Inspection Reports for Glenwood Health and Rehabilitation Center
4115 GLENWOOD RD, DECATUR, GA, 30032
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 12, 2021, found no deficiencies and confirmed compliance with infection control regulations related to COVID-19. Earlier inspections showed a mixed pattern, with some substantiated complaints that did not result in regulatory violations and prior deficiencies mainly related to physical restraint use, infection control, medication administration, and fire safety issues. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in 2021 that did not lead to citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies over time, with recent surveys indicating compliance and correction of earlier issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
188 residents
Based on a April 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 188
Deficiencies: 0
Date: Apr 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaints #GA00211424, #GA00211540, and #GA00211681.
Complaint Details
Complaint #GA00211540 was substantiated with no regulatory violations cited. Complaints #GA00211681 and #GA00211424 were unsubstantiated with no regulatory violations.
Findings
Complaint #GA00211540 was substantiated with no regulatory violations cited. Complaints #GA00211681 and #GA00211424 were unsubstantiated with no regulatory violations. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Complaint numbers investigated: 3
Inspection Report
Abbreviated Survey
Census: 181
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints received between July and December 2020.
Complaint Details
Complaints #GA00207733, #GA00206889, and #GA00206598 were substantiated with no regulatory violations. Complaints #GA00209846, #GA00209866, #GA00206886, #GA00206526, and #GA00206233 were unsubstantiated with no regulatory violations.
Findings
Several complaints were investigated; some were substantiated with no regulatory violations, while others were unsubstantiated with no regulatory violations found.
Report Facts
Complaints investigated: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
A desk review was conducted on documentation supporting completion of the approved Plan of Correction (POC).
Findings
The Fire Safety Supervisor conducted the review on 09/03/2020 and confirmed that the approved POC has been followed and all citations corrected.
Inspection Report
Routine
Census: 174
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with relevant federal regulations and recommended practices for COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Re-Inspection
Census: 175
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A revisit survey was conducted at Glenwood Health & Rehabilitation Center beginning on 7/27/2020 and ending on 7/29/2020 to verify correction of deficiencies cited in the 3/12/2020 Standard Survey.
Findings
All deficiencies cited as a result of the 3/12/2020 Standard Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 170
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at Glenwood Health & Rehabilitation Center to assess compliance with emergency preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 194
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and 42 CFR 483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 204
Deficiencies: 7
Date: Mar 12, 2020
Visit Reason
A Recertification with complaints and Facility Reported Incidents (FRIs) survey was conducted to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to failure to properly assess and evaluate use of physical restraints, inaccurate Minimum Data Set (MDS) assessments, failure to develop and implement comprehensive care plans including nutritional care, failure to timely complete Registered Dietician (RD) assessments, failure to administer insulin per physician orders and facility policy, and failure to implement effective infection prevention and control measures.
Deficiencies (7)
Failure to properly assess and evaluate use of physical restraint (lap belt) for one resident (R153).
Failure to ensure accuracy of MDS assessments for two residents (R198 and R153) regarding use of mechanical ventilator, splints, and lap belt.
Failure to develop and implement a comprehensive person-centered care plan for one resident (R153) related to use of splints and lap belt.
Failure to revise and update comprehensive care plans to include nutritional care and risk changes for seven residents (R1, R25, R42, R87, R143, R153, R183).
Failure to administer insulin within prescribed timeframes and document administration timely for five residents (R34, R77, R99, R157, R198), risking hypo/hyperglycemia.
Failure to complete timely and consistent Registered Dietician nutritional assessments for eight residents (R1, R25, R42, R51, R87, R143, R153, R183) per facility policy and MDS schedule.
Failure to implement effective infection prevention and control program including proper use of personal protective equipment and handling of meal equipment for one resident (R462) on contact isolation precautions.
