Gladeview Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review for 2 of 2 residents (Resident #6 and Resident #81), reviewed for positioning, the facility failed to ensure hand rolls were in place for Resident #6 and a lap tray was applied consistently for Resident #81 in accordance with the physician's order. The findings include: 1. Resident #6 's diagnoses included a contracture of unspecified joint, peripheral vascular disease, diabetes, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired and was totally dependent on facility staff for dressing, eating and personal hygiene. The Resident Care Plan dated 9/9/24 identified that Resident #6 was at risk for skin breakdown related to impaired mobility. Interventions included to apply bilateral palm guards and check skin integrity per the physician orders. A physician's order dated 10/8/24 directed to place rolled up washcloths in the palms of Resident #6's hands every shift. An Occupational Therapist…

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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #95) reviewed for nutrition, the facility failed to identify when a significant weight loss occured and implement nutritional supplements in a timely manner. The findings included: Resident #95 was admitted to the facility in April 2022 with diagnoses that included vascular dementia with psychotic disturbances, Down syndrome, depression, and hypothyroidism. A Resident Care Plan dated 2/19/24 identified a problem with Resident #95 having a significant weight loss in 6 months (weight of 195.4 pounds/lbs). Interventions included to start on nutritional supplements, encourage food/fluids, and obtain weights as ordered. Physician orders dated 3/14/24 directed weekly weights to be obtained every Friday. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident # 95 was severely cognitively impaired and required total dependance from staff for eating. Physician's orders dated…

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, interviews, record and policy review for 1 of 3 residents, (Resident #52), reviewed for respiratory care, the facility failed to follow physician's order for oxygen administration. The findings include: Resident #52's diagnoses included congestive heart failure, chronic kidney disease and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #52 was severely cognitively impaired, independent for eating, and required partial/moderate assistance for toileting and transfers. The Resident Care Plan dated 9/3/24 identified Resident #52 had a potential for alteration in respiratory status related to a diagnosis of asthma. Interventions included to administer oxygen per orders and monitor oxygen saturations per orders and as needed. The physician's order dated 11/1/24 directed to administer oxygen at 2 liters per nasal cannula at bedtime for shortness of breath. Observations on 11/18/24 at 2:23 PM, 11/19/24 at 10:17 AM, and 11/19/24 at 12:27 PM identified…

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 observations, review of clinical record, facility documentation, facility policy and interviews for medication administration, the facility to ensure that medication error rate of less than 5%. The findings include: 1. Resident #84 was admitted to the facility in February 2022 with diagnoses that included dementia with other behavioral disturbances and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #84 was severely cognitively impaired. Physician orders dated 11/12/24 directed to administer Trazodone 50 mg (milligrams) 2 times a day, Namenda 5 mg 2 times a day, Depakote 125 mg sprinkles 1 capsule in AM and 2 capsules at bedtime. The times of administration for the morning medications were to be given at 8:00 AM. Observation of medication administration with Licensed Practical Nurse (LPN) #8 on 11/20/24 at 10:30 AM identified Trazodone, Namenda and Depakote were due to be administered at 8:00 AM and medications were administered at 10:30 AM, an hour and a half…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed failed to act on a consultant recommendation timely and failed to ensure the physician was notified timely when a medication was not administered. The findings include: Resident #4 was admitted to the facility with diagnoses that included adrenal insufficiency, dementia, diabetes mellitus, and chronic kidney failure. The RCP dated 4/18/2024 identified Resident #4 was at risk for complications related to diagnoses of adrenal insufficiency. Interventions directed to administer steroids as per orders, observe for adverse effects and for signs and symptoms of complications that included extreme fatigue, weakness, reduced appetite reduced heart, low blood pressure, lightheadedness and fainting and update the physician or APRN if they occur. A 5-day MDS assessment dated [DATE] identified Resident #1 had moderate cognitive…

