONE HCl Capsule 5 MG Give 1 capsule by mouth every 4 hours as needed for Pain. The order was active from [DATE], to [DATE], when it was discontinued following her death. A nursing note for resident R1 signed by employee E3, dated [DATE], at 3:09 a.m. stated s/s (signs and symptoms) of pain. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a resident environment free of accident hazards for one resident (Resident R1), resulting in Resident R1, who was diagnosed with dementia, accessing the facility's main kitchen unattended and unsupervised during nighttime/after-hours. One of five residents reviewed.

Inspectors wroteBased on the review of facility documentation, clinical records and interviews with resident and staff, it was determined that the facility failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R2)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of five clinical records reviewed (Resident R2).

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to furnish an appointment for outside services in a timely manner for one of 5 residents reviewed (Resident R2). During an interview on September 17, at 10:30 a.m. Resident R2 stated he needed to see an outside provider for wounds on the lower extremity which was following him in the community. Resident stated staff missed his appointment and did not arrange the transportation two weeks ago and on September 16, 2025. Resident stated staff told him prior to the appointment that the transportation was arranged. He stated at the time of the appointment he was told there was no transportation and the appointment was not completed. [...]

Inspectors wroteBased on policy review, staff interviews, resident interviews, and clinical record review, it was determined that the facility failed to provide showers to Resident R1 and feeding assistance to Resident R3. These were two of eight residents reviewed who were dependent on staff for activities of daily living. (Resident R1, R3).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to a urinary catheter care for one of 9 residents reviewed (Resident R1).

Inspectors wroteBased upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow physician's orders for urinary catheter care for 1 of 3 residents reviewed and for the need of 1:1 staff supervision at all times for one of 9 resident reviewed. (Resident R1).

Inspectors wroteBased on a resident group interview, observations, and interviews with staff, it was determined that the facility failed to display proper contact information for the State Survey Agency, including the Hotline number on three of three nursing floors and lobby area. (Second, Third, Fouth Floor and lobby)

Inspectors wroteBased on clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure the pharmacist recommendations were reviewed by the physician in a timely manner for three of five residents reviewed related to medication regime reviews (Resident R78, Resident 93 and Resident R114).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for 6 of 6 residents interviewed (Residents R113 R195, R279, R103, R189 and R12).

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to appropriate cleaning techniques for medical equipment, on four of the seven Medication Administration Reviews (Residents R20, R176, R195, R227), and the Enhanced Barrier Precautions for four of seven residents treatments reviewed (R97, R168, R176, R195).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to monitor the urine output one of one resident review with a urinary indwelling catheter. (Resident R49)

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for one of 8 residents reviewed for nutrition. (Residents R38)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of six residents reviewed (R125).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for two of four dialysis residents reviewed (Residents R66, R125).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility did not ensure the timely acquiring of medications from pharmacy for a newly admitted resident for one of one of 35 residents reviewed . (Resident R277). Findings Include: Review of the Policy, Administering Medications, Revised April 2019, states Medications are administered in a safe and timely manner, and as prescribed. Interview with Resident R277 on April 21, 2025, at 11:00 a.m. revealed that he did not get his prescribed cardiac medications on the day of his admission on [DATE]. Resident R277's wife confirmed this stating that she was very upset that they did not have his heart medications available. [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of seven residents observed during medication administration (Residents R17, R20, and R195).

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to honor resident food and drink preferences by providing food that was requested by and acceptable to the residents for six of 35 residents reviewed (Residents R279, R103, R189, R31, R53 and R27).

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on interview with resident and staff, and review of facility provided documentation, it was determined facility failure to ensure that one of 12 residents receive the breakfast meal. ( Resident R3)

Inspectors wroteBased on clinical record review, observations, and interviews with staff, it was determined that the facility failed to provide incontinence care in a timely manner for four of six residents reviewed. (Resident R1, R2, R3, R4)

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety.

