Citadel of Glenview,The

In the surveyor’s words

From the most serious findings on record at Citadel of Glenview,The, in the surveyor’s own words.

• Actual harm, patternF689Apr 28, 2023

  Based on observation, interview and record review, the facility failed to develop and/or follow any fall prevention policy and procedures; failed to implement fall-risk care plan interventions to ensure the resident's immediate environment was free of accident hazards; failed to adequately supervise and monitor residents; and failed to ensure assistive/alerting devices were in place to prevent accidental falls with injuries for 4 (R1, R2, R3, R4) of 4 residents reviewed for accident/hazards in the sample of 7 residents. Theses failures resulted in R1 sustaining multiple fractures to the face, ribs, and shoulder, R2 sustaining a hip fracture with surgical intervention, R3 with massive bleeding due to head trauma with required suturing, and R4 with head trauma, bleeding, and sutures. […]

• Actual harm, isolatedF740Dec 4, 2023

  Based on observation, interview, and record review the facility failed to identify behaviors, failed to notify the psychiatric nurse practitioner of behaviors, and failed to provide appropriate behavioral health services to a resident with multiple mental health diagnoses for 1 of 3 residents (R1) reviewed for behavioral health services. This failure has resulted in R1 refusing to allow facility staff in her room, covering areas of the walls in her room with aluminum foil, towels, sheets, and covering the ceiling vent with plastic wrap. […]

• Actual harm, isolatedF600Sep 17, 2023

  Based on interview and record review, the facility neglected to provide care and services to adequately care for and manage the treatment of a resident admitted to the facility with a lower extremity immobilizer by not appropriately monitoring the condition of the resident's skin under the immobilizer for over two weeks. This failure applied to one (R3) resident reviewed for pressure ulcers and resulted in R3 developing an unstageable, deep tissue pressure injury, which was facility acquired. Findings include: R3 is an [AGE] year-old female admitted to the facility on [DATE] post hospitalization related to a right ankle fracture. R3 has a history of hypertension, pre-diabetes, gastritis, and hypokalemia. […]

• Actual harm, isolatedF686Sep 17, 2023

  Based on interview and record review, the facility failed to prevent skin breakdown by not regularly and thoroughly assessing and monitoring the condition of a resident's skin, who was at risk for skin breakdown and wearing an immobilizer on lower extremity. This failure applied to one (R3) resident reviewed for pressure ulcers and resulted in R3 developing unstageable, deep tissue pressure injuries to lower extremity, which were facility acquired. Findings include: R3 is an [AGE] year-old female admitted to the facility on [DATE] post hospitalization related to a right ankle fracture. R3 has a history of hypertension, pre-diabetes, gastritis, and hypokalemia. […]

• Actual harm, isolatedF686May 4, 2022

  Based on observation, interview and record review, the facility failed to follow its wound care policy and procedures and individual resident care plans to prevent and manage facility-acquired pressure ulcers for 1 (R5) of 3 residents reviewed for pressure ulcers from a sample of 3. These failures resulted in R5 sustaining 2 facility-acquired pressure ulcers to the sacrum and left ischial tuberosity (pelvis area). Findings include: On 4/27/22 at 11:20 AM, surveyor requested a wound report from V2 (Director of Nurses/DON). The report showed all pressure ulcers that were actively being treated by the facility. Shown on this report were two facility-acquired pressure ulcers for R5: #1. Sacrum; facility-acquired pressure ulceration; active status, clinical stage 4. #2. […]