Glendale Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to properly wash dishware when the water temperature was lower than manufacturer specifications. This deficient practice has the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all medically compromised residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual skills competency assessments for four of seven sampled nursing staff (Licensed Vocational Nurse [LVN] 2, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) as required in their Facility Assessment (a yearly review that identifies the staff, equipment, and resources the facility needs to safely and effectively care of its residents). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents sampled for pressure injury prevention (Resident 1), who had multiple pressure injuries, received necessary treatment and services consistent with professional standards of practice when Resident 1's low air loss mattress (LAL- a medical support surface that uses a constant flow of air to reduce pressure, heat, and moisture on the skin to help prevent or treat pressure injuries) was set to an incorrect setting. Based on Resident 1's weight of 161 pounds (lbs- a unit of weight), the LAL setting should have been at level 3. During the survey observation, Resident 1's LAL setting was found to be set at level 4. This failure had the potential to cause further worsening of Resident 1's pressure injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications (unexpected problems that may arise during treatment) of enteral feedings (liquid nutrition through a flexible tube that goes in directly into the stomach) for two of three sampled residents ( Residents 36 and 25) who was observed receiving enteral feeding continuously with head of bed (HOB) less than 30 degrees in accordance with the facility's policy and procedure titled Enteral Feedings - Safety Precautions This deficient practice had the potential to result in vomiting and/or aspiration pneumonia (severe lung infection) that could negatively affect Resident 36 and 25 qualities of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 don (put on) an isolation gown (designed to protect healthcare workers from blood, bodily fluids, and contaminants by covering the torso, arms, and back) when providing care for one of one sampled residents (Resident 7) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a Sacro coccyx (near the lower back and spine) wound. This deficient practice had the potential to result in Resident 7 acquiring MDROs and/or spreading MDROs to other residents in the facility which could result in wide spread infection in the facility affecting their health and quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 1) reviewed for anticoagulant (a medicine that prevented blood clots from forming in the bloodstream) and antiplatelet (a type of medicine that prevented platelets [a type of blood cell] from sticking together and forming a blood clot) medication by failing to implement a care plan for apixaban (also known as Eliquis, a type of medicine known as a blood thinner) and clopidogrel bisulfate (also known as Plavix, a medicine that prevented blood clots by making your blood cells [platelets] less sticky). These deficient practices had the potential for a lack of individualized care and to affect the quality of services provided to Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, intervene and evaluate care of two out of three sampled residents (Residents 28 and 31) by failing to: 1. Ensure Resident 28's wound on the left eye was identified and assessed by facility to ensure resident received timely and appropriate care for behavior of self -inflicted wound and scratching under the left eye. 2. Ensure Resident 31's daily episodes of emesis (vomit) where documented, assessed for the root cause, monitored and reported to the primary physician. As a result of these deficient practices, Resident 28 could develop worsened skin and wound infection and severe pain. For Resident 31 frequent vomiting could result in dehydration (significant fluid loss in the body) and electrolytes (essential minerals in the body for the cells to function) loss that leads to and organ failures.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) had an informed consent (the voluntary agreement of a resident or a resident's representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) prior to treatment of Amitriptyline (a medication used to treat depression [severe feeling of sadness and hopelessness] and neuropathic [damaged nerves] pain in adults). This failure violated the residents rights of Resident 19 or representative to make an informed decision about the treatments of Amitriptyline and its side effects such as increased agitation, irritability and worsened depression of the medication and any alternative treatments available.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 15 and 195) had a call light device (a device used to call for assistance) within reach. This failure had the potential to result in Residents 15 and 195 being unable to call for assistance when needed and not receive immediate care in the an emergency that could lead to falls, accidents and injury.

