Inspection Reports for Glenwood Health Center by Harborview
4115 Glenwood Rd, Decatur, GA , United States, GA, 30032
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Inspection Report
Deficiencies: 0
Jul 1, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Glenwood Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 207
Deficiencies: 0
Jun 1, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in a prior Complaint Investigation survey concluded on May 15, 2025.
Findings
All deficiencies cited as a result of the Complaint Investigation survey were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a Complaint Investigation survey concluded on May 15, 2025. All cited deficiencies were corrected.
Report Facts
Facility census: 207
Inspection Report
Renewal
Deficiencies: 0
May 15, 2025
Visit Reason
The visit was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
No State Health deficiencies were cited during the survey conducted from May 13, 2025, through May 15, 2025.
Inspection Report
Complaint Investigation
Census: 209
Deficiencies: 1
May 15, 2025
Visit Reason
An Abbreviated Survey was conducted to investigate two complaint intake numbers, GA00253495 and GA00253009, at Glenwood Health Center by Harborview.
Findings
The investigation substantiated one complaint involving verbal abuse by staff towards residents, resulting in deficiencies cited. Two staff members were terminated due to verbal abuse incidents involving residents.
Complaint Details
Complaint Intake Number GA00253495 was unsubstantiated. Complaint Intake Number GA00253009 was substantiated with a deficiency cited. The substantiated incidents involved verbal abuse by a housekeeper (HK EE) and a Certified Nursing Assistant (CNA FF) towards residents R5 and R6, respectively. Both employees were terminated following investigations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure two out of three sampled residents were free from verbal abuse. | SS=E |
Report Facts
Residents present: 209
Complaint Intake Numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HK EE | Housekeeper | Named in verbal abuse finding and terminated after substantiated complaint |
| CNA FF | Certified Nursing Assistant | Named in verbal abuse finding and terminated after substantiated complaint |
Inspection Report
Abbreviated Survey
Census: 213
Deficiencies: 0
Feb 3, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00253682.
Findings
The complaint GA00253682 was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00253682 was investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Dec 18, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Glenwood Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 211
Deficiencies: 0
Dec 18, 2024
Visit Reason
A health revisit survey was conducted from December 16, 2024, through December 18, 2024, at Glenwood Health Center Harborview to verify correction of deficiencies cited in the prior Recertification and Complaint Investigation survey concluded on October 11, 2024.
Findings
All deficiencies cited as a result of the Recertification in conjunction with a Complaint Investigation survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2024
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 have been corrected.
Inspection Report
Routine
Census: 210
Deficiencies: 8
Oct 11, 2024
Visit Reason
The inspection was a licensure survey conducted from September 22, 2024 through October 11, 2024, to assess compliance with state regulations including resident rights, care and treatment, smoking policy enforcement, infection control, and environmental sanitation.
Findings
The facility was found noncompliant in multiple areas including failure to provide language assistance to residents with limited English proficiency, failure to maintain resident dignity, failure to enforce smoking policies resulting in an Immediate Jeopardy, inadequate infection prevention and control practices, failure to assess residents for safe self-administration of medications, and failure to develop comprehensive person-centered care plans for several residents. Environmental sanitation issues were also noted including dirty bathrooms, malfunctioning equipment, and unsafe laundry conditions.
