Roosevelt Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Dec 29, 2021

  Based on observation, interview, record review, and pertinent facility documents, it was determined that the facility failed to a.) consistently follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) ensure an individualized comprehensive care plan interventions were developed and implemented to a prevent facility acquired pressure injury wound from developing, and c.) ensure a Registered Nurse assessed and documented the development of a stage IV facility acquired pressure injury identified on 10/29/21; and d.) ensure weekly skin checks were conducted according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 1:36 PM, the surveyor observed Resident # 117 in bed sleeping. […]

• No harm, potential for more than minimal, widespreadF755May 2, 2024

  Refer to F-760 Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) accurate documentation of the removal of a controlled substance for 1 of 5 residents (Resident #12), reviewed for an as needed (PRN) 5/325 milligram (mg) of Oxycodone/Acetaminophen (a narcotic medication, indicated for pain), b.) accurate reconciliation and administration of narcotic medication with potential for drug diversion for 2 of 5 residents (Resident #12 and #212) reviewed for a PRN pain medicine, c.) discontinued narcotic medications were removed from active inventory and disposed of after being discontinued on 11/27/23 (5 months) for Resident… […]

• No harm, potential for more than minimal, widespreadF760May 2, 2024

  Refer to F 755 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 5 residents (Resident #212) reviewed for prn narcotic administration. The deficient practice was evidenced by the following: On 04/30/24 at 10:35 AM, the surveyors requested a list of all residents receiving the prn narcotic oxycodone 5/325 mg (milligrams) from Director of Nursing (DON). […]

• No harm, potential for more than minimal, widespreadF812May 2, 2024

  Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to a) maintain proper kitchen sanitation practices and clean equipment, b) properly store foods in a safe manner to prevent the development of food borne illness, c) maintain 4 of 4 nursing unit kitchenettes used for residents in a sanitary manner, and d) properly dispose of used cooking oil according to regulations. These deficient practices observed as evidenced by the following: On 04/22/24 at 09:42 AM, in the presence of the Food Service Director (FSD) and the food service manager (FSM), the surveyor toured the kitchen and observed the following: 1. […]

• No harm, potential for more than minimal, patternF880May 2, 2024

  Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) the staff handled, stored, and processed linens and other supplies in a clean manner and to prevent possible contamination for two (2) of two (2) rooms (Laundry and Linen Storage) according to facility's policy and Centers for Disease Control and Prevention (CDC) guidelines, b) routine, ongoing, and systematic monitoring and tracking of facility's water management, and c) policy was reviewed and updated to reflect and address the need of the facility according to clinical standard of practice and CDC guidelines, d) maintain the resident's Tube Feed hydration bag with proper infection control practices for one (1) of five (5) residents reviewed for Tube… […]