Aliya of Glenwood

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the residents' rights to be treated in a dignified manner during meal service. This affects four of four (R69, R3, R79, R76) residents reviewed for dignity during meal service in total sample of 54. R69 face sheet shows diagnosis of dementia. R3 face sheet shows diagnosis of dysphagia. R79 face sheet shows a diagnosis of neuromuscular dysfunction. R76 face sheet shows a diagnosis of dysphagia. During lunch observation on 6/02/2026 at 12:08 PM, R82 and R64 was observed being assisted with their meal, R69 was seated at the same table, R69 did not have a meal tray. R69 was watching R82 and R64 eat. R69 received her tray at 12:18PM.On 6/02/2026 1:03 PM R3 received his lunch tray in his room. V23 (Certified Nursing Assistant) was observed at 1:15 pm, feeding R3, V23 was standing while feeding R3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its food storage policy to ensure dented canned goods were not stored or available for use. This has the potential to affect all 136 residents who receive meals from the facility kitchen

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy related to transmission-based contact precautions and hand hygiene upon exiting the isolation room on the B-Wing. This deficient practice had the potential to affect all 44 residents assigned to the B-Wing included in the review for infection control practices. R15 electronic medical record dated (5/21/26) documents strict contact isolation related to c-diff. R59 electronic medical record dated (6/1/26) documents strict contact isolation related to c-diff. On 6/2/2026 at 1:29 PM Observed staff V4 (health information manager) going inside R15 and R59. R15's and R59's room entrance observed to have a contact precaution sign. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for the administration of a PRN psychotropic medication (lorazepam) for one resident. Specifically, the facility administered lorazepam over a 14-day period without obtaining the resident's informed consent prior to administration and continued administering the medication after 5/21/26 without obtaining a current physician order. This affected one of three residents (R79) reviewed for chemical restraints in a sample of 54 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician orders and obtain daily weights; failed to notify the physician of weight gain of more than 5 pounds for one resident with a diagnosis of heart failure. This affected one of three residents (R1) reviewed for weight monitoring related congestive heart failure in a sample of 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that wound care treatments were implemented as ordered. This affected one of four residents (R3) reviewed for pressure ulcers in a sample of 54 residents. R3 care plan shows R3 has diagnosis of unspecified dementia, COPD, protein malnutrition, and lack of coordination. R3 MDS dated [DATE] section c for cognition shows BIMS score of five (cognitive deficits), section E for behaviors- rejection of care, 0 is documented (behavior not exhibited), section M for skin shows one stage 3 pressure ulcer, unhealed, M1200 for skin and ulcer treatment shows pressure reducing device for bed, nutrition or hydration interventions to manage skin problem, pressure ulcer/injury care and application of nonsurgical dressing. On 6/4/26 at 1:37pm R3 was observed resting in bed, awake and alert. R3 agreeable for wound observation. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Medication Administration policy and Controlled Substances policy by not administering PRN psychotropic medications in accordance with physician orders and by not documenting the effectiveness of the medication. This affected one of three residents (R79) reviewed for unnecessary medications in a sample of 54.

