Complete Care at Dawnview LLC

Inspectors wroteBased on observation and staff interview the facility failed to ensure the the most recent state inspection results were easily accessible to residents and others without having to ask. This was a random opportunity for discovery and had the potential to affect more than a limited amount of residents. Facility census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Level 1 pre-screening of a new residents for serious Mental Illness/Intellectual Disability (MD/ID) or a related condition prior to admission to the facility. This failed practice was true for four (4) out of 22 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #1, #7, #30 and #45. Facility Census: 61.

Inspectors wroteBased on Observations and staff interviews, the facility failed to maintain a safe and accident hazard free environment for the residents. Multiple residents had items/clutter both around and underneath their beds, making both normal movement and resident care dangerous. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident identifiers #33, #52, #36, #38, #45 and #3. Census: 61.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide dietary staff with proper food handlers certification. This deficient practice involved [NAME] #20. Facility census: 61.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure food was distributed and served accordance with professionalstandards for food safety. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: #31 and #34. Facility Census 61.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a clean, comfortable, and homelike environment for residents in Rooms #100, #102, and #205. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 61.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to report verbal grievances from resident Council meetings. This affected Residents #68, #3, #13, and #54. Facility census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure MDS Discharge assessments were completed and submitted in a timely fashion. This was a random opportunity for discovery. Resident Identifier: #46. Facility Census: 61.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure the nurse staffing post form, with the required census information listed, was easily accessible to residents. This was a random opportunity for discovery and could affect a number of residents. Facility Census: 61.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a safe, clean, homelike environment regarding the storage of unclean wheelchairs. This was a random opportunity for discovery. Resident Identifiers: #17, #35, #56, #47, #37, #57 and #2. Facility Census: 59. Findings Include: a) Storage of wheelchairs On 11/04/24 at 10:30 AM, a foul odor was noticed by the Surveyors at the end of the 100-hall next to the conference room. Upon further examination, the foul odor was lingering around the wheelchairs and wheelchair cushions were noted with debris and a dried substance. The wheelchairs without cushions were noted with a foul odor and debris on the seats. Most of the wheelchairs observed had the residents' names located on the handles of the wheelchairs. On 11/05/24 at 10:15 AM, the wheel chairs were observed at the end of 100 hall next to conference room. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan regarding a diagnosis of anemia, actual multiple falls with injuries, indicate the diagnosis of dehydration and the administration of intravenous fluids (IVFs), and the discontinuation of an anticoagulant for Resident #28 and Resident #18's transfer to hospice services. This was true for two (2) of 21 residents reviewed during the survey process. Resident Identifiers: #28 and #18. Facility Census: 59.

Inspectors wroteBased on observation and staff interview, the facility failed to provide an accident and hazard free environment as possible by having a treatment cart which would not lock properly on three occasions. These were random opportunities for discovery. Facility Census: 59. Findings Include: a) Treatment Cart On 11/04/24 at 11:40 AM, a treatment cart was observed unlocked behind the nurses' station which was unsecured and residents are able to ambulate in this area. On 11/04/24 at 11:43 AM, the Director of Nursing (DON) was notified of the treatment cart being unlocked and accessible to the residents. The DON stated, the lock is not working .I'll call Maintanence. At this time, the treatment cart was left in the same area behind the nurses' station. On 11/04/24 at 3:15 PM, the treatment cart was observed unlocked behind the nurses' station. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly investigate allegations of abuse and neglect, by failing to have witness statements signed by witnesses an alleged incident involving Resident #11, and failing to complete witness statements, and notify the police regarding an allegation of misappropriation of funds for Resident #38. This was true for two (2) of four (4) residents reviewed for abuse and neglect during the survey process. Resident identifiers: 11, 38. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed upon admission to identify a mental diagnosis for Resident #36 and related diagnoses of dementia and PTSD for Resident #42 on the PASARR. This was true for two (2) of three (3) resident's reviewed under the area of PASARR. Resident identifiers: #42 and #36. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to follow the proper procedures to appoint a healthcare surrogate for Resident # 35. This was true for one (1) of four (4) residents reviewed for advance directives during the survey process. Resident Identifier: 35. Facility census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record regarding transfer dates for Resident #28 and #36. This was true for two (2) of two (2) residents reviewed under the care area of hospitalizations. Resident identifiers: #28 and #36. Facility census: 59.

Inspectors wroteAn IJ at F600 was called on 04/03/24 at 1:26 PM . A Plan of Correction (POC) was approved on 04/03/24 at 4:56 PM. The IJ was abated on 04/04/24 at 10:15 AM. Based on record review, observations and staff interviews, the facility failed to protect a defenseless, non communicative resident from sexual abuse and to ensure other residents were protected from sexual abuse. This failed practice had the potential to affect all residents residing in the facility. Resident identifiers: #14 and #20. Facility census: 49.

Inspectors wroteAn IJ at F609 was called on 04/03/24 at 1:26 PM . A Plan of Correction (POC) was approved on 04/03/24 at 4:56 PM. The IJ was abated on 04/04/24 at 10:15 AM. Based on record review, reportables review, staff interviews, and policy review, the facility failed to report an allegation of sexual abuse within the required two (2) hour time. Resident identifiers: #14 and #20. Facility census: 49.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure a resident maintained a continuous oxygen supply. Resident #50 failed to receive oxygen therapy from a portable tank and oxygen concentrator for approximately 20 minutes. This failed practice had the potential to affect all residents receiving oxygen therapy. Resident identifier: #50. Facility census: 49.

