Foster Health & Rehab Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure full privacy by assigning two residents of different genders (R4, R6) of four reviewed a shared bathroom without adequate privacy safeguards or consent in a sample of seven.

Inspectors wroteBased on interviews and record reviews, facility failed to follow their policy to protect the resident's right to be free from [A] verbal abuse by a staff member for one [R2] of four residents reviewed for abuse, [B] failed to provide the abuse training to the alleged perpetrator [V6] staff member, and [C] failed to follow their Abuse Prevention Program Policy and report an allegation of abuse within 2 hours of the incident to IDPH (Illinois Department of Public Health) for one [R2] of four residents reviewed for abuseFindings include:R2 has diagnosis not limited to Hyperlipidemia, Type 2 Diabetes Mellitus, Repeated Falls, Anxiety Disorder, Dysphagia, Major Depressive Disorder, Spinal Stenosis, Cervical Region, Pain, Low Back Pain, Fibromyalgia, Morbid (Severe) Obesity Due to Excess Calories, Generalized Anxiety Disorder. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was properly assessed for the sizing of a wheelchair and failed to follow their Accident Incident/Fall Reporting Policy for one (R2) of three residents reviewed for wheelchair use. Findings Include:R2 has diagnosis not limited to Hyperlipidemia, Type 2 Diabetes Mellitus, Repeated Falls, Anxiety Disorder, Dysphagia, Major Depressive Disorder, Spinal Stenosis, Cervical Region, Pain, Low Back Pain, Fibromyalgia, Morbid (Severe) Obesity Due to Excess Calories, Generalized Anxiety Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R2's Care Plan document in part: Problem: R2 is High risk for falls r/t (related/to) gait/balance problems. Interventions: Review information on past falls and attempt to determine cause of falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to update a resident care plan as exacerbation of neurological symptoms began to occur. This failure affected 1 (R3) resident reviewed for care plan in the total sample of 5 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents' rights to be free from mental and physical abuse for 1 out of 4 residents reviewed for abuse. This failure does not conform with facility's abuse policy and affected one resident (R1), who experienced hair pulling by another resident (R2), resulting in R1 expressing anguish, fear for her safety, and danger of harm.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy of reporting incidents and/or allegations of abuse for 1 (R1) out of 4 residents reviewed for abuse. This failure affected 1 resident (R1) who experienced pulling of her hair by another resident (R2).

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy on investigating incidents and/or allegations of abuse for 1 (R1) of 4 residents reviewed for the right to be free from abuse. This failure affected 1 resident (R1) who suffered hair pulling by another resident (R2).

Inspectors wroteBased on observation, interview, and review of records the facility failed to identify and provide behavioral services to 1 (R1) out of 4 residents reviewed for all services provided by the facility. These failures do not conform with facility's Behavioral Assessment, Intervention, and Monitoring policy and affected 1 resident (R1) who expressed anguish, fear of her safety, and danger from harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labeled, dated, and stored, failed to properly rotate food using First In, First Out (FIFO) guidelines, and failed to ensure kitchen staff were wearing appropriate hair coverings. These failures have the potential to affect all 38 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to handle linen in a manner to prevent cross contamination, failed to conduct an annual review of its infection control policy and procedures, failed to post Enhanced Barrier Precautions (EBP) signage outside 2 residents (R21, R38) rooms with active wounds, and failed to have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These failures could potentially affect all 38 residents residing in the facility. Findings Include: R21's Treatment Administration Record (TAR) dated 9/1/24 to 9/30/24 shows R21 has venous wound of the left lateral leg with daily treatment. Progress note dated 10/10/24 documents in part: R21 on ABT Doxycycline 100mg PO bid x 10 days wound infection on the left leg. