Glisan Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 14, 2023

  1. Based on interview and record review it was determined the facility failed to monitor and assess Resident 7 after a fall and failed to recognize and treat a change of condition for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize a change of condition which likely resulted in Resident 7's severe health status change and hospitalization . Findings include: The facility's Accident/Incident Policy and Procedure, revised ,d+[DATE], directed staff to complete an incident investigation was to be completed for the following reasons but not limited to: falls with or with out injury, witnessed or unwitnessed; medication errors - if there was a negative effect on the resident or… […]

• Immediate jeopardy, isolatedF755Apr 14, 2023

  Based on interview and record review it was determined the facility failed to administer prescribed medications to residents for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to follow Resident 7's physician orders and obtain medications which likely resulted in Resident 7's severe change of condition and hospitalization . Findings include: The National Institutes of Health indicated the following: -Depakote [name brand for divalproex sodium], revised 2/2023. Do not stop taking without consulting a healthcare provider. Stopping suddenly can cause serious problems. Stopping a seizure medicine suddenly .can cause seizures. - Clobazam, revised 2/2023. Do not suddenly stop taking Clobazam. […]

• Actual harm, isolatedF689Jul 24, 2024

  Based on interview and record review it was determined the facility failed to ensure cognitively impaired residents did not have access to excessively hot liquids for 1 of 3 sampled residents (#2) reviewed accidents and hazards. This failure resulted in Resident 1 sustaining a second-degree burn (partial thickness involving the first two layers of skin) to her/his thigh. Findings include: Resident 2 was admitted to the facility in 9/2022 with diagnoses including diabetes. A 11/13/23 progress note indicated Staff 9 (Agency CNA) notified Staff 2 (LPN) that Resident 2 spilled hot coffee on her/his lap. A 11/13/23 facility investigation revealed nursing staff took the coffee cart out of the kitchen prior to the coffee cooling to a safe temperature. […]

• Actual harm, isolatedF689Mar 27, 2024

  Based on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 1 sampled resident (#1) reviewed for falls. As a result, Resident 1 fell and suffered a subarachnoid hemorrhage (brain bleed), and placed all residents at risk for significant injury. Findings include: Resident 1 admitted to the facility in 11/2011 with diagnoses including heart failure and osteoporosis. The 1/7/24 Annual MDS revealed Resident 1 had moderate cognitive impairment. […]

• Actual harm, isolatedF689Aug 11, 2023

  Based on interview and record review it was determined the facility failed to ensure fall risk interventions were followed for 1 of 1 sampled resident (#13) reviewed for accidents. This resulted in Resident 13 sustaining wrist and leg fractures which placed residents at risk for falls and injuries. Findings include: Resident 13 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (difficulty breathing), stroke and diabetes. Resident 13's Annual MDS dated [DATE] indicated the resident was moderately impaired in cognition and needed extensive assistance with ADLs. Resident 13's Care Plan dated 6/21/23 identified the resident was at risk for falls due to gait/balance problems. […]