Report Facts
Survey Census: 204
Sample Size: 41
Resident Weight Loss: 6
Meals Logged: 68
Meals Consumed >=75%: 47
Meals Consumed 50-75%: 13
Meals Consumed <50%: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RCS2 | Resident Care Specialist | Observed providing care to resident R462 without wearing required gown under contact isolation precautions |
| RCS3 | Resident Care Specialist | Observed handling resident R462's meal tray without covering or bagging tray to prevent cross contamination |
| LPN2 | Licensed Practical Nurse | Interviewed about insulin documentation practices |
| RN1 | Registered Nurse | Interviewed about insulin documentation practices |
| PA1 | Physician Assistant | Interviewed about expectations for insulin administration and documentation |
| IPADON1 | Infection Prevention Assistant Director of Nursing | Interviewed about infection control expectations and practices |
| DON | Director of Nursing | Interviewed about expectations for insulin administration and infection control |
| Administrator | Facility Administrator | Interviewed about RD services and infection control expectations |
| Medical Director | Medical Director | Interviewed about insulin administration and infection control expectations |
| RD | Registered Dietician | Interviewed about nutritional assessments and care plan updates |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 12, 2020
Visit Reason
Routine inspection of Glenwood Health and Rehabilitation Center to assess compliance with healthcare regulations including use of restraints, dietary services, infection control, and medication administration.
Findings
The facility failed to properly assess and document the use of physical restraints for one resident, failed to consistently complete medical nutrition therapy assessments for eight residents, failed to implement effective infection prevention and control for one resident under contact isolation, and failed to administer insulin medications timely and document administration properly for five residents with diabetes.
Deficiencies (4)
Failure to ensure one resident was properly assessed and evaluated for the use of a physical restraint (lap belt on wheelchair).
Failure to ensure medical nutrition therapy assessments were consistently completed for eight residents.
Failure to implement effective infection prevention and control for one resident on contact isolation precautions, including failure to wear gown and improper handling of meal equipment.
Failure to administer insulin within 60 minutes of prescribed time and/or following blood glucose readings for five diabetic residents, risking hypo- or hyperglycemia.
Report Facts
Sampled residents for restraint assessment: 41
Sampled residents for nutritional assessment: 35
Residents with incomplete nutritional assessments: 8
Residents with insulin administration issues: 5
Insulin administration time deviations: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RCS2 | Resident Care Specialist | Observed providing care to resident under contact isolation without wearing required gown |
| RCS3 | Resident Care Specialist | Observed handling resident's meal tray without covering or bagging it as required for isolation precautions |
| IPSDC | Infection Prevention Staff Development Coordinator | Provided information on infection control policy and confirmed PPE and meal tray handling deficiencies |
| IPADON 1 | Infection Prevention Assistant Director of Nursing | Primary Infection Preventionist who confirmed expectations for PPE use and meal tray handling |
| DON | Director of Nursing | Provided expectations for infection control and insulin administration compliance |
| Administrator | Provided expectations for infection control and insulin administration compliance | |
| Medical Director | Provided expectations for infection control and insulin administration compliance | |
| PA 1 | Medical Director's Physician Assistant | Provided expectations for insulin administration and documentation |
| RN1 | Registered Nurse | Described documentation practices for insulin administration |
| LPN 2 | Licensed Practical Nurse | Described documentation practices for insulin administration |
| NP 1 | Nurse Practitioner | Expressed concern about insulin administration inconsistencies and impact on resident care |
| Consultant Pharmacist | Provided professional opinion on importance of consistent insulin administration timing |
Inspection Report
Life Safety
Census: 204
Capacity: 225
Deficiencies: 3
Date: Mar 11, 2020
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to deficiencies including a damaged sprinkler system riser water flow switch with inadequate enclosure, a smoke barrier door at the West Wing that failed to close properly, and the use of an extension cord for permanent wiring creating a fire hazard.
Deficiencies (3)
Failed to maintain the sprinkler system riser water flow switch; it was damaged and the enclosure was old and decaying, risking failure to activate fire alarm.
Failed to maintain closure of the smoke door at the West Wing, leaving a gap for smoke migration.
