Foster Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Foster Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF725Aug 16, 2023

  Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff and failed to follow their medication policy to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse on duty to pass medications in the entire facility and as a result, 37 residents (R1- R37) did not receive their scheduled medications on 06/05/2023 and 06/06/2023 on the evening shift (3:00 PM - 11:00 PM). These failures have the potential to cause negative medical outcomes for all 37 residents. This was identified as an Immediate Jeopardy situation which began on 06/05/2023. On 07/28/2023 at 10:00 am, the Administrator was notified of the Immediate Jeopardy. […]

• Actual harm, patternF697Aug 16, 2023

  Based on interview and record review, the facility failed to ensure resident medications were administered according to physician orders on 06/05/2023 and 06/06/2023 for 6 (R1, R2, R3, R4, R5, and R6) out of 6 residents reviewed pain medication administration. This failure resulted in the residents experiencing pain score of 6 to 12, on a scale of 0 to 10. Findings include: 1. R1's Facesheet documents in part: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. […]

• Actual harm, isolatedF600Dec 20, 2024

  Based on observation, interview and record review, the facility failed to protect residents' rights to be free from mental and physical abuse for 1 out of 4 residents reviewed for abuse. This failure does not conform with facility's abuse policy and affected one resident (R1), who experienced hair pulling by another resident (R2), resulting in R1 expressing anguish, fear for her safety, and danger of harm. Findings include: R1 is [AGE] years old, initially admitted at the facility on 04/11/2022. R1's diagnosis includes visual impairment, anoxic brain damage, bipolar disorder, and depression. […]

• Actual harm, isolatedF689Nov 13, 2022

  Based on interview, and record review, the facility failed to implement adequate fall prevention and monitoring for one resident (R1) of 3 residents reviewed for falls. This failure resulted in R1 sustaining a fall with bilater femur fracture requiring R1 to be hospitalized . Findings include: R1 is [AGE] year old individual, admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS), dated 10/18/22, document R1 has BIMS score of 15/15. R1's Activities of Daily Living (ADL) Assistance, dated 11/9/22, documents R1 needs two person assistance and depends on staff for all ADL care. […]

• Actual harm, isolatedF583Aug 18, 2021

  Based on interview and record review, the facility failed to ensure that residents personal information was safeguarded from unauthorized disclosure without the resident's and/or the resident's representative's consent for four of four residents (R2, R3, R10, and R11) reviewed for privacy. This deficient practice resulted in residents' personal information being disseminated to unauthorized individuals. Findings include: On [DATE] at 9:37 AM, V16 (R1's Family Member) said, she had pictures V12 (CNA) provided to V16, including R3's personal information. V16 said she obtained R2's personal information, stating, I'm not gonna lie, I went behind the desk and got it. V16 provided pictures (undated) of texts that were sent to her by V12 (CNA). […]