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 was investigated. The complaint involved allegations of physical abuse by RN C towards a resident. The complaint was substantiated based on interviews, record reviews, and incident reports.

The facility failed to protect a resident from physical abuse when RN C slapped a resident's face in retaliation for the resident biting the RN's finger. The incident was investigated and RN C was suspended pending further action.

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 investigation was triggered by allegations that a CNA physically abused a resident. The facility failed to report the abuse immediately and did not conduct a thorough investigation. The abuse was substantiated as the CNA was found to have slammed the resident onto the bed causing injury. The facility's response and reporting were inadequate.

The facility failed to report allegations of abuse immediately and did not thoroughly investigate the abuse allegations. The CNA was reported to have physically abused a resident, and the facility did not take timely corrective actions or protect residents during the investigation.

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 facility failed to maintain the integrity of building construction fire ratings, ensure proper delayed-egress locking arrangements, maintain self-closing doors, and ensure proper maintenance of cooking facilities, smoking areas, dryers, and electrical equipment. These deficiencies had the potential to affect all residents, staff, and visitors.

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 facility failed to ensure an environment free of accident hazards as a Dietary Aide gave a non-prescribed controlled substance (THC gummies) to a resident. Multiple interviews and record reviews confirmed the administration of THC gummies without physician orders, violating medication administration policies.

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 failed to provide adequate processes and staffing to support resident self-determination in bathing and showering for five residents. Documentation of showers was incomplete or missing, and several residents reported not receiving showers as frequently as desired.

The complaint investigation substantiated that LPN A used inappropriate language and behavior toward a resident. The LPN was suspended pending investigation and received counseling. Multiple staff interviews confirmed that cursing at residents, even jokingly, was inappropriate and against facility policy.

The facility failed to ensure all staff treated residents with respect and dignity. A Licensed Practical Nurse (LPN A) spoke in a rude and harsh manner and used profane language when speaking to a resident, violating resident rights.

The facility was found deficient in multiple areas including resident rights and dignity, care plan timing and revision, cardiopulmonary resuscitation (CPR) procedures, free of accident hazards, infection control, food safety, and environmental conditions. Several residents' care plans were incomplete or not updated, and staff failed to provide proper catheter care and maintain dignity bags. Smoking policies and supervision were also deficient.

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 facility was found not to meet several provisions of the 2012 Life Safety Code, including issues with ceiling penetrations, cooking facilities, fire extinguishers, smoke barriers, fire drills, smoking regulations, and electrical receptacles. The facility had a capacity of 120 and a census of 79 at the time of the survey.

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.

The facility failed to meet several regulatory requirements including resident self-determination, Medicaid/Medicare coverage notices, quality of care related to wound treatment and infection control, and licensed nursing requirements. Deficiencies were documented with specific resident cases and policy reviews.

Complaint number M00146153 triggered the investigation. The complaint was substantiated based on findings related to infection control and catheter care.

The facility failed to follow infection control standards for Foley catheter insertion and care, including failure to use sterile technique, failure to measure urinary output as ordered, and allowing catheter bags to touch the floor, risking contamination and infection.

The complaint investigation was substantiated with findings of multiple deficiencies related to Medicaid/Medicare notices, resident transfers and discharges, assessments, care planning, infection control, and medication errors.

The facility was found noncompliant with multiple federal regulations including failure to provide proper Medicaid/Medicare notices, inadequate documentation of resident transfers and discharges, incomplete comprehensive assessments, deficient baseline care plans, infection control lapses, and medication administration errors. The facility census was 97 at the time of the survey.

The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations, improperly installed portable fire extinguishers placed too high, failure to conduct quarterly fire drills at unexpected times, and improper storage of oxygen cylinders. These deficiencies had the potential to affect all residents, staff, and visitors.