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 review of the clinical record, and interviews for one (1) of three (3) residents , (Resident #1), reviewed for falls, the facility failed to develop a baseline care plan for a resident identified at risk for falls on admission. The findings include: Resident #1 's diagnoses included dementia with behavioral disturbances, anxiety disorder, and weakness. The Nursing admission assessment dated [DATE] identified Resident #1 was cognitively impaired and required extensive assistance with transfers. Review of the admission Fall Risk assessment dated [DATE] identified that Resident #1 was at a high risk for falls. Additionally, the form states that if the total score is 10 or greater, the resident should be considered at high risk for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. A nurse's note dated 9/18/21 at 2:00 PM identified Resident #1 was observed climbing out of bed that morning. He/she was placed in a chair for breakfast and was observed…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) reviewed for change in condition, the facility failed ensure a medication was administered in accordance with the physician order. The findings include: Resident #4 was admitted to the facility with diagnoses that included adrenal insufficiency, dementia, diabetes mellitus, and chronic kidney failure. The RCP dated 4/18/2024 identified Resident #4 was at risk for complications related to diagnoses of adrenal insufficiency. Interventions directed to administer steroids as per orders. A 5-day MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required moderate assistance for bed mobility, transfer, and for mobility in a wheelchair. A physician's order dated 5/8/2024 directed to administer Hydrocortisone 20 milligrams (mg) by mouth one (1) time a day and 10 mg Hydrocortisone by mouth in the evening related to adrenocortical…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for falls, the facility failed to provide adequate supervision to a resident who was at high risk for falls, resulting in a fall with major injury. The findings include: Resident #1 's diagnoses included dementia with behavioral disturbances, anxiety disorder, and weakness. The Nursing admission assessment dated [DATE] identified Resident #1 was cognitively impaired and required extensive assistance with transfers, bed mobility, eating, and personal hygiene. Review of the Fall Risk assessment dated [DATE] identified that Resident #1 was at a high risk for falls. Review of the clinical record from 9/15 through 9/17/21 failed to identify a care plan to address Resident #1's high risk for falls. Review of the facility Reportable Event form dated 9/18/21 identified that at 9:40 AM Resident #1 fell out of his/her wheelchair at the nurse's station, hitting h/her…

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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was transferred with a Hoyer lift in accordance with physician orders. The findings include: Resident #1 was admitted with diagnoses that included post below the right knee and left toes amputations, anxiety disorder and major depression. An admission MDS assessment dated [DATE] identified Resident #1 was alert and oriented, and required extensive assistance with two (2) staff members for bed mobility and transfers. A physician order dated 7/7/2022 directed Hoyer lift for all transfers assist of two (2) staff. The RCP dated 7/27/2022 identified Resident #1 was at risk for falls due to impulsivity, had altered cognition with exhibited confusion and suspiciousness with altered physical mobility. Interventions directed to transfer as per order, with a Hoyer lift and assist of two (2) staff. A facility reportable report form…

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 clinical record reviews, facility policy and interviews for 1 of 2 units observed during mealtimes, the facility failed to ensure a dignified dining experience for 5 residents (Resident #46, Resident #65, Resident #67, Resident #91, and Resident # 93) by standing and feeding residents during community lunchtime meal. The findings included: 1. Resident #46 was admitted to the facility with diagnoses that included major depressive disorder, dementia, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 46 had severely cognitive impairment and required extensive assistance with 1 staff member for eating. An active physician's order for 12/13/22 directed to provide a pureed diet with nectar thick consistency and moist. Observation on of the lunch meal on 12/13/22 identified Resident #46 was seated with other residents at a dining room table between 12:15 PM and 12:45 PM, Nurse Aide (NA) # 3 was standing next not at eye level to Resident #46…

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 clinical record review, facility policy review and interviews for 1 of 2 residents reviewed for Advanced directives (Resident # 24) reviewed for advanced directive, the facility failed to ensure that the resident's Advanced directives were completed in accordance with facility policy. The findings include: Resident # 24 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, dementia, depression, atherosclerotic heart disease and hypertension. A Physician's order dated 2/23/2022 directed to provide Palliative Care, Comfort measures only (CMO), Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH), no intravenous (no IV's), no diagnostics and no laboratory work. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 24 had a severe cognitive impairment and required extensive assistance with Activities of Daily Living (ADL). The care plan revised on 8/16/2022 indicated the resident and or responsible party have elected DNR, DNH no laboratory…