Deficiencies (8)
| Description |
|---|
| Failure to provide language assistance services to a resident with limited English proficiency, resulting in communication barriers. |
| Failure to maintain resident dignity by displaying clinical information openly in a resident's room. |
| Failure to enforce smoking policy including allowing residents to smoke unsupervised, keep smoking materials, and failure to maintain accurate smoking assessments and care plans, resulting in Immediate Jeopardy. |
| Failure to maintain an effective infection prevention and control program including poor hand hygiene, improper cleaning of equipment, and inadequate storage of personal care items. |
| Failure to assess and determine if a resident was capable of safely self-administering medications prior to allowing self-administration. |
| Failure to develop and implement comprehensive person-centered care plans for multiple residents related to smoking and PTSD. |
| Failure to maintain a safe, clean, and comfortable environment including dirty bathrooms, broken equipment, rancid laundry room conditions, and unsafe laundry operations. |
| Failure to ensure a safe environment free from accident hazards including enforcement of smoking policy, hazardous materials in resident rooms, unsafe water temperatures, and unsecured oxygen cylinders. |
Report Facts
Residents present: 210
Residents reviewed for smoking: 44
Residents reviewed for care plans: 102
Residents assessed for smoking: 212
Residents identified as smokers: 61
Staff educated on smoking policy: 86
Smoking breaks per day: 12
Smoking breaks per day: 5
Staff in-serviced on smoking policy: 94
Residents with burn holes in clothing: 1
Residents with cognitive impairment: 6
Residents with unsafe smoking care plans revised: 8
Residents with smoking aprons required: 61
Laundry dryers not operational: 2
Laundry dryers total: 4
Laundry chute overflow: 1
Hand sanitizer dispensers not functioning: 4
Residents with medications at bedside without order: 1
Residents with burn holes in clothing: 1
Residents smoking unsupervised: 3
Residents with cognitive impairment: 3
Residents with no smoking care plan: 1
Residents with no smoking assessment: 1
Residents with PTSD without care plan: 1
Residents with unsafe smoking care plans: 6
Residents with hazardous materials in rooms: 3
Rooms with unsafe water temperature: 18
Rooms with environmental sanitation issues: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NN | Unit Manager | Named in communication barrier and language assistance deficiency |
| ZZ | Licensed Practical Nurse | Named in communication barrier and language assistance deficiency |
| UUU | Certified Nursing Assistant | Named in communication barrier and language assistance deficiency |
| RRR | Social Worker | Named in communication barrier and language assistance deficiency |
| AD | Admission Director | Named in communication barrier and language assistance deficiency |
| DON | Director of Nursing | Named in smoking policy enforcement and care plan deficiencies |
| RNC | Regional Nurse Consultant | Named in smoking policy enforcement and care plan deficiencies |
| VP of Quality | Vice President of Quality | Named in smoking policy enforcement and care plan deficiencies |
| LPN ZZ | Licensed Practical Nurse | Named in communication barrier and language assistance deficiency |
| LPN AA | Licensed Practical Nurse | Named in infection control deficiency |
| RT KK | Respiratory Therapist | Named in tracheostomy care infection control deficiency |
| RT JJ | Respiratory Therapist | Named in tracheostomy care infection control deficiency |
| MRC MM | Medical Records Clerk | Named in smoking policy enforcement deficiency |
| AA LL | Activity Assistant | Named in smoking policy enforcement deficiency |
| CNA MMMM | Certified Nursing Assistant | Named in smoking policy enforcement deficiency |
| LPN KKKK | Licensed Practical Nurse | Named in smoking policy enforcement deficiency |
| CNA NNNN | Certified Nursing Assistant | Named in smoking policy enforcement deficiency |
| LPN OOOO | Licensed Practical Nurse | Named in smoking policy enforcement deficiency |
| CNA II | Certified Nursing Assistant | Named in smoking policy enforcement deficiency |
| Housekeeping Aide AAA | Housekeeping Aide | Named in environmental sanitation deficiency |
| HD | Housekeeping Director | Named in environmental sanitation deficiency |
| MD | Maintenance Director | Named in environmental sanitation deficiency |
| RDO | Regional Director of Operations | Named in smoking policy enforcement and care plan deficiencies |
| MDS Nurse JJJJJ | Minimum Data Set Nurse | Named in smoking policy enforcement and care plan deficiencies |
Inspection Report
Abbreviated Survey
Census: 210
Deficiencies: 15
Oct 11, 2024
Visit Reason
A standard survey was conducted including complaint investigations, focusing on compliance with Medicare/Medicaid regulations and facility policies, including smoking practices and resident care.
