Roosevelt Park Nursing and Rehabilitation Communit

In the surveyor’s words

From the most serious findings on record at Roosevelt Park Nursing and Rehabilitation Communit, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 13, 2022

  Based on interview and record review, the facility licensed staff failed to follow professional standards of practice, monitor pertinent laboratory values, communicate effectively with a [CONDITION(S)] clinic and follow-up on pharmacy recommendations resulting in an Immediate Jeopardy (IJ) that was identified on 9/6/2022 and began on 2/8/2022 when the [CONDITION(S)] clinic discontinued testing PT/INR levels for Resident #26 who continued to receive [MEDICATION(S)] 6 mg (an anticoagulant) once a day at the facility for over 6 months without PT/INR monitoring. This deficient practice resulted in the high likelihood for Resident #26 to suffer an adverse drug reaction (hemorrhage or blood clot formation) that could result in serious harm, injury and/or death. […]

• Actual harm, isolatedF684Aug 18, 2023

  Based on interview and record review, the facility failed to ensure residents received comprehensive pain assessments for 1 resident (Resident #33) reviewed for quality of care, resulting in unidentified/untreated pain, unidentified fractures, and a delay in treatment and the potential for the worsening of medical conditions. Findings: Resident #33 (R33) Review of an Admission Record revealed R33 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: closed burst fracture of lumbar vertebra. […]

• Actual harm, isolatedF689Aug 18, 2023

  Based on interview and record review, the facility failed to implement a post fall intervention for 1 resident (Resident #33), reviewed for falls, resulting in a subsequent fall with major injuries. Findings: Resident #33 (R33) Review of an Admission Record revealed R33 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: closed burst fracture of lumbar vertebra. Review of a Minimum Data Set (MDS) assessment for R33, with a reference date of 7/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R33 was moderately cognitively impaired. […]

• Actual harm, isolatedF686Sep 13, 2022

  Based on observation, interview and record review, the facility failed to prevent the development of a wound for 1 Resident (Resident #332) reviewed for alterations in skin integrity, resulting in the development of a wound for R332 and the potential for further skin breakdown, delayed wound healing, infection, and overall deterioration in health status. Findings: Resident #332 (R332) Review of a Face Sheet revealed R332 was a [AGE] year-old male originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF656May 7, 2021

  This citation pertains to intake MI 734 Based on interview and record review, the facility failed to implement the comprehensive Care Plan for Falls to prevent a fall of a resident (Resident #14) that is at high risk for falls, resulting in a fall with fracture and the potential for all facility residents at risk for falls to not have Care Plan interventions implemented to prevent falls and injury. Findings include: Resident #14 admitted to the facility 2/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]