Glendale Gardens Nursing & Rehab

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide CNA) A spoke to one resident (Resident #1) in a rude manner while using profane language. The facility census was 92. Review of the Resident Rights, undated, shows residents should be treated with consideration, and respect, with full recognition of their dignity and individuality.1. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure all allegations of possible abuse were reported to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) within two hours of staff becoming aware of the allegation when the facility failed to report an allegation of staff to resident abuse involving one resident (Resident #1) until two days after the facility staff became aware of the allegation. The facility census was 99. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure an environment as free from accident hazards as possible when staff failed to analyze and identify the risks for falls, failed to implement new intervention to prevent future falls, and failed to care plan regarding new falls for three residents (Resident #1, #3, and #4) that sustained falls. The facility census was 93. Review showed the facility did not provide a policy regarding falls. [...]

Inspectors wroteBased on interview, and record review, the facility failed to notify all residents' families and physicians of all changes in condition and incidents when staff did not notify the physician and family of falls in a timely manner for two residents (Resident #1and #3). The facility census was 93. Review showed the facility did not provide a policy regarding falls or physician notification. Review of the facility policy titled Charting and Documentation, undated, showed the following:-The purpose of these guidelines is to provide a complete account of the resident's care, treatment, response to care and progress; guidance to the physician in prescribing appropriate medications and treatments; assistance in the plan of care for each resident; and an information source for resident changes;-Accidents/Incidents documentation does not take the place of the Event Report Form. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standard of practice when staff failed to document follow-up regarding edema (swelling/fluid retention), failed to obtain orders for the use of Tubi grips (a reuseable tubular elastic bandage used to provide support and compression,) and failed to care plan related to edema for one resident (Resident #1) and when staff failed to complete ordered daily weights and update the care plan related to edema for one resident (Resident #2). The facility census was 93. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate each resident's right of self-determination in support of resident choice when staff failed to honor resident preferences for shower frequency for four residents (Resident #6, #11, #23, and #33). The facility census was 91. Review of the facility procedure for Bath/Shower, undated, the purpose of a shower is to maintain the resident's skin integrity, comfort, and cleanliness.1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff notified the resident and/or the resident's representative in writing of a transfer at the time of transfer for two residents (Residents #8 and 104). The facility census was 91. Review of the facility's policy titled Discharge/Transfer of Resident, undated, showed the following:-Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care.-If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible.1. Review of Resident #41's face sheet (gives basic profile information at a glance) showed an admission date of 09/08/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system an effective system to make code status (whether or not the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency procedure used during cardiac or respiratory arrest)) of each resident available to staff at all times when staff failed to maintain accurate, current, and accessible code status information for nine resident (Resident #2, #10, #27, #30, #7, #8, #42, #33, and #68). The facility had a census of 91. Review of the facility policy titled, Advanced Directives, undated, showed Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care respiratory care per standards of practice when staff failed to administer oxygen per physician orders for one resident (Resident #110) and failed to obtain complete oxygen administration orders for three residents (Resident #2, #30, and #8). The facility census was 91. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide pharmaceutical services that provided a consistent system of reconciliation for all controlled substances, when staff failed to consistently sign the controlled medication count sheets at change of shift for two of seven medication/treatment carts in the facility. The facility census was 91. Review of the facility policy titled, Narcotic Count, undate, showed the following:-Purpose to complete a physical inventory of narcotics at each shift change to identify discrepancies;-The narcotic supply is to be kept under two locks at all times. The lock on the medication cart and the lock on the narcotics. These two locks and the medication room are to be locked at all times; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all resident medications were secure, when a staff member failed to lock 1 of 7 carts containing resident medications while out of his/her line of sight. The facility census was 91. Review of the facility policy titled, Storage of Medication, undated showed the following:-All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts;-All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room of otherwise made immobile;-All controlled substances must be stored under double lock and key;-An unattended medication cart must remain locked at all times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a manner to protect the food from possible contamination when staff failed to store food in sealed containers and failed to dispose of expired food items. The facility had a census of 91 residents. Review of the facility's policy titled, Safe Food Handling, dated April 2011, showed the following:-Food items are to be labeled and dated when removed from the freezer to be thawed;-No potentially hazardous food should be refrigerated over three days or per state regulation;-All food, including bulk items, should be tightly sealed with an identifying label and date. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement a complaint infection prevention and control program when the home failed to have processes in place to ensure each resident was screened annually for tuberculosis when staff failed to screen four residents (Residents #1, #42, #22, and #30) and when the facility failed to review and update their infection prevention and control program policies and procedures manual annually as required. The facility census was 91. 