Roosevelt Rehab: Oxycodone Recordkeeping Failure - PA
Not from the building. Not from the patient. From the record.
The woman, identified in federal inspection documents only as Resident R1, was a patient at Roosevelt Rehabilitation and Healthcare Center in Philadelphia. She had been admitted with a constellation of serious conditions: low back pain, end-stage renal disease, chronic pancreatitis, and osteoarthritis. A physician had ordered oxycodone, 5 milligrams by mouth, every four hours as needed for pain. The order was active and on file. She was dying, and she was in pain, and the medication was there to help her.
At 1:38 in the morning on the date in question, someone signed out a dose of oxycodone on the facility's narcotic reconciliation log. An hour and a half later, at 3:09 a.m., a nurse identified as Employee E3 wrote a note in the clinical record. Signs and symptoms of pain, the note said. One as-needed dose of oxycodone given. Positive result.
Two records. Same dose. Same night.
But when federal inspectors arrived and pulled the medication administration record — the MAR, the document that is supposed to capture every drug given to every resident — the dose was not there. No signature. No timestamp. No entry at all.
The narcotic log said the oxycodone left the controlled substance supply at 1:38 a.m. The nursing note said a patient received it at 3:09 a.m. The MAR said nothing happened.
That is the gap at the center of a federal inspection completed January 29, 2026, at Roosevelt Rehabilitation and Healthcare Center. The inspection was complaint-driven. Inspectors reviewed 12 clinical records. They found the problem in one of them, belonging to a woman who was no longer alive to speak for herself.
When inspectors sat down with Employee E1, the facility's Nursing Home Administrator, and Employee E2, the Director of Nursing, both confirmed what the documents showed. No dose of oxycodone had been signed out in the MAR on the date in question. Both said it was the facility's expectation that all narcotics be recorded in both places, the narcotic log and the MAR, every time.
They confirmed the gap. They did not explain it.
The inspection report does not say whether the facility knew about the discrepancy before inspectors arrived. It does not say whether anyone investigated after Resident R1 died and her records were closed out. It does not say whether the missing MAR entry was ever treated as a problem requiring an answer, or simply a loose end that stayed loose.
What it says is that one dose of a controlled opioid painkiller was signed out of the narcotic supply, administered to a dying woman in the middle of the night, documented by the nurse who gave it, and never entered into the record where it was supposed to appear.
Narcotic reconciliation in a nursing facility is not a bureaucratic formality. Controlled substances are tracked precisely because they are controlled, because the potential for diversion, for error, for harm runs in both directions. A dose that goes missing from a medication record could mean a patient received something they shouldn't have. It could mean a dose was diverted and never given at all. It could mean a clerical error in a facility that was otherwise doing everything right. The inspection report does not make a finding about which of those possibilities applies here.
What it makes a finding about is the record. The record was incomplete. The record was inaccurate. The record did not reflect what the narcotic log and the nursing note both said occurred.
Resident R1 was on an active oxycodone order from the date it was written until the date it was discontinued, which the inspection report notes was following her death. The order covered the night in question. The nurse's note confirms the medication was given and that the patient's pain responded. The only document that fails to reflect any of this is the one document that nursing home administrators and the Director of Nursing both said was required.
Federal inspectors classified the deficiency as minimal harm or potential for actual harm. They noted that few residents were affected. One record out of twelve reviewed. One dose. One night.
But the resident whose record it was had end-stage renal disease. She had chronic pancreatitis. She was in a facility, on a controlled substance for pain, and she died there. The inspection report does not describe the circumstances of her death or suggest any connection between the missing MAR entry and what happened to her. It does not allege that she was harmed by the recordkeeping failure.
It does establish that in the hours before or around her death, a controlled painkiller moved through the facility's narcotic supply, was administered by a nurse, was noted in a nursing entry, and left no trace in the medication administration record.
The administrator and the director of nursing sat across from inspectors and confirmed that this was not how it was supposed to work. The facility's own expectation, they said, was that both records be completed. Both were not completed. The inspection report ends there, with that confirmation, without an explanation for how the gap occurred or who, if anyone, was responsible for it.
Resident R1's oxycodone order was discontinued after she died. Her clinical record was closed. The narcotic log entry from 1:38 a.m. remains. The nursing note from 3:09 a.m. remains. The space in the MAR where someone was supposed to sign remains blank.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Rehabilitation and Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on January 29, 2026.
The woman, identified in federal inspection documents only as Resident R1, was a patient at Roosevelt Rehabilitation and Healthcare Center in Philadelphia.
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.