Glenville Health & Rehab

Inspectors wroteBased on record review and staff interview, the facility failed to enusre they referred a resident with a newly evident mental disorder to the appropriate state-designated authority for review. This was found to be true for three (3) of eight (8) residents sampled during the long term care survey process. Resident identifiers: #3, #5, #12. Facility census:

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for four (2) of eight (8) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifiers: #4, and #5, Facility Census: 63. a) Resident #5 This resident was first admitted to the facility on [DATE], with a re-admission date of 07/17/24. Upon admission, the resident had these diagnoses: -ALZHEIMER'S DISEASE, UNSPECIFIED 3/4/2021 Principal Diagnosis admission -UNSPECIFIED CONVULSIONS 03/3/2021 admission -MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 03/03/2021 admission The PASARR was completed on 03/01/21 in an acute care facility. The PASARR did not contain any of the above diagnoses. It is marked 'none' for current diagnoses. [...]

Inspectors wroteBased upon record review and staff interviews, the facility failed to revise residents care plan in a timely manner, following significant change in condition. This was found to be true for four (4) of 23 residents reviewed during the long term care survey process. Resident identifiers: #25, #9, #5, #50. Facility census: 63. Findings Include: a) Resident # 25 Resident #25, is [AGE] years old who has capacity to make own medical decisions. The resident was admitted to the facility on [DATE]. A trauma screening was performed on 01/14/26 by the Director of Social Services. To the question, Was care plan updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization. A response of yes was marked. From the care plan: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety and unsecured medication. This was random opportunity for discovery. Resident # 9, #52 and #6 . Facility census: 63. a)Resident #52 During an initial tour of the facility an observation completed on 04/13/26 at 12:16 PM, revealed Resident #6's bed had an approximate 12-inch gap between the mattress and head board. b) Resident #9 During an initial tour of the facility an observation completed on 04/13/26 at 12:30 PM, revealed Resident #9 was lying in bed with an approximate 12-inch gap between the mattress and head board. c) Resident #6 The observation noted Resident #52's bed. The bed had a large gap between the foot board and mattress. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure qualified dietary staff carried out the functions of food and nutrition services. This had the potential to affect all of the residents receiving nutrition from the kitchen. Census: 63Findings include: An interview with Dietician #90 on 04/14/26 at 2:30pm confirmed that she works remotely as a consultant and does not come to the facility in person. A review of current credentials revealed the Dietary Manager was not certified as a manager for dietary services. An interview with Regional Dietary Manager and Administrator on 04/14/26 at approximately 3:00PM confirms there is not a Certified Dietary Manager overseeing food and nutrition services at this time and that the Dietician works remotely.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the menu met the residents' daily nutrition requirements. This had the potential to affect a majority of the residents getting nutrition from the kitchen. Census: 63.

Inspectors wroteBased on observation, policy and staff interviews, the facility failed to ensure food was prepared and stored under sanitary conditions and that dishes were stored under sanitary conditions. This had the potential to affect a majority of residents receiving nutrition from the kitchen. Census: 63Findings include: a)A policy titled, Food Storage, contains the following: all foods should be covered, labeled and dated and routinely monitored to ensure they will be consumed by their use by dates. A policy titled, Cleaning Instructions: Microwave Oven, reads that the microwave oven interior should be cleaned after each use as needed. In the procedure section states to remove any food particles from the microwave oven interior with a clean, wet cloth and wipe the interior, including the ceiling, with hot sudsy water. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow their grievance policy as related to an investigation of neglect for Resident #36. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: #36. Census: 63.

Inspectors wroteBased on record review and staff interviews, the facility failed to identify a grievance as neglect and report that to the appropriate state agencies. This failed practice has the potential to affect more than a minimal number of residents. Census: 63Findings include: A policy titled Grievances/Complaints reads, The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. The grievance report for Resident #36 stated, Resident reported on 01/11/26 he had peed in the bed about 9:00 PM and did not get cleaned up until 3:00 AM and had call light on and reported staff turned off the light and left. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly investigate a complaint of neglect for Resident #36. Resident identifier: #36. Facility Census: 63.

