Glenwood Village Care Center

Inspectors wroteBased on interview and document review the facility failed to ensure the resident representative was notified of new bruising for 1 of 3 residents (R3) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement immediate interventions to prevent re-occurrence following a fall from a full body (EZ Way) mechanical lift for 1 of 1 residents reviewed (R4) who sustained two brain bleeds and a fracture. This resulted in an immediate jeopardy (IJ). In addition to the resident in immediate jeopardy, the facility failed to implement person centered fall interventions and complete a fall analysis for 1 of 3 residents reviewed (R1) who had multiple falls and fractures identified which resulted in actual harm. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 63 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date.

Inspectors wroteBased on interview and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of. This deficient practice had the potential to adversely affect all 63 residents which resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 residents (R34) reviewed for urinary tract infection (UTI) as part of their antibiotic stewardship program.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 5 residents (R 22 and R62) who resided on the Blue Horizon and [NAME] Ridge units reviewed for food. This deficient practice had the potential to affect all 23 residents residing on these units.

Inspectors wroteBased on observation and interview, the facility failed to disinfect a multi-use glucometer (a machine that is used for blood glucose monitoring) after use for 1 of 2 residents (R51) reviewed for blood glucose monitoring. This deficient practice had the ability to affect all 5 residents who required blood glucose monitoring.

Inspectors wroteBased on interview, and document review, the facility failed to ensure an allegation of employee to resident abuse was immediately reported no later than two hours, to the State agency (SA) for 1 of 1 residents (R15) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to submit to the State Agency (SA) the results of the investigation within 5 working days for 1 of 1 residents (R15) reviewed for abuse, for 1 of 1 allegations of abuse reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure the resident or legal representatives had been provided a written notice of transfer for 2 of 2 residents (R22, R64), and failed to be informed of bed hold rights for 1 of 2 residents (R22) reviewed for discharges. In addition, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 2 of 2 residents (R22, R64) reviewed for hospitalizations. Findings Include: R22 R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 was cognitively intact and had diagnoses which included: arthritis, hemiplegia (partial or total paralysis on one side of the body)affecting left side, and peripheral vascular disease (disease of the circulatory system outside of the brain and heart). [...]

Inspectors wroteBased on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R34) whose care plan was reviewed.

Inspectors wroteBased on observation , interview and document review, the facility failed to provide assistance with oral care for 1 of 7 residents (R34) and nail care for 1 of 7 residents (R40) reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R21) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 4 residents (R27) with a current pressure ulcer and for 2 of 4 residents (R21, R47) at risk for development of pressure ulcers. Further, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 4 residents (R21) reviewed for pressure ulcers. Findings Include: R27 R27's quarterly Minimum Data Set (MDS) dated [DATE], identified R27 had mild cognitive impairment and had diagnoses which included: dementia, cancer, and chronic obstructive pulmonary disease. R27 was dependent on staff to turn left to right, transfer, dressing, and personal and hygiene. Indicated R27 was at risk for pressure ulcers and had no unhealed pressure ulcers. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 1 (R15) residents identified at risk for falls.

Inspectors wroteBased on interview and document review, the facility's consultant pharmacist failed to identify and report irregularities related to prophylactic antibiotic use for 1 of 6 residents (R34) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure reevaluation for necessity and duration of ongoing antibiotic use for 1 of 1 residents (R34) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 2 residents (R23) reviewed for call light accessibility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow manufacturer's guidelines for a full body mechanical lift by ensuring the loops were secured to the hook on the lift, prior to lifting the resident for transfer for 1 of 3 residents (R1) reviewed. This resulted in actual harm when the hook came off the lift and R1 fell to the floor sustaining a large hematoma to the side of his head, a skin tear to finger and required an emergency department (ED) visit.

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess and provide appropriate interventions to respect and promote resident rights and meet individual needs for 1 of 3 residents (R1) who had a Wander Guard placed on his wheelchair to restrict his access to the community despite his intact cognition, independent mobility with his electric wheelchair and the facility's failure to attempt least restrictive measures.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 5 of 5 residents (R21, R27, R33, R42, R48,) reviewed for dining services.

Inspectors wroteBased on observation, interview and document review, the facility failed to serve food in a safe and sanitary manner to prevent the spread of cross contamination on 1 of 4 hallways reviewed for dining services. This deficient practice had the potential to affect all 15 residents who resided on the blue horizon unit of the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered safely for 2 of 2 residents (R13, R21) who had medications left at the bedside and had been assessed as not safe to self administer those medications.

Inspectors wroteBased on interview and document review, the facility failed to complete a discharge summary with recapitulation of stay, a final summary of the resident's status, or medication reconciliation for 1 of 1 residents (R57) who required home health services after discharge.