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 13 (R31, R11, R32, R4, R2, R35, R37, R5, R12, R19, R15, R24, R20) out of 26 residents reviewed for comprehensive resident assessments. Findings Include: On 10/09/24 at 2:27 PM, record reviews of the following Minimum Data Set (MDS) assessments revealed the following: 1. R31's Annual MDS assessment with assessment reference date (ARD) of 5/29/24, date signed assessment as complete on 7/15/24. 2. R11's Annual MDS assessment with ARD of 10/29/23, date signed assessment as complete on 12/3/23. 3. R32 Annual MDS assessment with ARD of 7/18/24, date signed assessment as complete on 9/19/24. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete MDS (Minimum Data Set) assessments using CMS - specified Resident Assessment Instrument (RAI) process within the regulatory timeframes. This failure can potentially affect 13 (R1, R6, R9, R13, R17, R21, R23, R26, R27, R30, R33, R34, R38) out of 26 residents reviewed for resident assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for 7 (R6, R17, R23, R27, R30, R34, R38) out of 26 residents' assessments reviewed.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's needs. This failure can potentially affect 5 (R1, R8, R27, R28, R39) of 5 residents reviewed for comprehensive care plan in the sample of 14.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure emergency supplies in the crash cart were securely locked at all times when not in used. This failure has the potential to affect 19 ambulatory residents residing in the facility (R12, R32, R33, R6, R22, R17, R19, R4, R35, R9, R39, R30, R37, R27, R28, R31, R13, R20, R10). Findings Include: On 10/08/24 at 9:47AM, observed emergency crash cart parked in the hallway easily accessible to anyone walking by the front lobby and the nurses' station. The emergency crash cart was not locked and some of the items found inside were intravenous (IV) line kits, multiple sizes needles, oxygen tubing, and four 1 Liter IV fluid bags. On 10/08/24 at 10:28 AM, V4 (Registered Nurse) and V5 (Registered Nurse) stated the night shift nurse checks the emergency crash cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform monthly medication regimen review (MRR) for 4 (R8, R28, R35, and R39) residents reviewed for psychotropics in a sample of 14. Findings Include: R35 was admitted to the facility on [DATE] with diagnoses not limited to Bipolar disorder, Major depressive disorder, Metabolic Encephalopathy, Long term use (current) of anticoagulants, and Anoxic brain damage. R35's MDS shows R35 is moderately cognitively impaired. On 10/10/24 at 10:04 AM, V3 (Director of Nursing/DON) stated that Medication Regimen Review (MRR) should be done monthly by the pharmacist, but V3 does not have any MRR done for R35 or any residents in this facility. V3 stated that it is important for the pharmacist to perform monthly MRR to evaluate the effectiveness, adverse reaction, and the safety of the medication to R35 or any residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly date opened multi-dose inhalers for 4 residents (R2, R23, R28, R31) and to dispose a house stock medication after the expiration date from one out of one cart reviewed for medication storage and labeling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide therapeutic diets as prescribed by the physician for 5 (R1, R5, R10, R15, R25) out of 5 residents reviewed in a total sample of 14. Findings Include: On 10/08/24 at 12:02 PM, R10's physician orders document a diet order of NCS (No Concentrated Sweets) diet, Pureed texture, Thin consistency (ordered on 4/28/24). R10's last Dietary Notes dated on 6/28/24 at 9:14 AM written by V18 (Former Dietitian) revealed R10's Diet: NCS, pureed texture, thin liquids. R10's face sheet documented in part medical diagnoses of Unspecified Dementia and Neurocognitive Disorder with Lewy Bodies. On 10/08/24 at 1:12 PM R10 was eating lunch in the dining room. R10 received chunks of chicken and pineapples, rice (no sauce), broccoli, canned mixed fruits, thin juice and water. R10's meal ticket shows STD-mechsoft. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one (R12) out of four residents reviewed in a total sample of 14 for call lights.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately document advanced directives code status for 1 resident (R12) out of a four residents reviewed in a total sample of 14 residents for advance directives.

