Pennsylvania Department of Health
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  208 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on February 7, 2024 it was determined that Roosevelt Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.











 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based 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).

Findings include:

Review of the facility policy titled " NutraCo" weight policy revised December 2023, revealed " It is the policy of this facility to weight each resident on admission, then for 4 weeks, then monthly thereafter, unless to 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.

Review of Resident R1's Admission MDS, dated November 29, 2023, revealed that the resident was admitted to the facility on November 22, 2023, and had diagnoses of rhabdomyolysis (condition characterized by the breakdown of muscle tissue that leads to the release of muscle fiber contents into the bloodstream), acute kidney failure with medullary necrosis, pneumonitis due to inhalation of food and vomit.

Review of the Resident Assessment Instrument 3.0 User's Manual effective August 2023 (assessment of resident's care needs), indicated that the resident the resident was cognitively intact.

Review of the monthly weight record revealed that at admission the resident weighted 160 pounds (Lbs.), continued review of the monthly weight record revealed that on December 21, 2023, the Resident R1 weighed 150 lbs.

Continued review of monthly weights revealed on January 8, 2024, the Resident R1 weighed 146.7 pounds (lbs.).

On February 7, 2024, the resident weighed 139.8 pounds which was -6.80 % weight loss in one months and -12.63 % weight loss since admission..

A review of clinical dietary progress notes revealed on January 24, 2024, Registered Dietician, Employee E3 recommended an intervention to complete weekly weight x 4 to monitor weight changes.

Review of the January and February 2024 physician orders did not reflect weekly weight x 4 to be on the Resident's R1 orders. Review of the weights after the recommendation of the dietician there was no weekly weights taken from January 24, 2024 - February 7, 2024.

Registered Dietician, Employee E3 was not available to be interviewed.

An interview with the Director of Nursing, Employee E2 on February 7, 2024, at 3:27 p.m. confirm that there was no physician order for the weekly weights.

28 Pa Code 211.12(d)(5) Nursing services



 Plan of Correction - To be completed: 02/27/2024

1) Resident was reweighed on 02/15/2024

2) An audit was completed of residents with recommendations for increased weight monitoring to ensure that physician's orders are in place. Variances were addressed at the time of the audit and placed on the facility audit tool.

3) The DON/Designee re-educated the Registered Dietician on the process for entering physician's orders after giving weight monitoring recommendations.

4) The DON/Designee will complete 10 random audits of weight monitoring physician's orders as well as weight compliance weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port