Inspectors wroteBased upon record review and staff interview, the facility failed to perform a comprehensive assessment following significant change in a resident with weight loss of over 18% in less than three (3) months. This was found to be true for one (1) of one (1) residents reviewed during the long term care survey process. Resident identifier: #9. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) was accurate regarding toileting schedule for Resident #48. This was true for one (1) of seven (7) residents sampled for accidents during the Long-Term Care Survey Process. Resident identifier: #48. Facility census: 63.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #6 received Oxygen therapy as ordered by physician. This was true for one (1) of two (2) residents sampled for Oxygen during the Long-Term Care Survey Process. Census: 63 Resident identifier:

Inspectors wroteBased on Interview, and record review the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for one (1) of five (5) residents reviewed for pain during the long-term survey process. Resident Identifier: #42. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to work to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization. This was found to be true for one (1) of two (2) residents reviewed for PTSD during the long term care survey process. Resident identifier: #25. Facility census: 63.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to provide treatment or services to prevent and heal pressure ulcers for one (1) of three (3) residents reviewed for pressure ulcers. The resident suffered actual physical harm when further avoidable facility acquired pressure ulcers developed. Resident identifier: #61 Facility Census: 63.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide each resident the right to be treated with dignity and respect when passing meal trays. This was true for four (4) of thirty-three (33) residents observed in the dining room. Resident identifiers: #9, #28, #31 and #61. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents were able to examine the results of the most recent survey. This had the potential to affect more than an isolated number of residents. Facility census: 63.

Inspectors wroteBased on observation and staff interview the facility failed to provide a home like environment. This was true for four (4) of nine (9) rooms observed. Room identifiers: #104, #108, #110, #213. Facility Census:

Inspectors wroteBased on medical record review and interview, the facility failed to develop person-centered comprehensive care plans. The facility failed to develop care plans for a lap tray, dental issues, specialty mattress and failed to develop a resident centered care plan. This practice affected four (4) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #2, #61, and #64. Facility census: 63.

Inspectors wroteBased on observation and staff interview the facility failed to maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections by not providing hand hygiene prior to meals. Facility Census:

Inspectors wroteThe facility failed to honor resident choices regarding the things that are important in her life regarding making her bed early in the morning. This is true for one (1) of (1) residents reviewed for choices. Resident Identifier #25. Facility census: 63.

Inspectors wroteBased on record review, family interview, and staff interview, the facility failed to provide appropriate notice of transfers or discharge for one (1) of two (2) residents reviewed for the care area of discharge. The facility failed to provide a facility-initiated discharge notice at least 30 days before the resident was discharged . For one (1) of five (5) residents reviewed for the care area of hospitalizations, the facility failed to notify the resident's representative of a hospital transfer and the reasons for the move in writing. Resident identifiers: #168, #47. Facility census: 63.

Inspectors wroteBased on record review, family interview, and staff interview, the facility failed to provide a written bed hold notice to the Medical Power of Attorney (MPOA) for one (1) of five (5) residents reviewed for the care area of hospitalizations. Resident identifier: #47. Facility census: 63.

Inspectors wroteBased on resident interview, medical record review and staff interview the facility failed to ensure they facilitated a resident's involvement and invited him in advance to his care plan meeting. Resident identifier: #54. Facility census: 63.

Inspectors wroteBased on record review, observation, resident interview, and staff interview the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident. This had the potential to affect a limited number of residents residing at the facility. Resident identifiers: #34 and #12. Facility census: 63.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure two (2) residents had received care and treatment in accordance with professional standards of practice, and the comprehensive care plan. For Resident #61 they failed to follow a physician's order for wound care and failed to provide. For Resident #33 they failed to follow the care plan for the use of a palm protector. Resident identifiers: #61, #33. Facility census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to monitor weights as ordered by the physician for a resident at risk for weight loss. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of nutrition. Resident identifier: #64. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to have laboratory reports filed in the resident 's clinical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #64. Facility census: 63.

