Glenwood Rehabilitation & Health Care Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure food was protected from possible contamination at all times when staff failed to properly store and label food and when the stacked dishes while still wet. The facility had a census of 54.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards when the resident accessible hot water temperatures in rooms of eight residents' (Resident #41, #27, #31, #42, #3, #7, #34, and #51) measured greater than 120 degrees Fahrenheit (F). The facility census was 54. Review showed the facility did not provide a policy regarding hot water temperature monitoring. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a complete infection prevention and control program when staff failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent, these pathogens are frequently resistant to most available antimicrobial agents) that employs targeted gown and glove use during high contact resident care activities)) when providing wound and incontinent care to one resident (Resident #3) with a wound. Staff failed to completed proper hand hygiene while providing incontinent cares for two residents (Resident #3 and #47). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) received the necessary services to maintain good personal hygiene when the facility failed to document reapproaches after bathing refusals for two residents (Residents #28 and #50) of 19 residents reviewed. The facility census was 54. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates did not exceed five percent when the facility completed two medication errors out of an 25 opportunities (an 8% error rate) affecting two residents (Resident #53 and #2). The facility census was 54. Review of the facility procedure titled Medication Pass Tips, dated 05/2019, showed the following:-Prior to preparing medication verify the resident's identity, verify each drug against the electronic medical record (eMAR); and if the resident requires the medication is to be crushed; check to see if the drug can be crushed;-Verify the route against the eMAR;-Administer each medication as instructed on the eMAR and within the timeframe established by the facility;-For insulin; prime insulin pens with two units (u) before each use. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors when the facility failed to administer noon insulin on dialysis (a life- sustaining treatment for kidney failure, filtering waste and excess fluid from the blood when the kidneys have less than 10-15 % function) days and failed to prime the insulin pen before administration for one resident (Resident #2). The facility census was 54. Review of the facility procedure titled Medication Pass Tips, dated 05/2019, showed administer each medication as instructed on the electronic Medication Administration Record (eMAR) and within the timeframe established by the facility. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were free from significant medication errors when one staff member (Certified Medication Tech (CMT) D) administered another resident's medication to one resident (Resident #1) resulting in a drop in blood pressure and the resident being sent to the hospital. A sampled of seven residents were reviewed in a facility with a census of 50. [...]

Inspectors wroteBased on observation and record review, the facility failed to maintain a complete infection prevention and control program when staff failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) testing for long-term care employees and per facility policy for three staff members (Director of Nursing (DON), Activity Director (AD), and Laundry E) of ten sampled staff members. The facility census was 36. Review of the facility's policy, titled Tuberculosis Control, undated, showed the following: -All employees will be screened for TB; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #7) who had a temporary approved level two Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 36. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #26) of three residents reviewed for PASARR. The facility census was 36. Review showed the facility did not provide a policy regarding PASARR requirements. 1. Review of Resident #26's face sheet (provides basic profile information) showed the following: -admission date of 01/06/22; -Diagnoses included schizophrenia (mental disorder affecting ability to think, feel, and behave clearly), anxiety disorder, psychotic disorder with delusions (firmly held false beliefs) due to known physiological condition, and encephalopathy (brain disease that alters brain function or structure). Review of the resident's care plan, last updated 04/15/24, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care consistent with professional standards of practice when staff failed to document a complete assessment of a new pressure ulcer and failed to update the care plan timely regarding the skin breakdown and intervention changes for one resident (Resident #20). The facility census was 36. Review of the facility policy, Wound Champion Program, undated, showed the following: -All residents will have a head-to-toe skin assessment completed by the licensed nurse every seven days. The weekly skin assessment should be documented via the electronic medical record's weekly skin assessment. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care consistent with standards of practice when staff failed to obtain physician orders for and care plan the use of a continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while a person sleeps) machine for one resident (Resident #140). Two residents were reviewed for use of oxygen in a facility with a census of 36. Review of a facility policy titled Continuous Pressure Airway Pressure (CPAP) Administration, undated, showed the following: -Purpose to administer continuous positive airway pressure to maintain open airway to the resident with obstructive sleep apnea (breathing repeatedly stops and starts) or respiratory problems breathing when sleeping. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an assessment of risk versus benefits of side rail use for one resident (Resident #1) and failed to obtain informed consent for the use of side rails prior to installation; failed to address the use of side rails in the care plan; failed to obtain physician orders for the use of side rails; failed to obtain gap measurement for the risk of entrapment; and failed to complete ongoing assessments to ensure the side rails were secure and appropriate for the use of two residents (Resident #1 and #20). The facility census was 36. Review of the facility's policy titled Side Rail/Positioning Bar Protocol, undated, 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 record review and interview, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) were accurate when staff failed to address one resident's (Resident #7) ostomy (a surgical opening through the abdomen to form an artificial anal opening) on the resident's MDS. The facility census was 36. Review showed the facility did not provide a policy regarding MDS documentation. 1. Review of Resident #7's face sheet (brief information sheet about the resident) showed the following: -admission date of 12/09/20; -Diagnoses included colostomy status (surgery to create an opening for the colon (large intestine) through the belly). Review of the resident's physician order sheet (POS), current as of 04/25/24, showed an order, dated 04/17/22, for colostomy care every shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications that were in possession of the facility for three residents (Resident #8, #97 and #98). The facility census was 48. Record review of the facility's Abuse Prohibition Protocol Manual, dated [DATE], showed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. Record review of the facility's undated policy for the Narcotic Count, showed the following: -Purpose to complete a physical inventory of narcotics at each shift change to identify discrepancies; -Controlled substances are available only to licensed nurse, pharmacists, and certified medical technicians; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain proof of the completed Nurse Aide (NA) Registry check for one newly hired staff to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility census was 48. Record review of the facility's protocol titled How to Hire an Employee, undated, showed the following: -The NA Registry is to be run and printed on all employees, before orientation; -This needs ran prior to the employees start (hire) date and a hard copy of the results put in the employee file. 1. Record review of the Director of Nursing (DON)'s personnel file showed the following: -Date of hire of 4/4/22; -The facility did not maintain a copy of DON's NA registry check. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the correct amount of an entrée to six residents on a puree or liquid puree diet. The facility census was 48. Record review of the facility's policy titled Menu's, dated 05/15, showed menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the Recommended Dietary Allowances. 1. Record review of a board in the kitchen showed five residents on puree diets and one resident on liquid puree diet. Record review of the facility's Diet Spreadsheet for Spring/Summer 2022 showed the following: -Cheese ravioli and marinara, two #8 scoops (3.7 ounces (oz.)) for puree diet. Observation on 6/2/22, beginning at at 10:25 A.M., showed the following: -Cook A placed a #12 scoop (2.3 oz.) by the puree cheese ravioli and marinara on the steam table; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in a manner to protect it from potential contamination when staff failed to have a light fixture repaired that contained insects in it above a food preparation area and when staff failed to properly wash hands before and after gloving and touching food. The facility's census was 48. 1. Record review of the facility's policy titled Cleaning Schedules, dated 05/2015, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the Dietary Department: Specify the day(s) the cleaning schedule will be done; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain documentation of maintaining a functioned Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility census was 48. 1. Record review of the facility's QAA/QAPI (Quality Assurance/Performance Improvement) Manual, showed the following: -Staff did not document the dates the QAA/QAPI committee met; -Staff did not document how many members attended the meetings; -Staff documented monthly concerns discussed, but did not document discussion plans to address the concerns discussed. During an interview on 06/03/22, at 1:54 P.M., the Administrator said the following: -She does not have a sign in sheet to show of who attended the QAA meetings; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Residents #6) who remained in the facility after discharge from Medicare Part A services. The facility census was 48. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/09/09, and showed the following: [...]