Glenwood Health Center by Harborview

Inspectors wroteBased on record review, interviews, and a review of the facility policy titled Fall Prevention Program, the facility failed to implement fall interventions to prevent falls for one of two sampled residents (R) (R18) reviewed for falls. Harm was identified to have occurred on 10/28/2025, when R18 sustained a fall, causing a laceration to R18's head, a nontraumatic intracranial (within the skull) hemorrhage (bleeding), and a nontraumatic subarachnoid (fluid-filled space around the brain through which major blood vessels pass) hemorrhage, which required hospitalization.

Inspectors wroteBased on record review, facility document review, interviews, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate and failed to maintain accurate documentation of investigations of abuse for four of the five (incident involving R97 and R176; incident involving R34 and Certified Medication Assistant(CMA)12; incident involving R59 and R194; and incident involving R171 and Certified Nursing Assistant(CNA)13) abuse allegations reviewed.

Inspectors wroteBased on record review, facility document review, interviews, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to report allegations of abuse to the state survey agency within two hours for two of five incidents (the incident involving R34 and the incident involving R208) of abuse reviewed.

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled Comprehensive Care Plans, the facility failed to include discharge goals in the comprehensive care plan for one of four sampled residents (R) (R104) reviewed for care planning.

Inspectors wroteBased on observation, interview, and a review of the facility policies titled Nail Care and Activities of Daily Living (ADLs), the facility failed to ensure staff provided nail care for one of seven sampled residents (R) (R35) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and a review of the facility policy titled Enhanced Barrier Precautions, the facility failed to maintain infection prevention and control practices to prevent the transmission and/or development of infection for one of three sampled residents (R) (R15) reviewed for Enhanced Barrier Precautions (EBP). Specifically, staff failed to wear appropriate personal protective equipment (PPE) while providing wound care to R15.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the vents directly over the food preparation areas were free from dirt and debris and failed to prevent flies from contaminating the prepared food. This failure has the potential to affect 194 residents that consume the food prepared in the kitchen.

Inspectors wroteBased on record review, observations, staff interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two of seven sampled residents (R) (R2 and R3). Specifically, R2 was seen touching the breast of R3.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA (against medical advice), the facility failed to have an effective discharge planning process in place for one (R13) of three residents reviewed for discharge. Specifically, the facility failed to ensure that R13, who required wound care services, was referred and accepted for services prior to discharge.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Documentation in Medical Record, the facility failed to keep accurate medical record for one of 27 sampled residents (R) (R7).

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the policy titled Comprehensive Care Plans, the facility failed to develop and/or implement the person-centered care plan for six residents (R) (R71, R266, R19, R25, R111, R118) reviewed for smoking. In addition, the facility failed to develop a care plan for one resident (R172) related to Post Traumatic Stress Disorder (PTSD). The facility's failures created potential risks for the safety and well-being of the residents. The sample size was 102 residents. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. [...]

Inspectors wroteE. Review of the clinical record revealed R25 was admitted to the facility on [DATE]with diagnoses including dementia, cognitive communication deficit, lack of coordination, atherosclerotic heart disease, mood and psychotic disorders, and generalized muscle weakness. Review of the quarterly MDS dated [DATE] documented a BIMS score of five, indicating severe cognitive impairments. Section J on the 3/24/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R25's name was on the list of residents identified as a tobacco user. Review of R25's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/12/2024. The smoking assessment revealed he prefers to smoke morning, afternoon, and evening. [...]

Inspectors wroteBased on observations, record review, interviews, review of the Administrator Job Description and Director of Nursing Job Description, and review of the policy titled Smoking Policy - Residents, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its smoking policy and failed to ensure that licensed nursing staff were knowledgeable and competent to assess residents and implement care plans for smoking. The facility's failures created potential risks for the safety and well-being of the residents. The census was 210 residents. Specifically 1. Facility Administrator and Director of Nursing (DON) failed to perform duties of their job descriptions that facilitated providing a safe environment to the residents of the facility. 2. [...]

Inspectors wroteBased on observations, interviews, and review of facility's policies titled Date Marking for Food Safety and Record of Food Temperatures, the facility failed to ensure proper food labeling and storage, failed to discard food items by the expiration dates, failed to ensure foods were maintained at proper temperatures, and failed to maintain sanitary conditions of the ice machine. The census was 210. Findings Include: Review of the undated policy titled Food Receiving and Storage, revealed Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Compliance: Number 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. Number 7. [...]

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment for 12 rooms (G224, G226, G227, G228, G229, G230, D201, W143, M101, M106, M107, M108) on four of five wings (Georgia Wing, [NAME] Wing, Dogwood Wing, and Magnolia Wing) including dirty bathrooms with noisy and dusty exhaust vents, broken light switches, dirty packaged terminal air conditioner (PTAC) units, a broken window, and dead insects in resident rooms. In addition, the laundry room had rancid odor, leaking pipes, dirty laundry overflowing from laundry chute onto floor, trash and lint atop the dryers, and a dusty fan in the clean laundry room. The census was 210.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Sufficient and Competent Nursing, the facility failed to ensure nursing staff provided supervision and oversight for residents, as evidenced by nursing staff sleeping and watching videos during a third shift observation. The census was 210.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policies titled Infection Surveillance, Infection Prevention and Control Program, Tracheostomy Care, Hand Hygiene, and Routine Cleaning and Disinfection, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation and control of infections to prevent possible cross contamination. Specifically, facility staff failed to wash and/or sanitize hands during the provision of tracheostomy care, during medication administration, during the handling of clean linens, passing ice to residents; failed to maintain hand sanitizer dispensers; failed to store residents personal care items appropriately; failed to clean and disinfect reusable equipment (blood pressure machine); and failed to clean resident bathrooms appropriately. [...]