Inspectors wroteBased on interview and record review, the facility failed to notify the primary physician of the signitficant change of condition for 1 of 3 sampled residents (Resident 31) who had daily episodes of vomiting for unknown period of time. This deficient practice resulted in the resident's delay in treatment and monitoring to prevent fluid loss, discomfort and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident specific comprehensive care plan that reflected the resident's current needs and health status for two out of eight sampled residents (Residents 6 and 39) by failing to ensure: 1. Resident 6's care plan for her weight loss had no measurable objectives and time frames such as the target weights for the resident. 2. Resident 39 did not have a care plan to address the care and monitoring of the resident ' s intravenous (IV- a thin, flexible tube that is inserted into a vein) insertion site. This deficient practice placed Resident 6 at risk for further weight loss. For Resident 39, the resident had the potential to be at risk of complications associated with IV insertion such as bleeding, infiltration (leakage of fluid from the vein to the surrounding tissue causing pain and swollenness) and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure 1 of 3 sampled residents (Resident 28) was provided care and services to maintain good grooming and personal hygiene by ensuring the resident's nail was free of dirt. This deficient practice had potential to lead to skin infection and poor body image from having dirt underneath nails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intravenous (IV- a thin, flexible tube that is inserted into a vein) catheter dressing was labeled with the date and time on when the IV dressing was changed, and the name or initial of the staff who changed the dressing. This deficient practice placed Resident 39 at risk of complications associated with IV insertion such as infection that can travel to the blood and result in sepsis (a severe life-threatening infection in the blood).

Inspectors wroteBased on interview, and record review, the facility did not ensure medical records are accurately documented for one of three sampled residents (Resident 1), the time of incident and vital signs recorded on Resident 1 ' s progress note (a type of documentation that is used to track and document patient's progress throughout treatment) and vital signs sheet (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) were not accurately documented per facility ' s policy. This deficient practice had the potential in miscommunication, provided inaccurate information affect to delivery of care and possible leading to the cause of death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one outdoor refuse container (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was closed with a tight-fitting lid and kept covered in accordance with the facility's policy and procedure titled, Food Related Garbage and Refuse Disposal. This failure had the potential to attract insects and harborage of pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection by failing to: 1. Ensure the facility monitors the water system for Legionella (bacteria most found in water, including groundwater, fresh and marine surface waters that causes severe pneumonia [severe infection in the lungs]. Legionella is transmitted through breathing in Legionella-contaminated, aerosolized [the form of a fine spray] water and is also possible from breathing in Legionella contaminated soil or while drinking water) as evidenced by not conducting water testing for Legionella. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light device (an alerting device for nurses or other nursing personnel to assist a patient when in need) was maintained within easy reach for one of one sampled resident (Resident 344), in accordance with the resident's care plan. This failure resulted in Resident 344 not being able to ask for staff assistance on 1/22/2024. A potential for further decline in the resident's activities for daily living, self-esteem, and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled resident (Resident 28) or his/her representative was assisted to formulate an Advance Healthcare Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility, and the AD was maintained in the resident's clinical records at all times. This deficient practice had the potential to cause conflict with Resident 28's wishes regarding health care treatment especially in an event of emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services in activities of daily living (ADL) to maintain good personal hygiene by ensuring the toenails were not thick and discolored and the fingernails were trimmed for one of two sampled residents (Resident 21) who had long untrimmed fingernails and toenails. This deficient practice had the potential for Resident 21 not to receive necessary services to maintain and achieve their highest potential and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate and communicate the care services of one of two sampled residents (Resident 6) with the hospice (an end-of-life care with focus on the resident's quality of life) staff as indicated in the facility's policy and procedure for hospice care titled, Hospice and Nursing Facility Services Agreement, This deficient practice had the potential to negatively affect the resident's psychosocial and physical well-being and/or delay the delivery of hospice care services to Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 24) receiving gastrostomy tube feeding (nutrition through gastrostomy tube feeding tube [GT-a flexible tube surgical inserted through abdomen into the stomach for feeding, fluid, and medication administration] was being fed continuously in accordance with the resident's physician's orders. This deficient practice had the potential to result in altered nutritional status resulting from inconsistent caloric intake and loss of weight to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to one of 2 sampled residents (Resident 21) by failing to follow the physician's order to provide podiatrist service (a physician specialized in foot care and foot diseases) for the foot care with long, thick discolored nails to Resident 21. This deficient practice resulted for Resident 21 not to have the toenails trimmed to prevent accidental injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing, and administering of all drugs and biologicals) to meet the needs of each resident by failing to destroy expired Lorazepam ( a medication used to treat anxiety [the fear of the unknown]) for one of one sampled resident (Resident 6). The deficient practice had the potential for medication diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and unauthorized release of residents' personal information.