Inspectors wroteBased on interview and record review, the facility failed to follow their policies and procedures for the Preadmission Screening and Annual Resident Review (PASARR) process for 2 (R2, R8) residents reviewed for a Level 2 PASARR Screening for Mental Disability (MD) and Intellectual Disability (ID) in a total sample of 14. Findings Include: 1. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively impaired. According to the admission Record, R2 is [AGE] years old, R2 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. There is no documentation to show that R2 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 10/09/24 at 3:10 PM, the surveyor asked V2 (Assistant Administrator) for a Level 2 PASARR screening for R2. V2 provided the surveyor with a Level 1 PASARR screening dated 4/20/15 for R2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 3 (R6, R22, R27) of 11 residents reviewed for medication administration. There was a total of 28 opportunities with 4 errors observed, which resulted in a medication error rate of 14.29%. Findings Include: On 10/08/24 at 11:31 AM, Surveyor observed V4 (Registered Nurse) checked R6's blood glucose. R6's blood glucose reading was 218. V4 stated, based on R6's insulin sliding scale order, R6 will be getting 1 unit of Fiasp insulin injection. At 11:59 AM, V4 was about to prepare R6's insulin injection, but V4 was unable to find R6's Fiasp insulin medication in the medication cart or the convenience box. V4 stated R6 will not be receiving the ordered insulin injection since it's not available. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that two residents (R6, R27) were free of any significant medication errors out of eleven residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and follow menus and recipes to ensure menu variety for three (R2, R5, R15) out of three residents reviewed for pureed menus in a final sample of 14. Findings Include: On 10/08/24 at 10:20 AM, V14 (AM Cook) stated there are no recipes in the kitchen to follow for pureed diet consistencies. V13 (Dietary Manager) stated the kitchen does not follow any production or spreadsheets and that the cooks know how to prepare and what to serve different diets because they have been working here a long time. On 10/08/24 at 12:55 PM, observed regular diets receiving Hawaiian Chicken with pineapple, white rice, broccoli, and fruit cocktail. Residents on pureed diets appeared to receive pureed white meat, mashed potatoes, pureed green vegetable and pureed canned fruit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label and date food items in resident personal refrigerators and failed to discard unlabeled/undated spoiled foods in resident personal refrigerators. This has the potential to effect one resident (R29) out of four residents reviewed for personal food storage in a total sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to protect one (R1) resident's right to be free from physical abuse out of three sampled residents. This failure resulted in R2 becomming physically aggressive to R1. Findings Include: R1's clinical records show R1 was admitted in the facility on 5/16/23 with diagnoses including but not limited to Unspecified Dementia Without Behavioral Disturbance and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has moderate cognitive impairment. R1's progress notes dated 7/22/24 written by V5 (Registered Nurse/RN) documents in part: On 7/22/24 at about 1:00 PM R1 was allegedly hit on the head and milk was thrown in the face by [R2]. The incident occurred in the dining room and was witnessed by staff. Staff intervened, both residents were separated and initiated one-on-one monitoring. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an allegation of abuse for one of three residents (R1) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for three (R1, R2, R3) residents reviewed for dignity bag on indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store biologicals in a safe manner, and failed to label opened multi dose vials. These failures have the potential to affect all 35 residents using this medication refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform proper hand hygiene; failed to appropriately don and doff personal protective equipment (PPE) for a contact and droplet isolation room; failed to post a contact and droplet precautions isolation sign outside a positive COVID-19 resident's isolation room; failed to provide a resident with a tracheostomy covering to prevent transmission of COVID-19 droplets when a COVID-19 positive resident exits out of the isolation room; failed to ensure a contaminated item removed from a contact and droplet isolation room does not contaminate surfaces outside of the isolation room; failed to ensure a nasopharyngeal COVID-19 test sample was not stored in the facility's medication refrigerator; and failed to follow the facility's COVID-19 policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a thermometer for four resident (R10, R30, R33, and R37) refrigerators; failed to properly log refrigerator temperatures for four residents (R10, R30, R33, and R37); failed to discard expired food from a resident (R10) refrigerator; and failed to clean a resident (R33) refrigerator. These failures affected R10, R30, R33 and R37 in the sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's (R2) indwelling catheter drainage bag was covered. This failure affected one resident (R2) reviewed for dignity in the sample of 24 residents. Findings Include: R2's admission record include diagnoses of hypertension, diabetes, cerebral infarction, urinary calculous, leiomyoma of uterus, and hydronephrosis with renal and urethral calculous obstruction. R2's (7/27/23) Resident Assessment Instrument documented, Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. R2's (Active as of 11/8/23) Order Summary Report documented, 16 French (indwelling) and insert 10 ml (Milliliter) balloon. R2's (6/6/23) Care plan documents, Problem: R2 has (indwelling) Catheter. On 11/6/23 at 10: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light was accessible within reach to call for staff assistance, which affected two (R1 and R10) residents in the sample of 24 reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to obtain a doctor's order and document the code status in one resident's (R17) electronic medical record. This failure affected one resident (R17) reviewed for Advanced Directives in a sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's low air loss (LAL) mattress was not layered with multiple linen layers, which affected one resident (R9) in the sample of 24 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an extra tracheostomy (trach) tube was stored at a resident's bedside, which affected one (R15) resident in the sample of 24 residents reviewed for tracheostomy status.

