Cook Hospital & Care Center

In the surveyor’s words

From the most serious findings on record at Cook Hospital & Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 2, 2022

  Based on observation, interview, and document review, the facility failed to follow the manufacturer's recommendation on the proper placement of a toileting sling for the overhead mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1, when she fell from the mechanical lift, resulting in a laceration to her head that required sutures. The immediate jeopardy (IJ) began on 4/23/22, at 2:40 p.m. when the facility failed to correctly place a toileting sling to a resident by crossing the leg straps, resulting in R1 falling out of the lift. The director of nursing (DON) was informed of the IJ on 4/29/22, at 2:00 p.m. The IJ was removed on 5/2/22/22, at 3:18 p.m. […]

• Actual harm, isolatedF689May 29, 2026

  Based on interview and document review, the facility failed to ensure care planned fall interventions were implemented for 1 of 4 residents (R29) reviewed for falls. This resulted in actual harm for R29 who fell and sustained a laceration to the forehead, requiring sutures. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. Findings include:R29's admission Minimum Data Set (MDS) dated [DATE], indicated significant cognitive impairment. Diagnosis included dementia with behaviors. […]

• Actual harm, isolatedF689Jan 29, 2025

  Based on interview and document review the facility failed to follow care planned interventions for transfers for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 fell when transferred with a mechanical standing lift and sustained a right clavicle (a break in the thin bone that connects the shoulder blade to the breastbone) fracture. This deficient practice was corrected prior to the start of the survey, therefore, was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment. R1's care plan dated 1/24/25, included diagnoses of Alzheimer's with agitation, diabetes, congestive heart failure (CHF), coronary artery disease (CAD), insomnia, and osteoarthritis. […]

• No harm, potential for more than minimal, widespreadF761Jan 28, 2021

  Based on observation, interview and document review, the facility failed to ensure controlled medications were stored in a manner to prevent and minimize the risk of diversion for 1 of 1 medication storage rooms. Findings include: On 1/28/21, at 10:48 a.m. the medication storage room was observed with licensed practical nurse (LPN)-A. LPN-A opened the medication refrigerator, inside a drawer there were 14 syringes of [MEDICATION NAME] (United States Drug Enforcement Administration Schedule IV drug categorized as an antianxiety medication). The drawer was not locked. LPN-A stated the medication refrigerator was kept in a room accessible only via electronic key card system. […]

• No harm, potential for more than minimal, patternF880May 2, 2024

  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. […]