1. Record review of the facility Infection Prevention and Control Policy (IPCP) manual showed the policy dates in the manual included 04/23/20, 08/11/20, 05/15/23, and 05/18/23. There was no documentation included in the manual showing staff reviewed and revised the manual on an annual basis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a process in place for periodic bed rail safety checks, to include measurements of the bed frame and bed rails for risk of entrapment, for seven residents (Residents #22, #30, #91, #1, #5, #8, and #21) out of a sample of 24 residents. The facility census was 91. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice and care plan when staff failed to complete accurate and timely skin assessment for two residents (Resident #27 and #23) with identified skin concerns and skin treatments in place. The facility census was 91. Review of facility policy titled, Wound Care and Treatment, undated, showed the following:-It is the purpose of the facility to prevent and treat all wounds;-On-going skin assessment with weekly documentation of status. Review showed the facility did not provide a policy regarding skin assessments. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegation of verbal abuse were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services; DHSS) within the required time frame when staff failed to report an allegation of verbal abuse involving one resident (Resident #1) until the following afternoon. The facility census was 99. Review of the facility policy entitled Abuse Prohibition, dated November 2016, showed the following:-It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely and thorough investigation, to include interviews with multiple staff and other residents, and steps taken to protect all residents during the investigation for an allegation of possible verbal abuse involving one resident (Resident #1). The facility census was 99. Review of the facility policy entitled Abuse Prohibition, November 2016, showed the following:-It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect each resident's right to be free from physical abuse when Registered Nurse (RN) C slapped one resident's (Resident #1) face in retaliation for the resident biting the RN's finger. The facility census was 89. Review of the facility's policy titled, Abuse Prohibition, dated 2016, showed the following: -It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident. To assist the facility staff members in recognizing incidents of abuse, the following definitions of abuse are provided; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to report all allegations of abuse immediately to management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required time two hour frame when an allegation of one staff member staff member (Certified Nursing Assistant (CNA) B) being physically abusive to one resident (Resident #1), out of five sampled residents, was made and not reported in a timely manner. The facility census was 96. Review of the facility's policy titled New Abuse/Neglect Report Regulations - Effective 11/28/16, revised 01/2017, showed the following: -With recent changes to Federal & State Regulations, one important change requiring immediate action involves Abuse Prohibition Protocol; [...]

Inspectors wroteBased on interview and record review, the facility failed following their abuse policy and take steps to protect all residents during an investigation of alleged abuse after staff reported that one resident (Resident #1) alleged a staff member (Certified Nursing Assistant (CNA) B) physically abused him/her and the CNA continued to work independently with residents. Five residents were sampled in a facility with a census of 96. Review of the facility's policy titled Abuse Prohibition, dated 11/2016, showed the following: -It is the purpose of this facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property and exploitation of any resident; -To assure that everything possible is being done to prevent abuse, the facility has implemented the following seven component processes: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to clean the microwave used to reheat resident food, the hand washing sink, the doors and adjacent walls of the walk-in freezer and cooler, the hot chocolate machine, the dust off ceiling vents, and the side of the dishwashing area. The facility failed to repair chipped paint around ceiling vents in the food service area and repair the floor under a food preparation table and three vat sink to ensure it was a cleanable surface. The facility failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; and failed to obtain gap measurements for risk of entrapment for two residents (Resident #86 and #20). Staff failed to care plan the use of and failed to obtain order for the use of side rails for three residents (Resident #86, #20, and #79). Staff failed to complete ongoing assessments to ensure the side rails were secure and appropriate for use for one residents (Resident #24). The facility census was 97. Review of the facility's current policy titled Side Rail/Positioning Bar Protocol showed the following: -Before placing a Side Rail/Positioning Bar, read the following process to ensure the appropriateness and safety for the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain an effective infection control program when staff failed to implement source control when the facility had one resident (Resident #299) positive for COVID-19, when staff failed to display signage on the resident's room for proper droplet isolation protocols and on the front entrance to the facility, and when staff failed to initiate contact trace or facility-wide test residents and staff for COVID-19 when the facility was in outbreak status. The facility census was 97. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to promote and facilitate self-determination when staff did not honor one resident's (Resident #24) preference to close his/her door when requested in a selected sample of 26 residents. The facility census was 97. Record review of the facility policy titled, Fall Precaution and Management Program and Guidelines, undated, did not show information regarding keeping doors open if resident is a fall risk. 1. Review of Resident #24's face sheet (document that gives a resident's information at a quick glance) showed the following: -admission date of 01/16/23; -Diagnoses included dementia and stroke with right sided paralysis. Review of resident's care plan, revised 05/30/23, showed the following: -At risk for falls; -Used a walker for short distances and wheelchair for long distances; -Could transfer unassisted; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care consistent with professional standards of practice when facility staff failed to obtain a physician's order for, failed to ensure a process of cleaning, and failed to care plan for use of a BiPAP (bi-level positive airway pressure - a device that helps with breathing while a resident sleeps) for one resident (Resident #13). A sample of two residents were reviewed in a facility with a census of 97. Review of the facility's policy titled Positive Pressure Airway Pressure (CPAP/BiPAP) Administration, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and assist with routine dental services for one resident (Resident #44). The facility census was 97 residents. 