Gladeview Health Care Center

In the surveyor’s words

From the most serious findings on record at Gladeview Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 30, 2022

  Based on clinical record reviews, facility policy review and interviews for 1 sample resident (Resident #67) reviewed for limited range of motion and contractures and history of resistance to care, the facility failed to ensure that licensed and non-licensed staff consistently monitored the resident for potential skin breakdown after ADL care and within accordance to facility practice to ensue the resident did not develop an open wound to the left antecubital elbow with tendon exposure and for 1 of 3 sampled residents (Resident #217) reviewed for hospitalization s, the facility failed to administer medications in accordance with the physician's written order. The findings included: 1. […]

• Actual harm, isolatedF689Oct 20, 2022

  Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred without injury. The findings include: Resident #1's diagnoses included type 2 diabetes mellitus, thrombocytopenia, hypothyroidism, hypertension, and dementia with behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment with no behavioral issues and required extensive assistance with bed mobility and transfers. A review of the Resident Care Plan dated 8/16/2022 identified Resident #1 required extensive to total assist with ADLs and transferred using a Hoyer with an assist of two persons. […]

• No harm, potential for more than minimal, patternF761Nov 22, 2024

  Based on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: a. An observation on 11/20/24 at 5:04 AM identified that the third floor rolling medication cart was located outside of the third-floor dining room in the lobby, was unlocked. There was one resident, unsupervised in a wheelchair, approximately 15 feet from the unlocked rolling medication cart. An interview with Licensed Practical Nurse (LPN) #10 on 11/20/24 at 5:08 AM identified that she was aware the medication cart was unlocked and she left it unlocked and unattended to attend to a resident's care down one of the hallways. […]

• No harm, potential for more than minimal, patternF812Nov 22, 2024

  Based on observations, staff interviews, and review of facility policy, the facility failed to ensure foods were dated when opened and expired food was disposed of timely. The findings include: On [DATE] at 10:52 AM, a tour of the Dietary Department with the Food Service Director (FSD) identified the following: a. In the dry storage area there was an opened and undated ,d+[DATE] bag of granola and 3 open bags of hamburger rolls. Attached to the ceiling to the right of the hamburger rolls was an approximate 12 inch section of fly paper with a dead fly attached. b. […]

• No harm, potential for more than minimal, patternF880Nov 22, 2024

  Based on observations, clinical record review, review of facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #7) reviewed for nebulizer equipment the facility failed to ensure the equipment was not on the floor, the mask was covered and tubing was dated when changed. Additionally, for 1 of 5 residents (Resident #85) observed for medication administration, the facility failed to ensure appropriate hand hygiene was performed during medication administration and for 2 of 4 sampled residents (Resident #7 and Resident #101) reviewed for pressure ulcers, the facility failed to ensure appropriate personal protective equipment (PPE) was donned for a resident on precautions and failed to ensure hand hygiene was performed in accordance with infection… […]