Inspectors wroteBased on interview and record review, the facility failed to follow hospital recommendations by not ordering a BiPAP machine to be used at night for a resident (R3) for four months for one out of three reviewed for supplemental oxygen in a total sample of 11. Findings Include: R3 is a [AGE] year old with the following diagnosis: multiple myeloma, chronic obstructive pulmonary disease (COPD), immunodeficiency, end stage renal disease with dependence on renal dialysis, and asthma. On 5/12/26 at 3:16PM, R3 was lying in bed. R3 reported R3 has been using a BiPAP at night since 2009. R3 stated R3 used a BiPAP at the previous facility which R3 was admitted from but was never ordered once R3 admitted to this facility in 01/2026. R3 reported R3 has been wearing oxygen to try to help with R3's sleep apnea which is the reason R3 must wear the machine at night. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure verification of license qualification was performed upon hire of a registered professional nurse for 1 of 3 (V4) reviewed for licensed professionals. Findings Include:On 5/6/2026 at 10:54 AM, V3 (Director of Human Resources) stated V4 (Registered Nurse) was hired in August 2025 as a as needed staff nurse. V3 said it was an oversight on her end for not properly verifying V4's registered nurse license upon hire. In March 2026, V3 and facility administration were notified by their corporate office that V4 did not have the license qualification as a registered nurse. On 5/6/2026 at 1:18 PM, V1 (Administrator) said V3 should have ensured nursing license was checked and verified upon hire. V4 was immediately released from her duties as staff nurse. V1 said facility has no Human Resource (HR) policy but only guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food as indicated in the menu and failed to provide/serve the food on the written menu. This failure affected all 137 residents that consume food from the kitchen. Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents three residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. On 4/25/2026 at 4:00 PM, V22 (Dietician) affirmed facility staff should be following all written menus and recipes. The facility menu cycle indicates on 4/25/2026, the lunch served is meatloaf, green beans, mashed potatoes, a dinner roll, bread pudding and a beverage. On 4/25/2026 at 11:31 AM, V25 (Cook) was observed temping the foods served for lunch. There were no dinner rolls in the plating areas. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food using methods that conserve nutritive value, flavor, and appearance; failed to serve food that was palatable, attractive, and at a safe/appetizing temperature. These failures have the potential to affect all 137 residents that consume food from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a sanitary manner, failed to ensure staff wear appropriate hair restraints, and failed to ensure the kitchen was regularly cleaned to remove dust, debris and grease to prevent growth of microorganisms. These failures have the potential to affect all 137 residents that consume food from the kitchen. Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents 3 residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. On 4/24/2026, at 12:34 PM, a kitchen tour was conducted. [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow their abuse policy by not investigating an incident involving alleged abuse. This deficiency affected one (R1) of three (R2, R7) residents reviewed for Abuse. R1 is an [AGE] year-old male, initial admitted to the facility 10/10/2022. R1s Minimum Data Set (MDS) dated [DATE] section C Brief Interview for Mental Status (BIMS) score is 12/15 cognitive moderately impaired. R1s medical diagnosis included, but are not limited to Chronic Respiratory Failure, disorder of the muscle, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Asthma, Hypertension, Type 2 Diabetes, difficulty in walking, abnormal posture. On 3/18/2026 at 9:34AM, R1 stated a few weeks ago his old roommate beat him up. R1 stated he took a broken rib. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to follow their Staffing Policy by not having the appropriate staff available to meet the needs of the resident resulting in a resident's (R10) fall. This failure affected 1 (R1) of 3 residents reviewed for staffing. On 3/18/2026 at 11:39AM called V9 (Certified Nurse's Assistant/CNA), no answer, left a voice message. On 3/19/2026 at 10:54AM V1 (Administrator) stated the facility was staffed accordingly with eight Certified Nurse's Assistant (CNAs) to the census on 3/3/2026, but there was call offs and only had 5 CNAs. On 3/19/2026 at 9:41AM V2 states the nursing management team alternates the staffing phone for staffing call offs. V2 stated if there is a call off, the nursing management team will find coverage immediately. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow complete Care plan indicating need for assistive bed devices. This deficiency affects one (R5) of three residents reviewed for Patient Centered Care plan.

Inspectors wroteBased on interview and record review, the facility failed to complete restorative assessment upon admission. This deficiency affects one (R5) of three residents reviewed for Restorative nursing program.

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy on Medication Administration. This deficiency affects one (R5) of three residents reviewed for Medication Administration.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to ensure that dental recommendations were followed, failed to follow-up with the provider as directed, and/or failed to ensure that timely dental care was provided to three of three residents (R2, R3, R4) reviewed for dental services. These failures have the potential to affect 143 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report malfunctioning handicap push buttons, failed to ensure that essential equipment was in safe operating condition, and failed to timely repair malfunctioning equipment. This failure has the potential to affect 143 residents residing at facility.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from physical resident-to-resident abuse when a resident (R12) punched another resident (R13) which resulted in a red mark on R13's face. This failure affected 1 resident (R13) of 3 reviewed for abuse. The noncompliance occurred from 10-22-25 to 11-23-25.

Inspectors wroteBased on observations, resident and staff interviews, and review of facility records, there is evidence to indicate that residents' dietary preferences are not consistently followed, and this failure affected 1 resident (R7) out of 3 residents reviewed for dietary services. R7, is a [AGE] year-old male who was admitted to the facility on [DATE] to receive skilled therapy services. R7's diagnoses include but are not limited to, vertebrogenic low back pain, post-traumatic stress disorder, atrial fibrillation, chronic low back pain, depression, polyneuropathy, and presence of a cardiac pacemaker. According to the Minimum Data Set (MDS) dated [DATE], R7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognitive function. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedures, failed to implement care plans, failed to follow physician orders, and failed to ensure that ordered dressing changes were provided for four (R1, R2, R3, and R4) of four residents reviewed for dressing changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse policy and failed to protect one resident (R1) from repeated verbal and psychological abuse by R2. This failure affected one (R1) of three residents reviewed for abuse. These failures resulted in R1 experiencing ongoing fear and anxiety related to being R2's roommate.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for residents residing in the facility and failed to perform a resident inventory check for one of three residents (R2) upon admission. This failure resulted in a weapon found in R2's possession due to facility not performing an inventory check.

