Glenwood Healthcare Center

Inspectors wroteBased on resident interview, staff interview, record review and observation, the facility failed to ensure an environment that was free from accident hazards over which the facility has control. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1, #7, #64, #72, #79 and #42. Facility Census: 90.

Inspectors wroteBased on observation and staff interview the facility failed to ensure proper handwashing and glove use was being utilized during meal service. This was found during the annual survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 91.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure residents' dignity and respect were maintained during meal service in the dining room. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #88 and #77. Facility Census: 90.

Inspectors wroteBased on document review and staff interview, the facility failed to notify the Ombudsman of a Resident's discharge from the facility and return to home. This was true for Resident #97. Resident identifier: #97. Facility Census: 90.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated for a resident with a new diagnosis of dementia after admission to the facility. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #8. Facility Census: 90.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was accurately completed on admission to the facility for a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Resident Identifier: #8. Facility Census: 90.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure care plans were reviewed and revised for three (3) residents. The issues included resident's a resident receiving a thirty (30) day notice of discharge, a resident's dialysis weight being documented in the medical record and a resident receiving tube feedings. Resident identifiers: #2, #8 and #59. Facility Census: 90.

Inspectors wroteBased on record review, staff interview, resident interview and observation, the facility failed to ensure a resident was able to utilize adaptive equipment for safe fluid intake appropriately. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #51. Facility Census: 90.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Packaged terminal air conditioner (PTAC) units contained dirt and debris. These were random opportunities for discovery. Resident identifiers: #1, #57, #23. Facility census: 80.

Inspectors wroteBased on record review and staff Interview, the facility failed to revise the care plan for Resident #49 in the area of weight management. Resident identifier: #49. Facility census: 80.

Inspectors wroteBased on observations and staff interview, the facility failed to appropriately dispose of a soiled brief for #46. This was a random opportunity for discovery during the Long - Term Care Survey process. Facility Census: 80 Resident identifier:

Inspectors wroteBased on Record Review, Staff Interview and Observation, the facility failed to provide posey palm protectors bilaterally as ordered for Resident #30 to prevent further avoidable reduction of range of motion (ROM). Resident identifier: #30. Facility census: 80.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide appropriate care and services regarding indwelling catheter care. This was a random opportunity for discovery. Resident identifier: #23. Facility census: 80.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure oxygen therapy services were administered in accordance with professional standards of treatment. Resident #42 and Resident #73's oxygen flow rates were not set at the physician prescribed rates. In addition, Resident #42's oxygen concentrator was not functioning properly. These were random opportunities for discovery. Resident I=identifiers: #42 and #73. Facility census: 80.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medical records were maintained accurately for two (2) of 27 residents. The facility did not obtain clarification for duplicate orders for bilateral posy palm protectors for Resident #30. Resident #12 had an incorrect order regarding PO (by mouth) medications. Resident identifiers: #12 and #30. Facility census: 80.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure they ahdered to safe and sanitary infection control practices. Direct care staff member was observed throwing a soiled brief and linens on a fall mat that was lying on the floor in the resident's room. This was a random opportunity for discovery during the Long - Term Care Survey process Resident identifier: #46. Facility census: 80.

Inspectors wroteBased on observations, resident interviews and staff interview the facility failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: # 4 and #51 Facility Census: 79.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Resident Identifiers: Resident #51. Facility Census: 78. Findings Included: a) Resident Interview During an interview on 12/18/23 at 10:41 AM Resident #51 stated the food was awful, very bland and had no variety. The food was always cold. They did not follow the menu. And they got things on their dislikes list like fish and carrots. Resident #51 said I have a bad allergic reaction to Shrimp, so I don't eat anything from the water. b) Test Tray On 12/19/23 at 11:49 AM two (2) state surveyors tasted the noon time meal for palatability. The Noon meal consisted of the following: [...]

Inspectors wroteBased on observation 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. These were random opportunities for discovery: a half-consumed bottle of diet soda was on the medication cart, and an improper wearing of a mask in a resident care area. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility inappropriately completed and implemented the Physicians Order for Scope of Treatment (POST) form for one (1) one of (1) residents reviewed for advanced directives. The facility changed the resident's wishes for full code to a do not resuscitate. The resident had not granted permission for her wishes for end of life care to be changed. This failed practice had the potential to affect only limited number of residents. Resident identifiers: #30. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Hospice agency developed a care plan with measurable goals. In addition, the facility failed to implement their Hospice care plan for notification of the Hospice agency when the resident experienced nausea and vomiting. The facility failed to implement their care plan for urinary catheter care. This was true for one (1) of 18 residents whose care plans were reviewed during the long-term care survey process. Resident identifier: 58. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility failed to have evidence of collaboration with the Hospice agency providing services for one (1) of one (1) resident reviewed for the care area of Hospice. In addition, the facility failed to assess patient's needs and notify the Hospice agency of a change in condition. Resident identifier: #58. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pressure ulcer care was provided consistent with professional standards of practice. A Registered Nurse (RN) failed to assess and stage the pressure areas within 24 hours of admission and/or after the development of pressure ulcers. This was true for two (2) of three (3) residents reviewed for the care area of Pressure Ulcers. Resident identifiers: # 42 and #327. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility failed to follow the current standards of practice for indwelling Foley catheter's for two (2) of four (4) residents reviewed for the care area of catheter during the long-term care survey process. Resident identifiers: #58 and #327. Facility census: 78.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The resident was prescribed a antipsychotic medication in absence of appropriate indication / rational for use, and absence of non-pharmacological interventions attempted before prescribing the medication. Resident identifier: #58. Facility census: 78.