Glenbrook

Inspectors wroteBased on interview and record review the facility failed to initiate nonpharmacological or behavioral intervention before initiating antipsychotic medications (medication to treat psychosis [mental disorder characterized by disconnection from reality]) for two of five sample residents (Residents 31 and 49). This deficient practice had the potential for Resident 31 and 49 to receive unnecessary antipsychotic medication or inappropriate dose for behavioral treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure three of four sampled residents (Residents 2, 44 and 11) knew the location of the survey results binder. This failure had the potential to keep residents, family members, and visitors from easily reviewing the most recent survey results and the facility's plan of corrections, which were essential for making informed decisions about living at the facility. During an interview on 9/17/25 at 2:30 PM, three of four residents polled at the resident council meeting did not know the location of the survey results binder. During a concurrent observation of the facility and interview with the Administrator (ADM) on 9/17/25 at 4:37 PM. The ADM verified the three locations of the survey results binders and confirmed there was no sign at one of the sites in the facility indicating where to find it. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) before discharge for two of four sampled residents (Resident 5 and 7). This deficient practice had the potential to leave residents unprotected from improper discharge and deny them access to an advocate for their options and rights.1. During a review of Resident 7's History and Physical (H&P), dated 9/2/25, the H&P indicated Resident 7 was sent to the hospital on 8/24/25, and came back to the facility on 8/30/25. During an interview with the SSD on 9/18/25, at 10:11 AM. She stated the facility must send written notification to the ombudsman when resident was discharged or transferred. Medical records staff must send the notification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly identify and provide necessary assistive devices for repositioning for one of the sampled residents (Resident 27). This failure had the potential to cause accident and injury to Resident 27. During a concurrent observation and interview with Resident 27 on 9/16/25 at 9:28 AM, Resident 27 was observed holding on to the bedside drawer while turning to their side. Resident 27 expressed difficulty repositioning in bed. Resident 27 had been using the bedside table drawer to assist in turning to their side. A review of Resident 27's admission Records dated 9/18/25, indicated Resident 27 was admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident ' s (Resident 1) written care plan for transfers was consistently implemented. Resident 1 had an unwitnessed fall while transferring into a chair.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the nutritional status was monitored and acceptable parameters were maintained for one of one resident, (Resident 23), with unintended, unplanned severe weight loss of 16.43% in six months (9/4/22-2/4/23) when: 1) The resident's nutritional status was not reassessed, the laboratory values were not drawn, or the interventions were modified after five, ten, or fifteen percent of weight loss occurred, according to facility policy and standards of practice. 2) The resident was not placed on weekly weights from 9/1/2022-3/31/2023 to monitor weight status after a loss of five or ten percent of body weight, according to policy. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure overall systems were met for the Food and Nutrition Services in the kitchen when: a resident experienced an unplanned insidious severe weight loss of 16% in a six months; residents' food temperatures were not monitored for safety and palatability; kitchen staff did not perform tasks competently for food safety in food preparation, food storage, and sanitation for dishwashing and dish storage; kitchen staff did not monitor the temperatures in the dry storage room and emergency food supply room closet to ensure safe quality of the food supply; recipes were not followed for time and temperature control for food safety foods (TCS); and fruit fly pests were found in the kitchen. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Kitchen staff did not correctly label and date TCS (Time/Temperature Controlled for food safety) foods in a walk-in refrigerator and did not monitor the dry storage room by correctly labeling, dating, and checking the quality of the food supply. 2. A Lead [NAME] (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 3. A Dishwasher did not enter the dish machine wash and rinse temperatures on a log in a timely manner. These failures placed all residents at risk of cross contamination and the potential to acquire food-borne illnesses. The census was 57.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. An ice scooper was left inside the ice machine. 2. The kitchen's clean dish storage area had dirty serving utensils and debris in tray with clean dishes. 3. A Lead cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 4. The floor in the walk-refrigerator and freezer had dirty label, brown stains, trash and other debris on the floor. 5. Fruit flies were in the flying around uncovered food in the kitchen and dry storage area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. The facility census was 57.