Inspectors wroteBased on observations, record review, interviews, and review of the facility's policy titled Promoting/Maintaining Resident Dignity, the facility failed to ensure resident's dignity was maintained by not displaying clinical information related to swallowing, openly posted in the resident's room for visitors to see when visiting resident or her roommate for one of one resident (R) R94 of 102 sampled residents.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled Resident Self-Administration of Medication the facility failed to assess and determine if one of one resident (R) (R83) from a sample of 102, for the ability to safely self-administer medications, prior to the resident exercising that right.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled Resident Rights, the facility failed to offer one of 13 sampled residents (R) (R266) baths as scheduled. This failure had the potential to affect the resident's comfort, body image and increase the risk for infections.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy titled, Language Assistance Service, the facility failed to ensure one of two sampled residents (R) (R182) with Limited English skills, was provided with resources to access and understand communications regarding his healthcare regimen.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to report injuries of unknown origin to the State Survey Agency (SSA) within the required timeframe for one of four sampled residents (R) (R154) reviewed for abuse and neglect. The failure of the facility to report this incident has the likelihood of leading to future unreported injuries of unknown origin, with the potential to affect resident's quality of life.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of one residents (R) (118) from a sample of 102, related to smoking.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled Medication Administration, and Medication Storage, the facility failed to maintain the correct narcotic count in one of five medication carts (West Wing); failed to ensure one of five medication carts (Dogwood Hall) was locked when not in use, and that medications were not left on top of cart, accessible to residents and non-licensed staff; and failed to ensure expired medications were removed from one of five med carts (Dogwood Hall). The facility census was 210.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy titled, Food Preparation Guideline, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for one of one residents (R) (R91) of 102 sampled residents .

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Answering the Call Light the facility failed to ensure resident call lights were within reach to allow the residents to call for staff assistance in seven of 22 rooms (101, 106, 105, 103, 104, 111, 107) on the memory care unit (Magnolia). This failure placed the residents at risk of accidents, injuries, and/or unmet needs.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Perineal Care, the facility failed to ensure full visual privacy was provided for residents (R) on three of five halls. Specifically, the facility failed to ensure proper-sized privacy curtains were in place and functional in twenty-one resident rooms on Magnolia Hall, one resident room on Dogwood Hall, and one resident room on East Hall. The census was 209 residents. This deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, staff interviews, review of the facility documents titled Employee Education Attendance Record: Topic of In-Service: Continent Care, and Attendance Form: Course title Incontinent Care, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from neglect by not ensuring that Activities of Daily Living (ADL) care was provided. Specifically, briefs and bed linen changes, were not provided as needed for seven Residents (R) (R6, R8, R11, R23, R25, R28, R29) out of 29 sampled residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment on one of five wings (Georgia) including dirty equipment, scuffed walls, broken furniture, dirty television stand, dirty privacy curtains, soiled mattress, dusty bathroom vents, slow draining sink and hole in sheetrock. The census was 193.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to implement an effective Infection Control Program (ICP) designed to prevent the development and transmission of infections by not ensuring staff perform hand hygiene and maintain appropriate standard precautions during the provision of tracheostomy care. In addition, the facility failed to store, handle, transport, and process linens properly. The census was 193.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled Administering Medication, the facility failed to ensure one resident (R) (R#76) of 68 sampled residents, was assessed to safely self-administer medications.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled MDS 3.0 Completion, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for one of 41 residents (R) (R#172) reviewed for smoking.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Advance Directives and Comprehensive Care Plan, the facility failed to develop a person-centered comprehensive care plan with measurable objectives for four of 66 sampled residents (R) (R#56 for Advanced Directives and Dialysis; R#31 for use of a soft helmet; R#172 for smoking; and R#144 for respiratory status and use of oxygen and nebulizer treatments). 1. Review of the policy titled Comprehensive Care Plans dated March 1, 2022, revealed the policy is to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. [...]

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed obtain a physician order for one resident (R) R#31, for the use of a soft helmet for protection of head during re-occurring seizure activity. The facility census was 193.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to implement care, handling, cleaning, and storage of nebulizers and BiPAP (bilevel positive airway pressure) equipment for three of eight residents (R) (R#144 R#121, and R#127 ) reviewed for respiratory care.

Inspectors wroteBased on observations, staff interviews, and review of the policy titled Storage of Medications, the facility failed to ensure medications were secure and locked on two treatment carts when not in use. The facility census was 193.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled, Therapy Screen, the facility failed to re-evaluate one of two residents (R) (R#128) reviewed for rehabilitation services, after a seven-day hospital stay. The facility census was 193.

Inspectors wroteBased on observations, interviews, and review of the policy titled Resident Rights, the facility failed to ensure privacy for one out of ten resident rooms observed (room [ROOM NUMBER]), by failing to provide a privacy curtain for bed B.