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 clinical record review, facility documentation, facility policy, and interviews for 1 of 2 sampled residents (Resident #63) reviewed for mistreatment, the facility failed to report an allegation of misappropriation to the state agency. The findings include: Resident #63's diagnoses included mild cognitive impairment, generalized anxiety disorder, and multiple sclerosis. Interview with Resident #63 on 12/13/22 at 11:53 AM identified (4) $20 bills were missing from his/her wallet earlier the previous week. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #63 was cognitively intact and required extensive assistance with bed mobility, transfers, and dressing. The Resident Care Plan (RCP) dated 10/19/22 identified that Resident #63 was anxious. Interventions included offering calm reassurances and clear explanations of what is going to occur. Interview with Director of Nursing (DON) on 12/15/22 at 12:58 PM identified that she was notified of Resident #63's missing money by 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 clinical record reviews, facility documentation, facility policy and interviews for 2 resident (Resident # 73) reviewed for hospitalization and( Resident 111 )who left Against Medical Advice (AMA), the facility failed to ensure the state ombudsperson was notified of a hospital transfer and the resident's discharge to the community. The findings included: 1.Resident #73 was admitted with diagnoses that included, atrial fibrillation, diabetes mellitus and hypertension. admission MDS (MDS) assessment dated [DATE] identified Resident #73 had severe cognitive impairment and required assist with personal care. The nursing progress note dated 10/13/22 noted Resident #32 experienced a change of condition that included shaking and complaints of being cold with hematuria (bleeding) coming from the Foley catheter line. 911 was activated, the Advanced Practice Registered Nurse ( APRN )notified, and staff received physician's orders to send Resident #32 to the hospital. The responsible party was updated, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for 1 sample resident (Resident #67) reviewed for limited range of motion, the facility failed to schedule a significant change status assessment when the resident experienced a decline in the resident's medical condition. The findings include: Resident #67's diagnoses rheumatoid arthritis, dementia, osteoporosis and anxiety. The significant change in status MDS assessment dated [DATE] identified Resident #67 had severe impaired cognition and required extensive assist of 1 person with transfer, bed mobility, toileting, hygiene and independent with eating. Unplanned weight loss was not indicated. The quarterly MDS assessment dated [DATE] identified Resident #67 had severe impaired cognition and required extensive assist of 1 person with bed mobility and transfer and became dependent with 1 person with toileting, hygiene and eating. Unplanned weight loss was identified. Resident #67 became dependent from extensive assist with toileting and hygiene and became dependent…

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 clinical record reviews, observations, review of facility policy and interviews for 1 of 3 residents (Resident # 26) reviewed for Activities of Daily Living (ADL), the facility failed to ensure develop a comprehensive resident care plan that met the individual needs of a dependent resident oral care and for 1 sampled resident ( Resident # 67 )reviewed for limited range of motion, the facility failed to develop a comprehensive care plan to prevent skin breakdown related to the left elbow contracture. The finding included: 1. Resident # 26's diagnosis included a neuro muscular disorder and dysphagia. A dental consultation dated 8/5/2019 indicated Resident#26 had severe inflammation, heavy plaque, and calculus, of teeth, allowed minimal scaling, was resistive to care and required total assistance for oral care needs. The consult further indicated that action required by the nursing care staff was to use a toothbrush not swabs for oral care, brush 2-3 times daily after meals concentrating on the gumline 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based clinical record reviews, review of facility policy and interviews for 1 of 2 residents reviewed for Nutrition (Resident # 46), the facility failed to ensure the Resident Care Plan was revised to meet the resident's feeding assistance needs and for 1 of 4 residents (Resident # 105) reviewed for care planning, the facility failed to review and revise the care plan with appropriate interventions for a resident who repeatedly violated the facility nonsmoking policy and also, discovered to have tested positive for an illicit substance and for 1 of 2 sampled residents, (Resident #74) reviewed for advance directive code status, the facility failed to review and revise the care plan to accurately reflect the documented and signed code status preference and for 1 of 2 sampled residents (Resident # 51) who was reviewed for a skin condition, the facility failed to review and revise the care plan to include refusals of care. The findings included: 1. Resident # 46's diagnoses included dementia, schizoaffective…