Inspectors wroteBased on review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide palatable, attractive, and at a safe and appetizing temperature meals during lunch for two of two meal observations. ( June 30, 2024, and July 1, 2024).

Inspectors wroteBased on review of clinical records, observation, and interview with staff, it was determined that the facility failed to implement enhanced barrier precautions and practice infection control practice relating to residents dining for 4 of 36 residents reviewed. (Resident 52, Resident R146, Resident 101, Resident 194)

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for six of six months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024, April 2024, May 2024 and June 2024). Findings Include: Review of facility policy Antibiotic Stewardship: Review and Surveillance of Antibiotic Use and Outcomes dated December 2016 , revealed the Antibiotic sage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. [...]

Inspectors wroteBased on the observations and interview with the staff, it was determined that the facility failed to ensure a clean and homelike environment two of three nursing units. (Third floor and Fourth Floor)

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of three residents reviewed related to respiratory care (Resident R266).

Inspectors wroteBased on review of facility documents and policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to smoking for one of three residents reviewed related to smoking (Resident R177).

Inspectors wroteBased on the observations, review of clinical records, and interview with staff and resident, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of one resident reviewed for positioning and mobility. (Resident R72). Finding Include: Interview with Resident R72 on June 30, 2024, at 9:52 a.m. stated he had contractures to his hand. Resident stated the contracture was a result of stroke. Resident stated he was not provided any services in the facility including exercise or splinting to prevent worsening of the contracture. Observation of Resident 72 June 30, 2024, at 9:52 a.m. revealed that the resident was laying in the bed. It was observed that both resident's hands appeared to be contracted. [...]

Inspectors wroteBased on the review of facility policy, clinical records and interview with staff, it was determined that the facility failed to provide acceptable nutritional parameters for one of 36 residents reviewed. (Resident R194) Findings Include: Review of facility policy Weight Policy dated December 2022, revealed that It is the policy of this facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. Any resident displaying a significant change in weight of greater than or equal to 5%. gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. [...]

Inspectors wroteBased on clinical record review, review of facility policy and staff interview, it was determine that the facility failed to ensure ongoing records of communication between the facility and the dialysis center for one of three residents reviewed receiving dialysis. (Resident R58)

Inspectors wroteBased on review of clinical record, review of facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 7 residents reviewed for nutrition (Resident R194).

Inspectors wroteBased on clinical record review, interview with staff, and review of facility policy, it was determined that the facility failed to ensure the physician documented the review of pharmacy recommendation and failed to document the rational for rejection of recommendation for one of three clinical records reviewed. (Resident R13)

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for four of six medication carts observed. (Second floor center, Third floor center, Third south, and Forth floor center).

Inspectors wroteBased on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide food products based on the resident's food preference for four of 36 residents (Resident R22, R23, R98, R155).

Inspectors wroteBased on observations, and interviews with residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for two resident rooms units reviewed. (room [ROOM NUMBER] and room [ROOM NUMBER])

Inspectors wroteBased on review of facility policy and documents, staff interviews, and observation it was determined that the facility failed to provide training on infection control procedures relating to enhanced barrier precautions for seven of eight employees interviewed.

Inspectors wroteBased on clinical record review, observations, and interview with staff, it was determined that facility failed to provide incontinence care in a timely manner for two residents out of 16 reviewed. (Resident R1 and R2)

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to weekly weights for one of 13 residents reviewed (Residents R1).

Inspectors wroteBased on facility policy review, clinical record review and interview with staff, it was determined that the facility failed to ensure that a safe environment was provided for one of 10 residents reviewed. (Resident R7).

Inspectors wroteBased on observations of the physical environment of the kitchen and basement of the facility, reviews of the pest control operators reports and interviews with staff and residents, it was determined that the facility was not maintaining an effective pest control program throughout the building.

Inspectors wroteBased on observations, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that pain assessments were documented for one of six clinical records reviewed. (Resident R1).