Fouraker Hills Rehab and Nursing Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatment and supports for daily living safely for five (Residents #64, #75, #14, #65, and #10) residents in five (rooms 204, 205, 208, 510, and 512) of 66 resident rooms, and in three (Halls 100, 500, and 200) of four hallways in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents in five (rooms 204, 205, 208, 510, and 512) of 66 resident rooms. Failure to correct this concern in a timely manner could negatively impact the the entire census of 105 residents.

Inspectors wroteBased on observations, resident and staff interviews, and a review of resident records, the facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for one (Resident #14) of one resident reviewed for communication, from a total survey sample of 34 residents.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #14) of four residents reviewed for ADLs, from 34 residents in the total survey sample, received necessary services to maintain grooming and personal hygiene. Resident #14 did not receive routine or scheduled showers, her hair was matted, and there was an offensive odor present.

Inspectors wroteBased on observations, resident and staff interviews, and a review of resident records, the facility failed to ensure that one (Resident #14) of two residents reviewed for vision/hearing/communication, from a total survey sample of 34 residents, received proper treatment and assistive devices to maintain hearing ability. Resident #14 was very hard of hearing, which compromised her ability to communicate. The facility had a visiting audiologist; however, the resident had not been referred for an evaluation.

Inspectors wroteBased on interviews, medical record review, and facility policy and procedure review, the facility failed to ensure residents were free from any significant medication errors, by failing to administer medications within the specified timeframe based on physicians' scheduling orders for four (Residents #1, #2, #3, and #6) of six sampled residents, from a total census of 111. Failure to administer medications in a timely manner can result in a resident's inability to maintain the proper level of medication in the bloodstream to be effective; reduced functional ability; lower quality of life; hospitalization, disease progression, and/or death.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to 1) ensure privacy and confidentiality of medical records for three (Residents #4, #5, and #6) of 10 resident records reviewed, and 2) failed to ensure personal privacy during wound care for one (Resident #2) of two residents reviewed for wound care, from a total sample of 24 residents.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to maintain standard precautions designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #2, #19, #7, and #3) of four residents reviewed for tube feeding, from a total of 24 residents in the sample.

Inspectors wroteBased on observations, interviews, medical record review, and facility policy review, the facility failed to 1) ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices regarding wound care for two (Residents #2 and #11) of three residents reviewed for wound care, from a total of 24 residents in the sample, and 2) failed to ensure quality of care, a fundamental principle that applies to all treatment and care provided to facility residents, by not performing regular control solution testing for five of five glucometers used for residents blood glucose monitoring.

Inspectors wroteBased on observations, interviews, medical record review, and facility policy review, the facility failed to ensure the residents received adequate supervision to prevent accidents, by failing to supervise residents on the smoking patio for two (Residents #8 and #9) of fifteen residents identified as smokers, from a total of 24 residents in the sample.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to provide medications as ordered by the physician to meet the needs for one (Resident #3) of three residents reviewed for compliance with medication administration, from a total of 24 residents in the sample.

Inspectors wroteBased on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide personal privacy during personal care for one (Resident #28) of a total sample of 37 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1) Provide appropriate treatment and services for residents who were dependent on staff for activities of daily living (ADLs), and 2) Ensure that a resident's activities of daily living abilities did not diminish for one (Resident #39) of three residents reviewed for activities of daily living, from a total sample of 37 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Resident #14) of six residents receiving oxygen therapy, received the correct oxygen flow rate as ordered by the physician, from a total of 37 residents in the sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist one resident (#68) from a total sample of 37 residents, in obtaining routine and 24-hour emergency dental care. Failure to provide dental care could result in dental caries, infection, pain and loss of teeth.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement abuse policies and procedures for an independently ambulatory resident with known aggressive behaviors, and a history of abusing another resident (Resident #28). On 7/12/21, the facility's census was 89 residents. All 89 residents were at risk for serious injury, serious harm, impairment, or death as a result of the deficient practice. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) began on January 13, 2021, and was identified on July 15, 2021 at 1:30 PM, which was on-going. On July 15, 2021 at 8:45 PM, the Administrator was notified of the IJ determination.

Inspectors wroteAssigned to [NAME] Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained free of accident hazards as is possible, and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 43 residents sampled, Residents #22, #28, #67 and #192.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to review the Pre-admission Screening for individuals with a mental disorder and individuals with intellectual disability to ensure that because of the physical and mental condition of the individual, the individual required the level of services provided by a nursing facility; and if the individual required such level of services, whether the individual required specialized services; that, because of the physical and mental condition of the individual, the individual required the level of services provided by a nursing facility; and if the individual required such level of services, whether the individual required specialized services for intellectual disability for one of 43 residents sampled, Resident #28.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement safety interventions per the comprehensive plan of care for 4 of 4 residents (Residents #67, #192, #28, and #22) reviewed for development and implementation of comprehensive care plans.