Used an extension cord for permanent wiring through drywall to supply a refrigerator, creating a smoke hole and electrical fire risk.
Report Facts
Census: 204
Total Capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 11, 2020
Visit Reason
A complaint survey was conducted from 2020-01-07 to 2020-01-08 and continued until 2020-02-11 to investigate complaints #GA00197962 and GA00199734.
Complaint Details
Complaints #GA00197962 and GA00199734 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The investigation determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 4, 2019
Visit Reason
A complaint survey was conducted on 2/4/19 to investigate complaint #GA00193884 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00193884 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA 00193204 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA 00193204 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 205
Deficiencies: 0
Date: Dec 17, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 11/1/18 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 17, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Routine
Census: 212
Deficiencies: 2
Date: Nov 1, 2018
Visit Reason
A standard survey was conducted at Glenwood Health and Rehabilitation Center from October 29, 2018 through November 1, 2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including improper use of physical restraints on one resident and failure to follow proper hand hygiene during wound care on another resident.
Deficiencies (2)
One resident (R#44) was physically restrained with a strap around her legs for approximately three hours without a physician's order or care plan reference, restricting her movement.
Licensed Practical Nurse (LPN) AA failed to perform proper hand hygiene prior to wound care on Resident #15, and was observed wearing artificial nails contrary to facility policy.
Report Facts
Resident census: 212
Wound measurements: 5.5
Wound measurements: 7.5
Wound measurements: 0.5
Wound measurements: 1.8
Wound measurements: 3.5
Wound measurements: 1
Wound measurements: 3
Wound measurements: 4.5
Wound measurements: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Unit Manager | Confirmed restraint strap was restricting resident's movement and discussed staff assignments related to restraint use |
| DD | Certified Occupational Therapist Assistant | Confirmed strap should not have been buckled around resident's legs and explained proper cushion placement |
| FF | Certified Nursing Assistant | Assigned to resident on morning of 10/31/18; unaware of restraint use; left early due to illness |
| AA | Licensed Practical Nurse | Observed performing wound care with improper hand hygiene and wearing artificial nails |
| BB | Registered Nurse, Wound Care Coordinator | Unaware of facility policy prohibiting artificial nails for direct patient care staff |
| ADON | Assistant Director of Nursing, Infection Control Nurse | Confirmed facility policy prohibits artificial nails and improper hand hygiene during wound care |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 1, 2018
Visit Reason
The inspection was conducted to assess compliance with state regulations regarding infection control practices and the appropriate use of restraints in the facility.
Findings
The facility was found deficient in infection control practices, specifically related to a licensed practical nurse wearing artificial nails during wound care and failing to properly sanitize hands, leading to contamination. Additionally, a resident was found to be improperly restrained with a wheelchair cushion strap without a physician's order, and staff were unaware of responsibility for the resident's care that morning.
Deficiencies (2)
Licensed Practical Nurse wore artificial nails and failed to sanitize hands properly during wound care, contaminating the wound care process.
Resident was improperly restrained with a wheelchair cushion strap without a physician's order or documented care plan.
Report Facts
Wounds measured: 3
Wound measurements: 5.5
Wound measurements: 7.5
Wound measurements: 0.5
Wound measurements: 1.8
Wound measurements: 3.5
Wound measurements: 1
Wound measurements: 3
Wound measurements: 4.5
Wound measurements: 2.5
Staff assigned: 1
Shift hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed wearing artificial nails and contaminating wound care |
| RN BB | Registered Nurse, Wound Care Coordinator | Unaware of facility policy prohibiting artificial nails for direct care staff |
| UM CC | Unit Manager | Confirmed improper restraint use on resident #44 and staff shift details |
| COTA DD | Certified Occupational Therapist Assistant | Confirmed improper use of wheelchair cushion strap as restraint |
| LPN EE | Licensed Practical Nurse | Unaware of staff responsible for getting resident #44 up on 10/31/18 |
| CNA FF | Certified Nursing Assistant | Assigned to resident #44 on 10/31/18 morning shift; left early due to illness |
| DON | Director of Nursing | Informed about improper restraint use on resident #44 |
Inspection Report
Life Safety
Census: 212
Capacity: 225
Deficiencies: 3
Date: Oct 29, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain documentation of the 5-year internal sprinkler system inspection, failure to maintain two exit doors that would not close and latch properly, and failure to maintain documentation of monthly load testing of the emergency generator.