Inspectors wroteBased on interview and record review , the facility failed to implement their abuse prohibition policy to ensure the safety of a resident when an employee is accused of abuse and was permitted to remain in the facility, the facility also failed to ensure a resident had an initial abuse screening and initial abuse care-plan and failed to revise the care-plan for 1 of 1 resident (R3) in a sample of 5 reviewed for Abuse.

Inspectors wroteBased on interview and record review the facility failed to effectively monitor and treat pain for a resident with bilateral burns to lower extremities for 1 of 1 resident (R3) reviewed for pain. Findings Include:On 8/19/2025 at 10:30am R3 said that on 8/17/2025 about 12:30am she informed the (Certified Nursing Assistant-CNA) that she needed some pain medication for her legs. At about 2:30am the night shift nurse entered her room and said she did not have any pain medication available and that it would be delivered in the morning. R3 said at that time her pain level was at an 8 out of 10. On 8/21/2025 at 1:00pm, V8 (Nurse) said she was R3's night nurse on 8/17/2025, the CNA informed me that R3 wanted pain medication. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's beta blocker medication was available for 1 of 3 residents (R1) and the facility failed to ensure that a resident's pain medication was available for 1 of 3 residents (R3) reviewed for medication administration in a sample of 5. Findings Include:On 8/19/2025 at 11:30am R1's electronic medication administration record was reviewed and the dates of 8/8-8/11/2025 Toprol XL 50mg, a beta blocker, was not administered. On 8/19/2025 at 1:45pm V4 (Nurse) said she was the nurse working on the following days of 8/8 - 8/11/2025 and that the medication was not available. V4 said she called the pharmacy and the pharmacy said they would deliver the medication as soon as possible, V4 said she should have retrieved the medication from the convenience box and did not. [...]

Inspectors wroteBased on interview and record review the facility failed to implement measures for unstageable wound. This facility also failed to implement wound care treatment orders and develop a wound care plan. This deficiency affects one (R4) of three residents reviewed for Wound/Pressure Ulcer Prevention and management.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow the infection control policy related to placement of isolation precaution signs and wearing of personal protective equipment before entering room and during provision of care for four (R51, R87, R99 and R107) of five residents in the sample of 41 reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff administer prescribed PRN (as needed) blood pressure medication for a resident; failed to assess and document vital signs for a resident with a change in condition; and failed to monitor and document a resident's blood sugar as ordered. This failure affected one (R2) of three residents reviewed for nursing care and resulted in R2 becoming unresponsive while at the facility and required hospitalization and treatment that included intubation and being admitted to the intensive care unit (ICU) for treatment of septic shock and healthcare associated pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff met professional standards of practice by not adequately monitoring and documenting all resident assessments, vital signs, results of blood glucose level for diabetic residents. This failure affected two (R1 and R2) of three residents reviewed for nursing care.

Inspectors wroteBased on interview and record review, the facility failed to accurately document a narcotic medication on the Medication Administration Record and only documented the medication give on the Controlled Substance Record for one out of three reviewed for medication administration in a total sample of four. Findings Include: R2 is an [AGE] year old with the following diagnosis: type 2 diabetes, stage 4 chronic kidney disease, heart failure, and neoplasm of the cerebral meninges. Due to R2's mental status only being alert to self, R2 was unable to answer any questions related to medication. On 3/4/25 at 1:19PM, V1 (Nurse) stated when any narcotic medication is administered it must be documented on the Medication Administration Record (MAR) and the Controlled Substance Sheet. [...]

Inspectors wroteBased on interview and record review, the facility failed to take and record food temperatures prior to serving in order to ensure meals were provided at an appetizing temperature. This failure affected five (R1, R2, R3, R4 and R7) of five residents who were reviewed for dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide timely incontinence care for one resident who is dependent on staff for activities of daily living including incontinence care. This failure affected one of one resident (R1) reviewed for incontinence care who developed moisture associated skin dermatitis.

Inspectors wroteBased on interview and record review, the facility failed to have physician ordered pain medication available for administration for a resident experiencing pain. This failure applies to one (R1) of four residents reviewed for pain management.

Inspectors wroteBased on interview and record review, the facility failed to supervise one resident (R2) who was diagnosed with Dementia, cognitively impaired with a history of falls and identified as high fall risk from sustaining three falls within forty-five days. This affected one of three residents (R2) reviewed for falls. This failure resulted in R2 sustaining an unwitnessed fall with a laceration to the back of the head injury requiring suture and staple repair and sustaining another fall with a laceration to the back of the head requiring staples.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its skin care prevention policy and implement effective interventions and monitoring to prevent one resident developing three facility acquired non-pressure wounds to the right foot and ankle. This affected one of three R1 residents reviewed for non-pressure wounds in a sample of 11. This failure resulted in R1 presenting to the hospital emergency room on 9/1/24 with sepsis secondary to a right heel wound that was infected and with acute osteomyelitis (bone infection).

Inspectors wroteBased on interviews and record reviews, the facility failed to implement effective pressure relieving interventions to prevent one resident, who's lower extremities are severely contracted, at very high risk for skin breakdown, and dependent on staff for all ADLs (activities of daily living), from developing a facility acquired pressure ulcer on the left posterior distal thigh due to pressure from posterior mold splint on the left lower leg. This affected one of three residents R1 reviewed for pressure ulcers in a sample of 11. This failure resulted in R1 presenting to the hospital emergency room on 9/1/24 with a pressure wound to the left posterior distal thigh with hamstring tendon exposed.

Inspectors wroteBased on observation, interview, and record review the facility failed to account for the usage, disposition, and reconciliation of all controlled medications. This deficiency affects all 4 (four) medication carts reviewed for Controlled Substance reconciliation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects all two (2) medication storage rooms reviewed for Medication Storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene during medication administration in between residents, failed to disinfect medical equipment such as pulse oximeter and Blood pressure (BP) machine after each resident use, and failed to disinfect glucometer properly as manufacturer recommendation. The facility also failed to implement enhanced barrier precaution (EBP) during intravenous ( IV) medication administration to resident with central line. The facility also failed to store the nebulizer mask in a plastic bag. This deficiency affects all 7 residents (R5, R16, R22, R31, R39, R68 and R77) in the sample of 26 reviewed for infection control during medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure immunization documentation for 5 of 5 residents (R13, R17, R40, R55, R71) reviewed for immunization administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during wound care treatment for 1 of 2 residents (R5, R40) observed for wound treatment in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to perform criminal history background checks within 24 hours of admission for three of five residents (R118, R322, R323) reviewed for criminal history background check in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and maintain hygiene for the resident's nails for 1 of 7 residents (R98) in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete smoking assessment to a resident who smokes and formulate care plan for smoking safety. The facility also failed to initiate fall investigation and update fall care plan. This deficiency affects two (R46, R55) of five residents in the sample of 26 reviewed for Smoking Safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medication as ordered by physician. This deficiency affects two (R5 and R54) of three residents in the sample of 26 reviewed for Significant medication error.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician order for resident on hospice care and failed to access hospice staff documentation of visit to ensure coordinated care and communication. This deficiency affects one (R71) of three residents in the sample of 26 reviewed for Hospice care management.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a plan of care was followed to review information on past falls, attempt to determine cause of falls, and anticipate and meet the resident's needs. The facility also failed to follow their fall protocol to ensure effective interventions for safety were in place to reduce the risk for falls for 1 of 3 resident's (R1) reviewed for safety. This failure resulted in R1 sustaining a left hip fracture of the femur head on 4/21/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to aid with dressing, incontinent care, and provide clean linen in a timely manner to a resident identified as dependent for needing assistance with Activities of Daily Living (ADL) for 1 of 3 resident's (R2) reviewed for ADL care.

Inspectors wroteBased on interview and record review the facility failed to developed a resident specific care plan with interventions to address a residents drug use history. This failure resulted in R1 being found unresponsive, non-breathing and was pronounced dead at the hospital. This failure affected R1 out of 8 residents reviewed for comprehensive care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure window screens were free of damage/holes for 14 of 14(R8-R20) windows reviewed for environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their pressure ulcer prevention policy by not preventing a resident from developing a facility acquired Stage 3 pressure ulcer and failed to have effective interventions and physician orders in place for the treatment of the pressure ulcer once acquired. This failure applied to one (R3) of one resident reviewed for pressure ulcers and resulted in R3 not receiving the care and services required to aid in the healing and prevention of pressure ulcers. R3 developed a new stage 3 pressure ulcer to his left ischium.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide sufficient nursing staff to provide daily care needs for dependent residents. This failure applies to three of seven residents (R2, R4 and R6) reviewed for staffing and has the potential to affect all 116 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff were provided with training to ensure that Certified Nursing Assistants had the required competencies and skills to provide service to residents with special care needs. This failure affected two (R3 and R7) of seven residents reviewed for special care.

Inspectors wroteBased on interview and record the facility failed to have a Registered Nurse (RN) on duty for a least eight consecutive hours a day, 7 days a week. This has the potential to affect all 113 residents.

Inspectors wroteBased on interview and record review the facility failed to follow its Abuse Prevention and Reporting policy by not providing a resident secure environment free from verbal abuse for 3 of 4 residents (R5, R7 and R8) reviewed for abuse in a sample of ten.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions for residents with a history of multiple falls. This deficiency affects two (R1 and R2) of three residents reviewed for Fall Prevention Management Program.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's order to provide therapy services to a resident who has a decrease in functional mobility. This deficiency affects one (R3) of three residents reviewed for specialized rehabilitation services.