Roosevelt Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 24, 2023

  Based on the review of clinical records, facility investigation, facility policies, interviews with staff and facility documentation, it was determined that the facility failed to provide appropriate supervision for Resident R1 which resulted in Resident R1 eloping from the facility and remaining out of the facility for approximately 13 hours. This failure placed Resident R1 and other residents who were identified as high risk for elopement at risk for serious harm and resulted in Immediate Jeopardy situation for one of eight residents reviewed. […]

• Actual harm, isolatedF686Apr 20, 2023

  Based on clinical record review, review of facility policy, and interviews with staff, it was determined the facility failed to ensure one of three residents reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new pressure ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R455. Findings include : Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated stated, The nurse shall describe and document the full assessment of a pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. […]

• Actual harm, isolatedF686Dec 13, 2022

  Based on a review of clinical records and facility policies, observations and staff interviews, it was determined that the facility failed to implement wound care practitioner's recommendation of heel protection and pressure reduction to Resident R1's bony prominence, to consistently provide pressure ulcer interventions in accordance with the resident's plan of care; to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who developed five new facility acquired pressure sores, for one of five clinical record reviewed. (Resident R1) Findings include: A review of an undated facility policy entitled, Pressure Ulcers/Skin breakdown-Clinical protocol, 1. […]

• Actual harm, isolatedF600Jun 10, 2022

  Based on interviews with residents and staff, review of clinical records, review of facility policies and review of facility documentation, it was determined that the facility failed to implement interventions to assure one resident (Resident R151) was free from physical abuse and mental anguish resulting in actual harm to Resident R151 who was hit on the face on two separate instances for one of 39 resident records reviewed (Resident R151). Findings include: Review of the facility's policy titled, Abuse Prevention Program, not dated, revealed that the facility's residents have the right to be Free from abuse and neglect. This includes, Verbal, mental, and physical abuse. […]

• No harm, potential for more than minimal, widespreadF812Jul 3, 2024

  Based 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. Findings include: Facility's Policy titled Food Receiving and Storage last revised [DATE] revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Under Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (used by date). Under Refrigerated/Frozen Storage further states 1.All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. […]