Inspection Reports for
Glendale Gardens Nursing & Rehab

Complaint #2659996 regarding failure to notify physician and family after resident falls, failure to provide appropriate care and documentation related to falls and edema, and failure to update care plans and implement interventions.

The facility failed to notify physicians and families timely about resident falls, failed to update care plans and implement interventions after falls, and failed to properly document and monitor edema treatment including physician orders and daily weights. The facility also failed to analyze fall risks and update care plans accordingly for multiple residents.

The complaint involved an allegation of verbal abuse by a Certified Nursing Assistant (CNA C) toward Resident #1. The allegation was not reported to the Director of Nursing or State Survey Agency within the required two-hour timeframe. The investigation was incomplete and delayed, and the alleged abuser was not removed from the worksite pending investigation.

The facility failed to report an allegation of verbal abuse immediately to management and the State Survey Agency, and did not conduct a timely and thorough investigation including interviews and protective steps for residents. The alleged abuser was not removed from the worksite pending investigation.

Complaint MO00239672 regarding physical abuse by RN C who slapped Resident #1 after being bitten on the finger while attempting to remove an object from the resident's mouth. The complaint was substantiated with witness statements and interviews confirming the incident and inappropriate reaction.

The facility failed to protect the resident's right to be free from physical abuse when RN C slapped the resident's face. The incident was witnessed by nurse aides and investigated by the facility, resulting in RN C being suspended. The reaction by RN C was deemed inappropriate by the Director of Nursing and Administrator.

The complaint involved an allegation by Resident #1 that CNA B physically abused him/her by grabbing the resident's wrist and slamming him/her down onto the bed. The allegation was reported late to the State Survey Agency, five hours after the initial report to staff. The facility failed to suspend the accused CNA immediately, allowing the CNA to continue working with other residents during the investigation.

The facility failed to report allegations of abuse within the required two-hour timeframe and failed to protect all residents during the investigation, as the accused staff member continued to work independently with other residents. The resident had a small bruise and reported being slammed onto the bed by the staff member.

The visit was complaint-related due to failure in infection control practices during a COVID-19 case. The facility was found not to have conducted appropriate outbreak testing or contact tracing for all relevant exposures, and staff did not consistently wear masks as source control. The complaint was substantiated with findings of minimal harm.

The facility failed to implement source control when one resident tested positive for COVID-19, did not display proper signage for droplet precautions on the resident's room or at the facility entrance, and did not initiate contact tracing or facility-wide testing during outbreak status. Staff did not wear masks as source control outside the resident's room, and outbreak testing was not conducted despite CDC guidance.

The facility was found deficient in multiple areas including failure to honor resident self-determination regarding room door closure, failure to obtain physician orders and care plan for BiPAP use, inadequate documentation and consent for bed rail use, failure to provide routine dental care, improper food storage and sanitation practices, and inadequate infection control measures during a COVID-19 case and outbreak.

The complaint investigation substantiated that Dietary Aide A gave Resident #1 two THC gummies on 3/07/2023 without a physician's order or documentation. The resident admitted to consuming the gummies. Staff interviews confirmed the violation and the potential risk to resident health.

The facility failed to ensure an environment free of hazards by allowing a dietary aide to give THC gummies to a resident without a physician's order or medication administration record entry. Multiple staff interviews confirmed that only licensed nurses or medication technicians are authorized to administer medications, and giving non-prescribed substances like THC is against protocol and puts residents at risk.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, failure to invite residents or families to care plan meetings, inconsistent documentation of residents' code status, inadequate smoking safety assessments and supervision, improper catheter care, inadequate cleaning and maintenance of CPAP equipment, food safety violations including wet stacked dishes and dented cans, and facility safety issues such as missing backflow preventers on hoses and damaged bathroom doors.

The complaint investigation was triggered by allegations that the facility failed to provide showers/baths according to residents' preferences and care plans, failed to provide required Medicare notices, failed to provide appropriate wound care, and failed to follow infection control procedures.

The facility failed to provide showers/baths as per residents' preferences and care plans for two residents, failed to provide Skilled Nursing Facility Advance Beneficiary Notices for two residents, failed to provide wound care as ordered and per standards for multiple residents, and failed to follow infection control procedures during and after incontinent care for one resident.