Hoeger House

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety and failed to consistently document dish machine temperatures. This placed the resident at risk for foodborne illnesses.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with one reviewed for re-hospitalization. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of Resident (R) 16's discharge from the facility. This deficient practice placed R16 at risk for impaired resident rights.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 23, who had a surgical incision (a surgical cut made in the skin). The deficient practice placed residents in the facility at risk of infectious disease processes.

Inspectors wroteThe facility documented a census of 28 residents. The sample included 13 residents with three reviewed for falls. Based on record review and interview, the facility failed to ensure a safe environment free from preventable accidents when staff failed to ensure Resident (R) 67 had foot pedals on her wheelchair before staff propelled the resident down the hallway to her room. The resident was unable to hold her legs up and placed her foot on the floor which caused the resident to fall forward out of the wheelchair. The fall resulted in a broken left femur (thigh bone).

Inspectors wroteThe facility identified a census of 28 residents with one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to sanitary food and equipment storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 08/29/23 at 07:05AM a walkthrough of the facility's kitchen was completed. An inspection of the facility's freezer unit revealed opened but undated/unlabeled bags of potato wedges, breaded meat patties, and sliced strawberries. An inspection of the equipment storage rack revealed a large pasta strainer on the top shelf stored upward (not inverted) towards the ceiling. An inspection of the facility's deep fryer station revealed a sheet pan covering the fryer unit. [...]

Inspectors wroteThe facility identified a census of 28 residents. The sample included 13 residents. Based on record review, observations, and interviews, the facility failed to track and analyze infectious organisms related to its infection surveillance. The facility also failed to follow transmission-based precautions during wound care for Resident (R)169. This deficient practice placed the residents at risk related to infectious diseases.

Inspectors wroteThe facility identified a census of 28 residents. The sample included 13 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing measures according to the plan of care were implemented for Resident (R) 69's bilateral lower extremities and a cushion in the wheelchair to prevent worsening of pressure ulcers. This placed R69 at increased risk for pressure ulcer development and worsening of right heel pressure ulcer.

Inspectors wroteThe facility identified a census of 28 residents. The sample included 13 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve Resident (R)167's bladder incontinence or prevent further loss. This deficient practice placed R167 at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R167's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), repeated falls, chronic obstructive pulmonary disorder (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neuralgia (severe nerve pain), and insomnia (inability to sleep). [...]

Inspectors wroteThe facility reported a census of 28. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to implement monitoring for behaviors and side effects associated with Residents (R)9's psychotropic medications (class of medications that chemically alter the brain to effect mood, perception, and behaviors). This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects.

Inspectors wroteThe facility had a census of 28 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)218's insulin (hormone which allows cells throughout the body to uptake glucose) pen with the date opened and discard date and failed store his medications securely. This placed R218 at risk for ineffective or diverted medications.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents with five residents reviewed for food services. Based on observations, record reviews, and interviews, the facility failed to serve food at an appetizing temperature to resident (R) 8, R11, R12, R13, and R123. This deficient practice placed the residents at risk for decreased nutrition and a delay in recovery. Findings Include: - The electronic medical record (EMR) documented the following diagnosis for R8: [...]

Inspectors wroteThe facility identified a census of 21 residents with one kitchen and one main dining room. Based on observation, interview, and record review, the facility failed to ensure sanitary food services and failed to document the daily cleaning and sanitation process. This deficient practice placed residents at risk for food borne illnesses and food safety concerns. Findings Include: - During the initial inspection of the kitchen on 01/25/22 at 07:15 AM the facility's dishwasher sanitation log was missing documentation in December of 2021 for 13 dates (12/13, 12/14,12/17, 12/18, 12/19, 12/21, 12/22, 12/24, 12/25, 12/26, 12/29, 12/30, and 12/31). An inspection of the main oven and fryer area revealed grease covering the top surfaces of the fryer and oven. Several old, cooked French fries sat in area between top burners and fryer. [...]

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to ensure that staff did appropriate hand hygiene in between cares for residents and proper disinfecting of equipment used in between resident cares. This deficient practice placed the residents at risked for increased infection and transmission of communicable disease.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents with two residents reviewed for reasonable accommodation. Based on observations, record reviews, and interviews, the facility failed to provide Resident (R)12 an alternate method of summoning assistance which relayed directly to nursing staff during a call light system failure on 01/20/22. The deficient practice placed the resident at risk for a delay in care or assistance.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to implement a person-centered care plan that included the minimum information necessary to properly care for one resident (R), R14 who required off-site dialysis services, and failed to implement a baseline care plan for R18 who required the use of pressure reducing devices, which had the potential for R14 and R18 to have unmet care needs.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents, with one resident reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed ensure pressure reducing measures were placed on Resident (R) 18's bilateral lower extremities to prevent pressure ulcers. This placed R18 at increased risk for pressure ulcer development.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents. One resident (R) was sampled for dialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review and interview, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, and failed to monitor R14's dialysis access port (a vascular access to the bloodstream) daily, which had the potential for unwarranted and unidentified physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents, which five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure antihypertensive medications (class of medication used to treat high blood pressure) were administered as ordered and physician notification for blood sugar outside ordered parameters for Resident (R) 120. This placed R120 at risk for unnecessary medication use and unwarranted side effects.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents with one resident reviewed for food preferences. Based on observations, record reviews, and interviews, the facility failed to provide R11 with food ordered on his dietary menu and did not notify of changes or substitutions to his meal. This deficient practice placed the resident at risk for malnutrition and impaired quality of life.

Inspectors wroteThe facility identified a census of 21 residents. The sample included 15 residents with one resident reviewed for dietary drinks. Based on observations, record reviews, and interviews, the facility failed to provide R11 with drinks during meal service. This deficient practice placed the resident at risk for dehydration and health complications.