Roosevelt Rehab: Shower, Feeding Failures Found - PA
When inspectors arrived at Roosevelt Rehabilitation and Healthcare Center on August 26, 2025, they found two residents whose most basic daily needs had been quietly set aside. One wasn't getting the showers her care plan required. Another sat in front of her meal with no one to help her eat.
The resident who needed showers, identified in inspection records as Resident R1, had been admitted to the facility on July 12, 2025. Her diagnoses included lack of coordination, protein calorie malnutrition, muscle wasting and atrophy, and muscle weakness. A cognitive assessment conducted two days after admission found her fully intact mentally, with a score indicating she understood her situation and could communicate her needs.
Her care plan, written on the day she arrived, was specific: she preferred showers, she needed one staff member to assist with bathing, and she required help with turning and repositioning. The plan called for showers twice a week, on Mondays and Thursdays.
None of that was documented as happening.
When inspectors reviewed R1's clinical record with the unit manager, Employee E9, there was no record showing showers had been provided on either day. The unit manager confirmed the schedule should have been Mondays and Thursdays. Then, during the inspection itself, she entered the shower schedule into the facility's task documentation system, an acknowledgment that it had never been properly set up to begin with.
R1 told inspectors directly what had been happening. She said she received showers only once a week, on Mondays. "I would like to get showers twice a week," she said.
For a resident whose body was already losing muscle and struggling to maintain weight, basic hygiene isn't a comfort measure. It's part of care. The facility's own clinical team had assessed her needs and written them down. The documentation just didn't follow.
The second finding involved a resident identified as Resident R3, who was observed during the lunch meal. A staff member brought her a tray, cut her food into pieces, and poured syrup over her pancakes. Then the staff member left. R3 began eating on her own, picking up the cut pieces from her plate.
What inspectors noted was the absence: no feeding assistance was provided. The inspection report does not describe what R3's care plan required or what her diagnoses were, but the facility's own administrator and director of nursing later confirmed the failure. The facility did not provide feeding assistance to Resident R3.
That confirmation came at 2:45 p.m., when the nursing home administrator, Employee E1, and the director of nursing, Employee E2, sat down with inspectors and acknowledged both violations. The facility had not given R1 showers twice a week. The facility had not provided feeding assistance to R3.
The inspection was conducted as a complaint investigation. The violations were cited under F0677, which covers activities of daily living, and assigned a harm level of minimal harm or potential for actual harm. The residents affected were described as few.
What the report captures, underneath the regulatory language, is a particular kind of institutional failure: not dramatic, not violent, but corrosive. A woman with wasting muscles and coordination problems, cognitively sharp enough to know exactly what she was supposed to be getting and exactly what she wasn't, telling an inspector she would like to get showers twice a week. A care plan that said she should. A documentation system that showed she didn't. And a unit manager who entered the correct schedule into the system only after inspectors were already in the building.
R1 had been at Roosevelt for six weeks by the time anyone checked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Rehabilitation and Healthcare Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 26, 2025.
One wasn't getting the showers her care plan required.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.