Inspectors wroteBased on interview and record review, the facility failed to ensure care/treatment was provided according to professional standards of practice for two of 15 sampled residents (Resident 3 and 45) when: 1. Licensed nurses (LN) did not respond to Resident 3's low blood glucose reading (a value less than 70 mg/dl [milligrams/deciliter]) by assessing the resident for signs and symptoms of hypoglycemia (low blood glucose/sugar) and notifying the resident's physician. In addition, LN did not clarify Resident 3's physician order related to a low blood glucose parameter. 2. A response to a change of condition related to nutritional assessment was not conducted in a timely manner. As a result, there was the potential risk to the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of eight sampled residents (Resident 361) reviewed for medication administration, received the medication in accordance with the physician's orders. This failure had the potential for the for Resident 361 to experience unexpected medication side effects or decreased drug action.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when holding temperatures on the steam table and resident trays were below acceptable range. These failures had the potential to result in decreased food intake and further compromise the nutritional status of medically vulnerable residents in the facility. The facility census was 57.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a visitor wore the proper personal protective equipment (PPE) while in contact with one of one sampled resident (Resident 8) on isolation precaution. As a result, there was a potential for spread of infection.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the kitchen and dry storage room was free of pests. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. The facility census was 57.

Inspectors wroteBased on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day to day oversight of dietary operations may have placed 84 facility residents at health and nutritional risk of unsafe, unsanitary, and ineffective food practices that could further compromise their health status. (Cross reference F801, F802, F805, F812, F813, and F814)

Inspectors wroteBased on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective oversight of dietetic services was provided to the food and nutrition services department, as evidenced by lapses in the delivery of food services associated with tags 800, 802, 803, 805, 812, 813 and 814. This failure to ensure effective oversight of day to day food and nutrition services operations placed 84 facility residents at nutritional risk, and in turn, may have further compromised their health and nutrition status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff were competent to carry out the functions of the food and nutrition services in a safe and sanitary manner when: 1. Wet dish pans were stacked with clean dry pans in the storage area. 2. Dirty serving scoops with brown crusted food residue were stored with clean scoops. 3. Kitchen staff incorrectly demonstrated thermometer calibration. 4. Kitchen staff did not know the cool down process for ambient (room) temperature foods. These failures placed 84 residents at risk of widespread food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff followed recipes and menus accurately as printed when: 1. The Daily Spreadsheet Menu for lunch was not followed when a CK served 1 ¾ oz. meat entrée portions instead of 3 oz. portions. 2. The recipe for Sausage Jambalaya was not followed 3. The lunch puree recipe for roast turkey was not followed. These failures resulted in a vulnerable resident population receiving inadequate and/or incorrect nutrition that could compromise their health status. The facility census at the time of survey was 84.

Inspectors wroteBased on observation, staff interviews, and record review the facility did not ensure food was stored and prepared in safe and sanitary conditions according to professional standards of practice; and kitchen equipment was maintained according to manufacturer's guidelines in the Food and Nutrition Services department when: 1) Unpasteurized eggs were served to residents; 2) The hot water in the hand wash sink at the main kitchen entrance was 80.6 degrees; 3) Unlabeled, undated, and expired food items were stored in kitchen refrigerators and the dry storage area, and in the nursing unit; 4) Pots, pans and dishes were stacked and stored wet; 5) The ice machine had blackish-brownish smudge inside the condenser of the ice making section; 6) Lack of cool-down process for ambient temperature foods; 7) Use of a non-food grade approved chemical to clean food-contact surfaces; [...]

Inspectors wroteBased on observation, interview, and departmental document review, the facility failed to follow the policy on Food from Outside Sources that included provisions on how they will provide safe food handling practices for resident food brought from the outside. This failure had the potential to lead to food borne illnesses in a medically compromised population of 83 out of 84 residents who could consume food.

Inspectors wroteBased on observation, interview, and departmental document review, the facility failed to ensure the appropriate food texture was served to 11 residents who were on mechanical soft diets (a diet with a soft and chopped texture for one who had difficulty chewing or swallowing) when they received a whole meatloaf slice instead of meatloaf chopped into bite size pieces. This deficient practice had the potential for residents to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) on unchopped food, which could further compromise their medical and nutritional status.

Inspectors wroteBased on observation, interview, and departmental document review, the facility failed to dispose of garbage and refuse properly when a dietary staff did not cover the garbage receptacles with lids when removing trash from the kitchen to the dumpster. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement correct infection control practices when a licensed nurse did not consistently perform hand hygiene (hand washing or use of hand sanitizer) after glove removal during a gastrostomy tube (g-tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) dressing change on Resident 50. This failure had the potential to transmit infectious agents to Resident 50.