Inspectors wroteBased on observation and staff interviews, the facility failed to store a resident's beverages in accordance with professional standards for food service safety related to storage. This has the ability to affect more than a limited number of Residents. Facility census: 63.

Inspectors wroteBased on a review of the Electronic Medical Record (EMR) and staff interview, the facility failed to maintain an accurate medical record for Resident #6. This was true for one (1) of three (3) residents reviewed for pressure ulcers. This had the potential to affect a limited number of residents. Resident identifier: #6. Facility census: 62.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the daily nursing posting was completed accurately for 13 of 16 days. This was a random opportunity for discovery. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure alleged violations involving resident abuse were reported, not later than 2 hours after the events / allegations were brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery during a complaint survey. Resident identifier: #29. Facility census: 61. Findings iincluded: a) Resident #29 On 02/20/24 at 12:25 PM, a review of facility reportables from September 2023 - Present was completed. There was an abuse reportable, dated 02/05/24, which revealed the following details: -An allegation of abuse was made against Licensed Practical Nurse (LPN) #70. -The victim of abuse was Resident #29. Resident #29 was an [AGE] year-old white female who was admitted as a long-term care resident on 04/04/22. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for behaviors. This was true for one (1) of three (3) residents reviewed during the Complaint Survey Process. Resident Identifiers: Resident #63 Facility Census 61. Findings Included: a) Resident #63 On 02/20/24 at 12:05 PM, a brief medical record review found Resident #63 was admitted to the facility on [DATE] with a Brief Interview of mental status (BIMS) of 3 and lacking capacity. Further review of the medical record found the following physician order: behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression and refusing care. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure they maintained housekeeping and maintenance necessary to maintain a sanitary, orderly and comfortable interior. Environmental issues were found on both of the facility's hallways. These observations were random opportunities for discovery. Facility census: 58.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure when (1) of three (3) residents reviewed had a change in medication and issues with sexually inappropriate behaviors the medical power of attorney was notified. Resident #59. Facility census: 58.

Inspectors wroteBased on medical record review, observations and staff interview the facility failed to ensure three (3) randomly observed residents received the assistance needed to promote adequate grooming. Residents were observed with long, dirty fingernails. Resident identifiers: #23, #51, and #47. Facility census: 58.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure one (1) of three (3) resident's drug regimen was free from unnecessary drugs. Resident #59 had been prescribed a medication without indication for use. Resident identifier: #59. Census: 58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) for Resident #13, #5 and #20 was coded to accurately reflect the residents status. This was true for three (3) of 21 sampled residents during the long term care survey process. Resident Identifiers: #13, #5 and #20. Facility Census: 57. Findings Included: a) Resident #13 A review of Resident #13's medical record on 11/28/22 found the resident was sent to an acute care hospital on [DATE]. Further review of the record found a Minimum Data Set (MDS) with an Assessment Reference Date of 08/06/22. This MDS was coded under section A0310. Type of Assessment F. Entry/discharge reporting with a number 10 indicating the resident was discharged with a return not anticipated. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all nurse aides had an employee performance review completed at least annually. This was true for five (5) of five (5) Nurse Aides reviewed. This failed practice had the potential to effect more than an isolated number of residents. Employee Identifiers: Nurse Aide (NA) # 49, NA # 53, NA #54, NA #30 and NA #40. Facility Census: 57. Findings Included: a) Employee Performance Reviews On 11/29/22 the Nursing Home Administrator (NHA) was asked to provide the current nurse aide performance reviews for Nurse Aide (NA) #49, NA #53, NA #54, NA #30, and NA #40. On 11/30/22 at 8:20 am the NHA was asked if she had the requested NA performance reviews. She stated, We have not done those within the last year. When asked when the last one was completed she stated, The last one was done before COVID. .