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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #72) reviewed for accidents, the facility failed to complete a post fall risk assessment after an unwitnessed fall with a major injury within accordance to professional standards and facility policy. The findings include: Resident #72 was admitted to the facility with diagnoses that included fracture of the pelvis, chronic obstructive pulmonary disease (COPD), osteoporosis, muscle weakness and difficulty in walking. A fall risk assessment completed on 10/10/22 identified Resident # 72 was a low risk for falls. An admission minimum data set (MDS) assessment dated [DATE] identified Resident #72 was cognitively intact requiring an assist of 2 staff for transfer, extensive assistance with 2 staff members for toileting and noted utilization of a wheelchair or walker for mobility. A care plan initiated on 10/10/22 identified Resident #72 was at risk for falls due to a history of right pelvis…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 105) reviewed for care planning, the facility failed to ensure a resident with limited mobility received appropriate services and assistance to maintain or improve mobility according to physician orders recommended by rehabilitation services and for 1 of 3 sampled residents, (Resident #39) reviewed for activities of daily living, the facility failed to apply a positioning device for a dependent resident with a contracture. The findings included: 1. Resident #105 was admitted with diagnoses that included hemiplegia (weakness) and hemiparesis (paralysis) following a cerebral infarction (stroke) and bipolar disorder. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #105 was without cognitive impairment, required one-person physical assist with transfers, supervised assist with locomotion on the unit using a wheelchair or walker and one-person physical assist with…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents, (Resident # 32) reviewed for nutrition, the facility failed to address a significant weight discrepancy for a resident identified at nutritional risk. The findings include: Resident #32 was admitted with diagnoses that included atrial fibrillation, peripheral vascular disease dementia. The quarterly MDS assessment dated [DATE] identified Resident # 32 had severe cognitive impairment and required two persons assist with bed mobility, transfers, and personal care. The care plan dated 9/13/22 identified Resident #32 was at risk for weight loss related to diuretic use. Interventions included dietitian to follow, obtain weight as ordered and report significant change to Medical Doctor (M.D). The weight record dated 9/21/2022, noted a documented weight of 137 lbs. The weight record dated 9/28/2022 noted a documented weight of 129.7 lbs. indicating a 7.3 lb or 5.3% weight loss in one week. There was no…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 86) reviewed for respiratory care, the facility failed to ensure respiratory equipment was stored according to infection-controlled practices. The findings include: Resident #86 was admitted with diagnoses that included obstructive sleep apnea, hypertension, and vascular dementia. The physician's orders dated 9/11/22 directed Bi-Pap (bilevel positive airway pressure; positive airway pressure for those with obstructive airway disorders) 14cn/EPAP 8 cm (measurement of expiratory positive airway pressure) at bedtime and naps. The quarterly MDS assessment dated [DATE] identified Resident #86 with moderate cognitive impairment and the resident required assist with personal care. The care plan dated 10/20/22 identified Resident #86 used a Bi-Pap with a full face ask related to a diagnosis of obstructive sleep apnea. Interventions included Bi-Pap settings as ordered, report difficulty in tolerance,…

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 review of staffing, facility documentation, facility policy and interview, the facility failed to ensure that annual intravenous (IV) competencies and education were completed for licensed staff. The findings include: A review of annual competencies and education for licensed IV certified staff during the survey identified no documented update for skills or instruction for licensed staff since 2019. An interview and facility documentation on 12/19/22 at 9:20AM with RN #4 identified she worked as the staff development nurse for the facility for one month. RN #4 indicated there was no documented competencies and education for licensed staff since 2019. Although requested, a policy for annual competencies and education for licensed staff was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and interviews for one of five sampled residents (Resident #32) reviewed for unnecessary medications, the facility failed to conduct appropriate behavior monitoring and failed to provide an appropriate clinical indication for antipsychotic medication use. The findings include: Resident # 32's was admitted on [DATE] with diagnoses that included unspecified dementia, urinary tract infection, and pain. Review of the admission physician's order dated 8/24/22 directed to administer Seroquel 100 mg (a medication used to treat psychotic disorders and schizophrenia) by mouth at bedtime and Seroquel 50 mg by mouth daily. The physician's order failed to identify an indication for Seroquel administration. The admission Minimum Data Set assessment dated [DATE] identified Resident # 32 had severe cognitive impairment, and required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Review of Resident #32's behavior monitoring sheets from 9/1/2022…

