Roosevelt Rehabilitation And Healthcare Center

F 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of five clinical records reviewed (Resident Resident R2).Findings include:Review of Resident Resident R1's physician progress note dated September 6, 2025, indicated that resident was noted with elevated potassium level 5.5. and indicated that

the blood likely hemolyzed (a condition where red blood cells (RBCs) burst, releasing their contents into the blood plasma or serum, which gives it a reddish tinge after centrifugation) and to repeat BMP (Basic Metabolic Panel) on September 8, 2025Review of Resident Resident R1's physician progress note dated September 12, 2025, indicated that repeat BMP ordered for September 8, 2025, was not done and ordered for CMP (a blood test that measures multiple substances in the body to assess overall health and identify potential medical conditions).Continued review of clinical records for Resident Resident R2 revealed no evidence that the lab ordered by the physician for September 8, 2025, and ordered on September 12, 2025, was completed.Interview with the Director of Nursing, Employee E2 on September 12, 2025, at 12:00 p.m. confirmed that the staff did not obtain lab work as ordered by the medical practitioner for September 8, 2025, and ordered on September 12, 2025.28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)Nursing services28 Pa. Code 211.12(d)(3) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Roosevelt Rehabilitation and Healthcare Center

7800 Bustleton Avenue Philadelphia, PA 19152

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to furnish an appointment for outside services in a timely manner for one of 5 residents reviewed (Resident Resident R2).During an interview on September 17, at 10:30 a.m. Resident Resident R2 stated he needed to see an outside provider for wounds on the lower extremity which was following him in the community. Resident stated staff missed his appointment and did not arrange the transportation two weeks ago and on September 16, 2025.

Resident stated staff told him prior to the appointment that the transportation was arranged. He stated at

the time of the appointment he was told there was no transportation and the appointment was not completed.Resident Resident R2's clinical record revealed an admission date of August 28, 2025, with diagnoses that included cellulitis (infection of skin) of right lower extremity and chronic venous hypertension ulcer of right lower extremity. Review of hospital record for Resident Resident R2 on August 28, 2025, revealed that an appointment request to follow up with podiatry on September 2, 2025.Review of clinical record for Resident Resident R2 revealed no evidence that the resident was seen by an podiatry as ordered by the hospital discharge summary. There was no documented reason for the cancellation of the service.Review of clinical record for Resident Resident R2 revealed a wound care/podiatry consult report dated September 9, 2025, which indicated a follow up appointment with the provider on September 16, 2025, at 1:30 p.m.Review of clinical record for Resident Resident R2 revealed no evidence that the resident was seen by an podiatry on September 16, 2025, at 1:30 p.m. There was no documented reason for the cancellation of the service.During an interview with Employee E2, Director of Nursing, on September 12, 2025, at 12:00 p.m. could not give a reason for not sending Resident Resident R2 the appointment. Employee E2 confirmed that the facility missed Resident Resident R2's appointment on September 2 and September 16. 28 Pa. Code 211.12(d)(3) Nursing services

Event ID:

Facility ID:

If continuation sheet