Inspectors wroteBased on record review and staff interview the facility failed to ensure the nurse staffing information posted daily contained the correct number of staff working including the actual hours worked for each licensed and unlicensed staff directly responsible for resident care per shift. This failed practice had the potential to more than a limited number of residents currently residing in the facility. Facility Census: 57.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #49's drug regimen was free from unnecessary psychotropic medications. Resident #49's physician agreed to decrease Resident #49's antipsychotic medication on 06/20/22. This medication was not decreased until 07/18/22 which was 28 days after the physician agreed to discontinue the medication. In addition nursing staff was identifying on the Medication Administration Record (MAR) that Resident #49 had side effects related to psychotherapeutic medications, but failed to identify what the side effect was and/or to implement an alternative plan of care without side effects. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifier: #49. Facility Census: 57. Findings Included: a) Resident #49 1. [...]

Inspectors wrotec) Resident (R) #20 Review of the medical record on 11/30/22 revealed R #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician's history and physical dated 08/05/2022 states past medical history: As above, and see hospital records and no change in condition under the psychiatric system. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The diagnosis section of the medical record and the admission minimal data set (MDS) assessment with an assessment reference date of 08/15/20 are silent for the diagnosis of anxiety. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed R#20's active diagnosis of anxiety is not listed in the diagnosis section of the medical record or in the admission MDS assessment. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff were unaware of the correct procedures to follow for residents in isolation, isolation carts for soiled gowns were not hands free, and medications were not administered safely in an isolation room. This practice has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 57.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a baseline care plan in a timely manner. This was true for one (1) of ten (10) new admissions reviewed. Resident identifier #258. Facility Census: 57. Findings Included: a) Resident #258 A review of Resident #258's medical record found the resident was admitted on [DATE] with a femur fracture and urinary tract infection (UTI) as well as Alzheimer's disease, a history of falls, hypertension, coronary artery disease, muscle weakness and difficulty walking. Further review of the medical record on 11/30/22 found no baseline care plan for Resident #258. An interview with the Administrator on 11/30/22 at 1:00 pm confirmed Resident #258 did not have a baseline care plan and should have. .

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan to meet Resident #20's mental and psychosocial needs. This is true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long term survey process. Resident identifier: #20. Facility census: 57.

Inspectors wroteBased on medical record review and staff interview the facility failed to review and revise the care plan in relation to the Resident's nutrition assessment orders. This was true for One (1) of 21 sampled residents reviewed during the long term care process. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 A review of Resident #41's medical record found the following current physician orders: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t (related to) weight loss. Order date 7/26/22 -- Regular diet Regular Texture texture. Order date 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 Resident #41's current care plan (created on 6/28/22) read as follows: Focus: [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow their own policies, or state law as related to discharges which are Against Medical Advice (AMA) for Resident # 55. These practices affected one (1) of two (2) resident's reviewed for the care area of discharges during the Long-Term Care Survey Process (LTCSP). Resident Identifier #55. Facility census 57. a) Resident #55 A review of Resident #55's medical record on 11/29/22 found Resident #55 was discharged from the facility on 11/12/22. Contained in the medical record was a Voluntary Discharge Against Medical Advice form that was signed by Resident #55 dated 11/12/22. A review of the facility's policy titled, Discharge Against Medical Advice (AMA) with an effective date 06/01/96, found the following: . Documenting the AMA : . 7. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to obtain a re-weight after the Resident experienced a significant weight loss. This was true for one (1) of four (4) residents reviewed for weight loss. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 Resident #41 has current orders for: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t weight loss. Order date: 07/26/22 -- Regular diet Regular Texture texture. Order date: 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 The medical record contained the following weights: [...]

Inspectors wroteBased on observation and staff interview the facility failed to serve food in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered dietary staff had not used proper hand sanitation. This failed practice had the potential to affect a limited number of residents. Facility census: 57.

Inspectors wroteBased on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated care plan for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process. The care plan for Resident #34 did not specify when and what services were to be provided by the hospice staff. Resident identifier: #34. Facility census: 57.