Cook Hospital & Care Center

Based on interview and document review, the facility failed to develop a baseline care plan to ensure immediate resident needs were identified and addressed for 1 of 5 residents (224) reviewed for comprehensive care planning and new admissions. Findings include: R224's face sheet indicated an admission date of 4/2/25, with a diagnosis of cerebral vascular accident. R224's paper baseline care plan indicated a completion date of 4/7/25. During an interview on 4/10/25 at 10:39 a.m., registered nurse (RN)-A stated the initial care plan was filled out in paper form and started at the time of admission. It took about 5 days for the initial care plan to be completed. During an interview on 4/10/25 at 11:48 a.m., the director of nursing stated the care plan needed to be done within 24-48hrs after admission. Facility policy Charting last reviewed 11/18/24, indicated a baseline care plan would be developed within 24hours of admission addressing pertinent problems/needs of the resident

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess each fall to ensure interventions were followed; and failed to ensure fall interventions were care planned timely and implemented to prevent falls for 1 of 1 resident (R5) reviewed for falls. Findings include: R5's annual Minimum Data Set (MDS) dated [DATE], identified R5 had moderate cognitive impairment and diagnoses that included dementia, depression, osteoporosis and neurogenic bladder (as medical condition that causes bladder control issues). R5 had a history of fall without injury in the last 90 days. R5 had a bed alarm and chair alarm in place to monitor R5's movement and alerted staff when movement was detected. R5's care plan started 9/28/24, identified R5 was at risk for fall as evidenced by a history of falls, wandering, dizziness, impaired balance, impaired cognition and a history of self-transferring. Interventions included a post fall root cause analysis, bed sensor pad, fall risk assessment and vital signs. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide appropriate side effect monitoring with antipsychotic medication consumption related to residents who did not have an Abnormal Involuntary Movement Scale (AIMS) for 1 of 5 residents (R14) reviewed for unnecessary medication use. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had intact cognition. Diagnoses included psychotic disorder and post-traumatic stress disorder. R14's active order list undated, indicated R14 received Zyprexa, an antipsychotic medication that can cause involuntary muscles movements of the body, 5 milligrams (mg) by mouth in the evening. R14's medical record lacked documentation an AIMS assessment was performed prior to the start of the medication or since the medication was started. During an interview on 4/9/25 at 12:45 p.m., registered nurse (RN)-B stated when a resident was put on an antipsychotic medication an order was entered to monitor for side effects such as nausea,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to perform appropriate hand hygiene when doing a finger stick for blood sugar. This had the potential to affect all residents that needed finger sticks to check blood sugars. Findings included. R19's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment. Diagnoses included dementia. During observations on 5/1/24 at 7:18 a.m., licensed practical nurse (LPN)-A entered R19's room to perform a blood sugar test. After placing gloves on her hands LPN-A proceed to utilize a lancet to puncture a small hole into R19's finger to obtain a blood sample. After puncturing then skin LPN-A then proceeded to place her gloved hand into her pocket and could be heard moving items around in her pocket. LPN-A then took the contaminated gloved hand out of her pocket and proceeded to push on the opening in the finger without changing gloves or washing hands. During interview on 5/1/24 at 8:02 a.m., LPN-A stated that she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment for 1 of 1 resident (R12) reviewed for wandering. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], identified R12 was cognitively intact, used a manual wheelchair with substantial/maximal assistance for mobility, and did not exhibit wandering behavior. Diagnoses included depression and diabetes mellitus and identified R12 was cognitively intact. R12's care plan last reviewed on 3/25/24, gave no indication R12 exhibited wandering behaviors. Review of R12's mood and behavior monitoring sheets from January 2024 to April 2024 gave no indication R12 exhibited wandering behaviors. Review of R12's assessments gave no indication R12 was assessed for wandering. During interview on 4/29/24 at 2:12 p.m., R15 stated R12 enters R15's room uninvited at least once per week and has done so for at least the last 6 months. When R12 enters R15's room, R15 will use her call light to alert staff and staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to ensure eye drops were dated as to when opened and when they were to expire. This had the potential to affect all residents who utilized medicated eye drops. Findings include: On 5/1/24 at 9:015 a.m., a review of the North hallway medication cart was performed. Observation was made of latanoprost 0.005% medicated eye drops in the medication draw with the protective seal removed. An opened date and 'expiration date sticker was on the bottle but was not filled out. During an interview on 5/1/24 at 9:22 a.m., registered nurse (RN)-B reviewed the medication and confirmed the medication was currently in use and there was no open date or expiration date. RN-B stated the open date and expiration date had to be on the bottles so the staff would know how long the medication was good, once opened. During an interview on 5/1/24 at 12:21 p.m., pharmacist stated bottles of medicated eye drops needed to have the open date and expiration date written on them. Eye drops such as latanoprost were only good for 28 days after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure an injury of unknown origin was reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had memory impairment. The MDS indicated R1 required extensive assistance with toilet use, and supervision for bed mobility, transfers, and eating. R1's progress note dated 4/7/24 at 3:01 p.m., indicated at 6:50 a.m. R1 was found in her room in her recliner with a large hematoma (collection of blood outside of a blood vessel) on her right forehead, and a swollen and bruised right eye. R1 was unable to tell staff what happened, and no evidence of a fall was found. R1's Nursing Home Incident Report (NHIR) to the SA dated 4/7/24, indicated the report was submitted on 4/7/24 at 11:25 a.m. On 4/11/24 at 1:05 p.m., licensed practical nurse (LPN)-A stated they were busy that morning, and shorthanded, and she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure care-planned interventions for safety checks were consistently implemented for 1 of 3 residents (R1) reviewed for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had memory impairment. The MDS outlined R1 required extensive assistance with toilet use and supervision for bed mobility, transfers, and eating. R1's care plan reviewed 3/15/24, identified R1 was to be checked on every hour by staff. On 4/11/24 at 1:05 p.m. licensed practical nurse (LPN)- A stated on 4/7/24, between 6:45 a.m. and 6:50 a.m. she went into R1's room and found R1 in her recliner. R1's right side of her face was bruised, her right eye was swollen shut, and she had a hematoma (collection of blood outside of a blood vessel) on the right side of her forehead. LPN-A stated this was the first time she had seen R1 that day. On 4/11/24 at 3:30 p.m., nursing assistant (NA)-A stated R1 was on hourly safety checks, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.