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 clinical record review, review of facility documentation and interviews for 1 of 4 resident's (Resident # 26) reviewed for Activities of Daily Living, the facility failed to ensure that the medical record was accurate and complete regarding the resident's dental consultation. The findings include: Resident # 26's diagnosis included a neuro muscular disorder and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #26 had severely impaired cognitive function and required extensive assistance of 2 people for personal hygiene (including brushing teeth). A review of the clinical record for Resident # 26 dental consultation on 12/19/22 identified the last dental consultation in the clinical record was dated 8/5/2019. The 8/5/2019 dental consultation noted Resident#26 had severe inflammation, heavy plaque, and calculus, of teeth, allowed minimal scaling, was resistive to care and required total assistance for oral care needs. The consult further indicated that…

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 clinical record reviews, review of facility documentation, review of facility policy and staff interviews, for 5 of 5 sampled residents (Residents #14, #21, #53, #54 & #66) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccination history was complete and pneumococcal vaccinations were offered. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, depression and atrial fibrillation. A significant change MDS assessment dated [DATE] identified Resident #14 was [AGE] years old, did not receive the pneumococcal vaccine and was not offered the pneumococcal vaccine. Review of the clinical record and the facility vaccination tracking log failed to identify consents for the pneumococcal vaccines, historical information inclusive of vaccination history and documentation of administration of the Pneumovax 23 (PPSV23) or Prevnar 13 vaccines *PCV13). Resident #21 was admitted on [DATE] with diagnoses that…

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 clinical record review, review of facility documentation and interviews for 2 of 6 sampled residents (Residents #14 & #80) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure a referral was made to the state designated authority when a new psychiatric diagnosis was identified. The findings include: a. Resident #14 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, chronic atrial fibrillation and dementia. A PASARR level 1 assessment with a review date of 7/11/18 failed to identify the diagnosis of dementia and noted the outcome of the assessment was Resident #14 did not have a level 2 condition therefore the determination was that the resident was level 1 negative (level 1 negative means that there isn't a qualifying psychiatric diagnosis to warrant conducting a level 2 assessment). A significant change MDS assessment dated [DATE] identified Resident #14 was not considered by the state level II PASARR process to have a…

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 a review of the clinical record, review of facility documentation and staff interviews for 1 of 7 sampled residents (Resident #39) reviewed for accidents, the facility failed to accurately complete an elopement/wandering risk assessment and implement a plan of care for a resident who exhibited wandering behaviors. The findings include: Resident #39 was admitted on [DATE] with diagnosis that included anxiety and dementia with behavioral disturbances. The admission assessment dated [DATE] identified Resident #39 was uncooperative, restless and anxious. The assessment further noted that Resident #39 required assistance of 1 person for transfers, bathing, dressing, toilet use and utilized a wheelchair for mobility. The baseline care plan dated 01/03/20 identified Resident #39 utilized a walker for ambulation with the assistance of one person. A registered nurse's note dated 01/03/20 on the 3:00 PM to 11:00 PM shift identified Resident #39 was confused and displayed exit seeking behavior at times. An LPN's…

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 review of the clinical record, interviews and review of facility policy for 1 of 3 sampled residents (Resident #79) reviewed for psychotropic medication use, the facility failed to follow physician orders related to orthostatic blood pressures. The findings include: Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disorder, traumatic subdural hemorrhage, psychotic disorder with delusions, muscle weakness, difficulty in walking, repeated falls and cognitive communication deficit. A physician's order dated 11/26/19 directed to administer Seroquel (antipsychotic) 25 milligrams (mg) by mouth at bedtime. An admission Minimum Data Set (MDS) dated [DATE] identified that Resident #79 was severely cognitively impaired, displayed wandering behaviors on a daily basis, required extensive assistance of two people for bed mobility, transfers and toilet use. The assessment further noted that the resident did not ambulate, utilized a wheelchair for mobility 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.