1. Review of Resident #44's face sheet (document that gives resident's information at a quick glance) showed the following: -admission date of 05/19/23; -Diagnoses included diabetes, protein-calorie malnutrition, and vitamin deficiency. Review of resident's admission Clinical Assessment, dated 05/19/23, showed the following: -Broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose); -No dentures. Review of the resident's Speech Therapy Evaluation and Plan of Treatment, dated 05/21/23, showed dentition, oral hygiene, and oral motor structure and function were within functional limits. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect food from possible contamination when shelves in the kitchen and walk-in refrigerator were kept clean, when dishes were stacked while still wet, and when dented cans were stored with other food items to be used. The facility census was 79. 1. Record review of the facility policy, Nutrition and Dining Service Manual, Section 8, Sanitation, dated April 2011, showed the following: -Dish room work surfaces must be maintained in a clean and sanitary condition; -All items are to be air dried; -No moisture can be found on any stacked item; -All items must be stored inverted, covered, or stacked with top of dish/tray inverted; -Pots, pans and utensils will be air dried before being stored or will be stored in a self-draining position; -Water pitchers will be air dried; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure all hoses which extended below the flood plane had a backflow preventer. This had the potential to contaminate the entire facility's potable water supply. The facility staff failed to ensure the resident's bathroom doors were free of gashes. The facility had a census of 79. 1. Observation on 11/2/21, starting at 10:30 A.M., showed no backflow preventer devices on the hoses located in the following rooms that could extend below the flood plane: - A101; - A103; - A105; - A109; - B201; - B205; - B207; - B209; - B213; - C-hall main shower room; - C305; - C307; - C309; - C311; - C313; - D400; - D403; - D405; - D409; - D411; - D417. During an interview on 11/3/21, at 12:01 P.M., the Maintenance Supervisor said he did not know all hoses that extended below the flood plane needed a backflow preventer. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to invite the resident, or the resident's family representative, to care plan meetings for four residents (Resident #9, #46, #49, and #74). The facility census was 79. Record review of the facility's policy titled Care Planning-Interdisciplinary Team , dated March 2012, showed the following: -The interdisciplinary care plan team, with input from the resident, family, and/or legal representative, will develop and maintain a comprehensive care plan for each resident; -The resident, the resident's family and/or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan; -Every effort will be made to schedule care plan meetings at the best time of day for the resident and family; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity when they failed to provide a dignity bag for a catheter (a sterile tube inserted into the bladder to drain urine) bag, failed to keep the resident covered as much as possible during cares, and failed to cover to knock before entering the room for one resident (Resident #55). The facility census was 79. Record review of the facility's (undated) policy, titled Resident's Rights, showed the following information: -A resident has the right to privacy and respect; -Residents should be treated with consideration and respect and full recognition of their dignity and individuality. 1. Record review of Resident #55's face sheet showed the following: -admission date of 3/10/2019. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (the desire to be resuscitated or not if breathing and pulse stops) accessible to staff in the event of an emergency matched through out the medical records for two residents (Resident # 32 and Resident # 60). The facility census was 79. Record review of the facility's policy titled Advanced Directive, from the Nursing Guidelines Manual, dated March, 2012, showed the following: -The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were kept as free from accident hazards as possible when staff failed to care plan and implement now interventions regarding smoking for resident (Resident #64) who had a change of condition. The facility census was 79. Record review of the facility's (undated) Resident Smoking Policy, showed the following information: -The purpose is for the facility to establish and maintain safe resident smoking practices; -Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate smoking preferences; -The staff shall consult with the attending physician and the Director of Nursing (DON) to determine any restrictions on a resident's smoking privileges; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide urinary catheter (care of a sterile tube inserted into the bladder to drain urine) in a manner that prevented possible infection for one resident (Resident #55). The facility census was 79. Record review of the facility's indwelling catheter care policy, dated March 2012, showed the following information: -Provide privacy; -Wash hands and put on gloves; -Change the position of the washcloth with each downward stroke. -Use a clean washcloth with warm water to cleanse and rinse the catheter from insertion site to approximately four inches outward; -Wash hands. Record review of the Centers for Disease Control and Prevention (CDC), Infection Control, Catheter-Associated Urinary Tract Infections (CAUTI), updated 2009, showed the following: -Do not rest a catheter bag on the floor. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff routinely cleaned and maintained a continuous positive airway pressure (CPAP-treatment for obstructive sleep apnea (breathing repeatedly stops and starts during sleep), with a hose and mask or nose piece to deliver constant and steady air pressure) according to professional standards for one resident (Resident #46). The facility census was 79. Record review of the facility's policy titled Continuous Pressure Airway Pressure (CPAP) Administration, dated March 2012, showed the following: -Unplug the unit when cleaning; -Wipe the outside of the CPAP unit with a damp cloth and let air dry; -Inspect the filter on the machine; -Replace the disposable filter monthly or sooner if appears dirty; -Clean the tubing weekly with mild soap and water. [...]