Deficiencies (3)
Failed to maintain documentation on the 5 year internal inspection report on the sprinkler system.
Failed to maintain 2 exit doors at the Georgia Hall and Magnolia Hall stairwells that would not close and latch properly.
Failed to maintain documentation of the monthly load testing of the emergency generator.
Report Facts
Census: 212
Total Capacity: 225
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Census: 216
Deficiencies: 0
Date: May 23, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00187865 at Glenwood Health and Rehabilitation Center.
Complaint Details
Complaint GA00187865 was investigated during the abbreviated survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Facility census: 216
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 11, 2018
Visit Reason
A revisit survey was conducted on 1/10/18-1/11/18 to verify correction of deficiencies from the 11/8/17 recertification survey and to investigate Complaint Intake Number GA00182436.
Complaint Details
Complaint Intake Number GA00182436 was investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies identified.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 11, 2018
Visit Reason
A revisit survey was conducted on 1/10/18 - 1/11/18 in conjunction with the investigation of Complaint Intake Number GA00182436.
Complaint Details
Complaint Intake Number GA00182436 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 11/8/17 recertification survey were found to be corrected. The complaint investigation was unsubstantiated.
Inspection Report
Life Safety
Census: 204
Capacity: 225
Deficiencies: 0
Date: Nov 2, 2017
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
Glenwood Health and Rehabilitation Center was found in substantial compliance with the Life Safety Code requirements during the survey.
Inspection Report
Abbreviated Survey
Census: 205
Deficiencies: 0
Date: Oct 19, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00180891 from October 17 through October 19, 2017, and was continued in conjunction with the Recertification survey from October 30 through November 8, 2017.
Complaint Details
Complaint #GA00180891 was substantiated with deficiencies.
Findings
The complaint was substantiated with deficiencies, and the Recertification survey revealed the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Report Facts
Resident Census: 205
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 28, 2017
Visit Reason
A follow up survey was conducted to verify correction of a previously identified deficiency.
Findings
The deficiency identified in the prior inspection was corrected as of the follow up survey date.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 12, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00177028 at Glenwood Health and Rehabilitation Center.
Complaint Details
Complaint GA00177028 was investigated and found to be not substantiated.
Findings
The complaints were not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 8, 2017
Visit Reason
An abbreviated complaint survey was conducted from June 7, 2017 through June 8, 2017 to investigate concerns related to employee health screening compliance.
Complaint Details
The visit was complaint-related, triggered by complaint GA00175887. The complaint investigation found deficiencies in employee health screening documentation and compliance.
Findings
The facility failed to ensure that annual Purified Protein Derivative (PPD) tuberculosis skin tests were performed for three employees and documentation was missing for one employee. The Nursing Home Administrator confirmed the requirement for annual PPD testing and noted missing employee records due to recent staff resignation.
Deficiencies (2)
Failure to ensure annual PPD tuberculosis skin tests were done for three employees ('AA', 'BB', and 'JJ').
Missing employee file and no evidence of PPD testing for employee 'PP'.
Report Facts
Employees reviewed: 11
Employees missing annual PPD: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2017
Visit Reason
A complaint survey was conducted to investigate multiple complaints identified by codes GA00172485, GA00172374, GA00170116, GA00168647, GA00167614, and GA00167363.
Complaint Details
The complaint survey investigated six complaint codes and concluded that all complaints were unsubstantiated with no deficiencies cited.
Findings
All complaints investigated during the survey were found to be unsubstantiated, and no deficiencies were cited.
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