Fleetwood Post Acute

In the surveyor’s words

From the most serious findings on record at Fleetwood Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 9, 2023

  Based on review of the facility policy, record review, and interview, the facility failed to provide life saving practices in a timely manner for 1 of 1 residents. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide life-saving practices in a timely manner constituted Immediate Jeopardy (IJ) at F684. […]

• Immediate jeopardy, isolatedF689Oct 9, 2023

  Based on record review and interviews, the facility failed to ensure Resident (R)1 received proper supervision to prevent asphyxiation. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide proper supervision to prevent asphyxiation constituted Immediate Jeopardy (IJ) at F689. […]

• Immediate jeopardy, isolatedF808Oct 9, 2023

  Based on review of facility policy, record review and interview, the facility failed to provide Resident (R)1 with a therapeutic diet as prescribed by the physician. Specifically, R1 had a physician order for Dysphagia Mechanical Texture Soft Diet and on [DATE] R1's meal did not reflect the prescribed diet orders resulting in R1 suffering asphyxiation requiring Cardiopulmonary Resuscitation (CPR) and being sent to a local hospital. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• No harm, potential for more than minimal, widespreadF812Dec 29, 2023

  Based on observation, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety for 1 kitchen and 3 of 3 unit nourishment refrigerators for residents. Specifically, concerns were noted with food not being labeled or dated. This had the potential to affect 94 of 95 residents (one resident received nutrition via tube feeding) who received food from the kitchen. Findings include: Review of the facility's policy titled, Food Storage: Dry Goods dated 5/2014 and revised 2/2023, revealed, All dry goods will be appropriately stored in accordance with the FDA Food Code . […]

• No harm, potential for more than minimal, patternF689Dec 29, 2023

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure no smoking/oxygen in use signs were posted on the entry ways of residents' rooms or a no smoking sign was posted at the entrance of the facility to alert visitors that oxygen was in use for 4 of 12 residents (Resident (R) 29, R79, R87, R145) reviewed for accidents, out of 33 sampled residents. This failure had the potential to cause a fire if any visitors smoked in the facility while oxygen was in use. Findings include: Review of the facility's undated policy titled Oxygen Administration, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . General Guidelines . 2. […]