Inspectors wroteBased on interview and record review, the facility failed to complete the annual Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 35 (R6, R9, R27, R183, R21, R22; R17; R24; R23; R1; R5; R30; R28; R86; R11; R31; R20; R87; R3; R26; R16; R29; R19; R14; R25; R8; R82; R4; R7; R83; R2; R32; R84; R182; R10) of 35 residents reviewed for resident comprehensive assessment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for all 36 (R6, R9, R85, R27, R183, R21, R22, R17, R24, R23, R1, R5, R30, R28, R86, R11, R31, R20, R87, R3, R26, R16, R29, R19, R14, R25, R8, R82, R4, R7, R83, R2, R32, R84, R182, R10) residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored in the freezer was stored in a sanitary manner. This failure has the potential to affect 35 residents who are on an oral diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to (a) screen visitors and staff upon entering the facility and inform visitors of appropriate infection prevention and control actions to take while in the facility; (b) failed to review their Infection Prevention and Control Program (IPCP) at least annually; and (c) failed to ensure appropriate infection procedures were followed for one residents (R2). These failures have the potential to affect all 36 residents residing in the facility reviewed for infection prevention and control and infection surveillance for COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to designate at least one qualified Infection Preventionist (IP) who is responsible for the facility's Infection Prevention and Control Program (IPCP) that has completed the specialized training in infection prevention and control. This failure has the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview and record reviews, the facility (a) failed to develop policies and procedures of COVID-19 immunizations for the residents; (b) failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine to 4 (R8, R10, R30, R183) of 8 residents that refused the COVID-19 vaccine; and (c) failed to document the dates and each dose of COVID-19 vaccine administered to the residents. These failures affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide non-disposable cutlery and dishware including cups, bowls, and plates at all meals. These failures affected 4 (R3, R5, R23, R31) of 6 residents reviewed for homelike, de-institutionalized environment in the sample of 12 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 21 residents (R6, R27, R21, R17; R24; R1; R5; R28; R86; R11; R31; R20; R87; R26; R16; R19; R14; R7; R2; R32; R84) of 32 residents reviewed for resident assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative treatment services to prevent the potential for decrease in range of motion for 4 residents (R2, R5, R20, R23) out of 5 residents reviewed for range of motion in a total sample size of 12. Finds include: 1. R23 has diagnoses not limited to Spastic Diplegic Cerebral Palsy. R23's MDS (Minimum Data Set), signed on [DATE], documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response and functional status (section G) functional limitation in range of motion to upper and lower extremity impairment on both sides and extensive assistance with bed mobility, dressing, toileting, personal hygiene and total dependence with transfers. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to follow policy on Influenza and Pneumococcal Vaccine for 4 (R25, R10, R83, R183) out of 6 residents who did not receive influenza and/or pneumococcal vaccination, and documentation as to person, time and date of education was provided prior refusal. These failures affect 4 residents (R25, R10, R83, R183) reviewed for vaccine(s).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 1 (R5) out of 6 residents reviewed in a total sample of 12 for call lights.

Inspectors wroteBased on Observations, interviews and records review, the facility failed to follow their medication administration policy for one resident (R183) reviewed for safe medication administration, in a sample of 12 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement adequate fall prevention precautions during transfer for one resident (R182) of 12 residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and prevent nasal cannula from touching the floor for 1 (R20) out of 1 resident reviewed for oxygen usage in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for 3 of 4 residents (R183, R86, R27) in the sample reviewed. There were 35 opportunities and 10 errors, resulting in a 28.57% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R27) of 4 residents observed for medication administration was free of significant medications errors. R27 is a [AGE] year old male admitted on [DATE] with medical diagnoses that include and are not limited to low back pain, unspeficied; spinal stenosis, cervical region; fibromyalgia. R27's order summary report, dated December 15, 2022, reads in part: Bactrim DS Oral Tablet 800-160 MG Give 1 tablet by mouth two times a day; Morphine Sulfate ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 12 hours; Lyrica Capsule 100 MG Give 1 capsule by mouth two times a day; Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day. R27's care plan, initiated on 4/17/2022, reads in part: The resident has a deep vein thrombosis (DVT) r/t disease process. Care plan interventions read in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure antibiotic use is monitored and to determine if antibiotics are ordered accordingly based on appropriate diagnosis or based on corresponding assessment tool for 2 (R20, R27) of 2 residents reviewed for antibiotic stewardship.