Inspectors wroteBased on observation, record review, and staff interview, the facilty failed to ensure pharmaceutical services were provided to ensure routine medications were available to administer to residents in accordance with physician orders. This was true for three (3) of five (5) residents observed during the Medication Observation task of the LTCSP. Resident identifiers: Resident #5, Resident #39, and Resident #48. Census:

Inspectors wroteb) Resident (R) #48 During an observation of medication administration on 01/04/23 at 08:10 AM, Quetiapine (Seroquel) 150 milligrams (mg) an atypical antipsychotic med used for treatment of schizophrenia and major depressive disorders was not available to be given To R#48 as scheduled. Registered Nurse (RN) #62 reported pharmacy delivers nightly and acknowledged the Seroquel was not refilled and available to be given to R#48 as prescribed. Random observations on 01/03/23 at 09:33 AM and 01/04/23 at 8:30 AM, found R#48 sitting up in her bed and crying. On 01/04/23 at 2:45 PM, the Activities Director (AD) #54 reported R #48 has intermittent crying episodes that usually last one to two days. Review of the medical record on 01/04/23, revealed R #48 was admitted to the facility with a diagnosis of Non-Alzheimer's dementia. [...]

Inspectors wrotee) Personal Protective Equipment disposal containers 1) Resident #2 An observation , on 01/03/23 at 03:41 PM , revealed Resident #2 was in isolation precautions related to an infection which required staff to use PPE when caring for the resident. Further observation of the room, revealed there was no appropriate trash receptacle in place. The trash bin in the room, had no hands free lid which forced staff to come into contact with the lid prior to and/or after disposing of soiled items. 2) Resident #104 An observation, on 01/03/23 at 01:50 PM, revealed Resident #104 was in isolation precautions related to an infection which required staff to use PPE when caring for the resident. Further observation of the room, revealed the trash receptacle in place was not in good repair. the container lid was broken and could not be hinged and there was no foot pedal to assure hands free use. [...]

Inspectors wroteBased on observation, staff interview, the facility failed to ensure residents' side rails were maintained in accordance with manufacturer's recommendation as evidenced by the use of zip ties to secure side rails. This was a random opportunity for discovery and found to be true during an observation of room [ROOM NUMBER]. This deficient practice had the potential to affect more than a limited number of residents. Census: 56.

Inspectors wroteBased on observation, and staff interview, the facility failed to ensure care was provided in a manner to promote a resident's dignity. The facility failed to ensure staff covered a Foley catheter drainage bag for Resident #45. This failed practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: Resident #45. Census:

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to secure personal and medical information in a manner that protected a resident's health related information from the public view. The facility posted personal health information, which included treatment modalities and health related information, on the wall in the resident's room in plain sight of anyone entering the resident's room. This was identified on a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #1. Census: 56.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the facility was maintained with a clean and safe environment in good repair. The facility failed to ensure carpeted resident areas were clean and free of stains or frayed areas, failed to ensure floor tiles were secured and unbroken and failed to ensure a bedside table was intact and free of loose parts. This failed practice was identified through a random opportunity for discovery and for two (2) of two (2) current residents reviewed for environment during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #2 and Resident #13. Census: 56.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with mental and psychosocial needs. This was found for two of five reviewed for unnecessary medications. Resident identifiers: 48 and 17. Facility census: 56.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to provide treatment to a resident, in accordance to professional standards of practice, when the resident was assessed with limited range of motion (ROM) and had physician orders for treatment modalities. This deficient practice was identified for one (1) of one (1) resident reviewed for positioning/range of motion (ROM) during the Long Term Care Survey Process ( LTCSP). Resident Identifier: Resident #1. Census:

Inspectors wroteb) Resident #14 On 01/03/23 at 12:20 PM, based on staff observation, resident #14 observed with nasal cannula tubing running to her nose which had an attached tag which was dated for 11/27/22. On 01/03/23 at 2:00 PM, based on record review, resident #14 has the following physician's order in her chart, Change oxygen tubing and ensure to place new padding on tubing for behind the ears, label with date and initials, every night shift every Sat. The order date is 12/6/2022. On 01/03/23 at 3:35 PM, Licensed Practical Nurse (LPN) #23 interviewed as to what the date on a nasal cannula meant. She stated that they date the cannula was placed into service on the cannula. LPN #23 was notified that the nasal cannula for resident #14 had a date of 11/27/22 and she stated it would be immediately changed for the resident. [...]

Inspectors wroteBased on observation, medical record review, family interview and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for residents with dementia. This is true for two of five reviewed for unnecessary medications. Resident identifiers: 48 and 17. Facility census: 56.

Inspectors wroteBased on policy review, staff interview and medical review, the facility failed to develop and maintain a policy for the monthly drug regimen review with time frames for the different steps in the process. The pharmacist failed to identify a drug irregularity for a psychotropic medication order without an adequate indication for use. This is true for one of five residents reviewed for unnecessary medications. The policy related to monthly drug review has the potential to affect a limited number of residents. Resident identifier: #16. Facility census: 56.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's psychotropic medication was prescribed with an adequate indications for use. This is true for one of five residents reviewed for unnecessary medications. Resident identifier: #16. Facility census: 56

Inspectors wroteBased on observation, staff interview, medical record review, and resident interview, the facility failed to assure medications were available to be administered as prescribed and scheduled. Resident (R) #22's blood sugars increased when Insulin was not available to be given as ordered. Bumetanide (a loop diuretic) was not available for a resident with heart failure and an identified risk of fluid overload. This was true for one of five residents observed during medication administration and a random opportunity of discovery. Resident identifiers: #39 and #22. Facility census: 56.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored, and labeled in accordance with current accepted professional practices. The facility failed to ensure medications were dated when opened and put in to use or was expired and still being stored for use. This was true for medications stored in one (1) of two (2) medication carts and one (1) of one (1) medication storage rooms inspected. This practice had the potential to affect a limited number of residents. Facility census: