Glasgow Gardens

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents. The facility census was 36. Review of the facility's policy, Staff Scheduling, dated April 2015, showed an RN must work eight consecutive hours on the day shift every day, seven days a week. 1. Review of the facility's RN daily staffing sheets and time-clock data, dated December 2024, showed the facility did not have documentation to show an RN (including the Director of Nursing (DON)) worked on 12/01/24, 12/07/24, 12/13/24, and 12/26/24. Review of the facility's RN daily staffing sheets and time-clock data, dated January 2025, showed the facility did not have documentation to show an RN (including the DON) worked on 01/13/25, 01/19/25, and 01/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete or maintain documentation of a two-step or prior two step Tuberculin Skin Tests (TST), or a chest x-ray in the last year, as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing), and failed to complete annual TB screening as required for three residents (Resident #17, #239, and #15), in a review of five sampled residents evaluated for immunization status. The facility failed to ensure there was a complete water management program in place to reduce the risk of legionellosis (any disease caused by Legionella (a bacteria which people can breathe in without knowing, sometimes causing infection in the lungs)) in the facility. The facility census was 36. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow the facility's policy for the antibiotic stewardship program by not reporting infections to the infection preventionist as directed in policy, and failed to timely track infections and review antibiotic use following initiation of the medications. The facility census was 36. Review of the facility's undated policy, Surveillance: Antibiotic Stewardship Program, showed the following: -Measures of Antibiotic Prescribing, Use, and Clinical Outcomes: -The Infection Preventionist/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription; -The Infection Preventions/designee will be responsible for auditing the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy, and indication; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccinations (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for four residents (Residents #15, #25, #6, and #34), of five five residents reviewed for immunization status. The facility census was 36. Review of the facility's undated policy, Immunization, showed the following: -Pneumococcal vaccination in persons age [AGE] and older years, unless contraindicated, would be administered according to the following guidelines when determining the vaccination status; -Adults 65 years or older who have not already received a pneumococcal conjugate vaccine should receive either a single dose of PCV15 followed by a dose of PPSV23 one year later, or a single dose of PVC20. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, person centered care plan for two residents (Resident #35 and #89), in a review of 15 sampled residents. The facility census was 36. Review of the facility's undated policy Care Plan Comprehensive, showed the following: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is ongoing and the care plan will be revised as changes occur in the resident's condition; -The comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; -Periodic review and updating of care plans will occur: a. When a significant change in the resident's condition has occurred; b. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident (Resident #38), in a review of one closed records. The facility census was 36. Review of the facility's undated policy for discharge/transfer showed the following: -Purpose of the policy was to provide safe departure from the facility and provide sufficient information for after care of the resident; -Complete a discharge summary and post discharge plan of care form which included: a. List of medications with instructions in simple terms; b. Instructions for post discharge care and explain to the resident and/or representative; c. Have resident and/or representative responsible for care sign the discharge summary and post discharge care form; d. Give a copy of the form to the resident and/or representative responsible for care; e. [...]

Inspectors wroteBased on observations, record reviews, facility policy review, and interviews, it was determined that the facility failed to perform assessments and obtain consents for bed rails for 3 (Residents #19, #24, and #26) of 3 residents reviewed for the use of bed rails. This affected 27 residents that had bed rails on their bed.

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 36 out of 59 beds in the facility with bed rails.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment as required for 2 (Resident #26 and Resident #8) of 19 sampled residents. Specifically, the facility failed to conduct a significant change MDS when Resident #26 had a decline in two areas of activities of daily living (ADL) and when Resident #8 was admitted to hospice services.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to revise a care plan for 1 (Resident #24) of 19 residents reviewed for care plans. Specifically, the facility failed to ensure Resident #24's care plan was appropriately revised when the resident's diet status changed by removing the portions of the care plan that were no longer pertinent.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to assess an open wound for 1 (Resident #8) of 13 sampled residents after hospice staff identified superficial areas to Resident #8's buttocks on 08/04/2023.

Inspectors wroteBased on observation and interview, the facility failed to maintain housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for the residents. The facility census was 34. Observation on 1/13/20, at 10:24 A.M., on the 100 hallway showed the following: -Each residents' room door was scratched the entire width, in several places from the middle of the door to the bottom of the door; -A piece of handrail was missing at the beginning of the 100 hall by room [ROOM NUMBER]; -The doors to storage areas and offices on the 100 hallway were scratched and marred; -The door to the shower room had deep scratches and chips to the exterior, exposing the particles inside the door; -The shower room wall, located to the right of entrance to the shower room, was scratches and marred. The lower trim board was missing paint and the wood underneath was exposed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for three residents ( Residents #8, #14, and #32) in a review of 12 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 34. 1. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific condition, needs and risks to provide person centered care that met professional standards of quality care, and reviewed or provided a printed copy to the resident/responsible party for four residents ( Resident #8, #137, #6,and #10) in a review of 12 sampled residents, and one additional resident (Resident #187). The facility census was 34. 1. Review of Resident #8's Electronic Medical Record (EMR) showed the following: -Admit 7/1/2019; -Diagnoses of chronic pain, stress fracture of left tibia (lower leg bone), depression, acquired absence of left leg below knee, and edema. Review of the resident's EMR showed no interim care plan to meet the resident's immediate needs completed within 48 hours of facility admission. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and revise comprehensive, person centered care plans for two residents (Resident #10 and #32) in a review of 12 sampled residents. The facility census was 34. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/19, showed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan is an interdisciplinary communication tool. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and obtain medication timely for a yeast infection for one resident (Resident #21) in a review of 12 sampled residents. The facility census was 34. 1. During interview on 1/16/2020 at 2:55 P.M., the associate director of nursing (ADON) said the facility did not have a policy regarding following physician's orders. 2. Review of Resident #21's physician's orders dated 12/14/19-12/20/19, showed the resident's diagnoses included candidiasis (yeast infection), type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the resident's progress notes dated 1/13/2020 at 7:07 P.M., showed the following: [...]