Findings
The facility was found not in substantial compliance with regulations, with Immediate Jeopardy identified related to unsafe smoking practices, failure to maintain resident dignity, medication self-administration issues, bathing neglect, language assistance failures, environmental cleanliness issues, failure to report injuries timely, inaccurate MDS assessments, deficient care plans for smokers and PTSD, unsafe water temperatures, unsecured oxygen cylinders, unlocked medication carts, food safety violations, infection control breaches, and call light accessibility problems.
Severity Breakdown
J: 3
E: 5
D: 7
Deficiencies (15)
| Description | Severity |
|---|---|
| Immediate Jeopardy related to unsafe smoking practices including unsupervised smoking, inaccurate smoking assessments, and failure to enforce smoking policies. | J |
| Failure to maintain resident dignity by displaying clinical information openly in resident rooms. | D |
| Failure to assess and determine resident ability to safely self-administer medications prior to allowing self-administration. | D |
| Failure to offer scheduled baths to a resident, risking comfort and infection. | D |
| Failure to provide language assistance to a resident with limited English proficiency, causing communication barriers. | D |
| Facility environment deficiencies including dirty bathrooms, broken light switches, dirty air filters, leaking pipes, rancid laundry room odor, and broken laundry machines. | E |
| Failure to report injuries of unknown origin to the State Survey Agency within required timeframes. | D |
| Inaccurate MDS assessments related to resident smoking status. | D |
| Failure to develop and implement person-centered care plans for smokers and a resident with PTSD. | J |
| Failure to ensure sufficient and competent nursing staff; staff observed sleeping and watching videos during night shift. | D |
| Medication management deficiencies including narcotic count discrepancies, unlocked medication carts, and expired medications not discarded. | D |
| Failure to prepare food by methods that conserve nutritive value, flavor, and appearance; residents served burnt food. | E |
| Food safety violations including unlabeled, expired, and improperly stored food items; dirty ice machine and kitchen equipment. | E |
| Failure to maintain effective infection prevention and control program including poor hand hygiene during tracheostomy care and medication administration, improper handling of linens, and inadequate cleaning of equipment and resident bathrooms. | E |
| Failure to ensure resident call lights were within reach in multiple rooms on the memory care unit. | D |
Report Facts
Resident census: 210
Smoking residents assessed: 212
Residents who smoke: 61
Staff in-service completion: 86
Water temperature: 124
Water temperature: 130
Water temperature: 125
Water temperature: 120
Medication cart narcotic count discrepancy: 1
Expired food items: 3
Unlabeled food containers: 7
Ice machine dust: 1
Hand sanitizer dispensers not working: 3
Resident rooms with call light out of reach: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in medication administration and narcotic count discrepancy |
| RN BB | Registered Nurse | Named in medication cart unlocked and unattended |
| RT KK | Respiratory Therapist | Named in tracheostomy care with poor infection control practices |
| RT JJ | Respiratory Therapist | Named in tracheostomy care infection control interview |
| Cook EEE | Cook | Named in food preparation of burnt food |
| LDA DDD | Lead Dietary Aide | Named in food safety and labeling deficiencies |
| CNA GGGG | Certified Nursing Assistant | Named in smoking supervision and call light accessibility |
| LPN GGGG | Licensed Practical Nurse | Named in smoking policy in-service and supervision |
| LPN HHHH | Licensed Practical Nurse | Named in smoking policy in-service and supervision |
| CNA SSS | Certified Nursing Assistant | Named in hand hygiene and ice handling |
| LPN TTT | Licensed Practical Nurse | Named in infection control and shared equipment cleaning |
| Housekeeping Aide AAA | Housekeeping Aide | Named in improper handling of toilet brush |
| CNA II | Certified Nursing Assistant | Named in hand hygiene during ice handling and linen handling |
| DON | Director of Nursing | Named in multiple interviews regarding smoking policy, infection control, and staff supervision |
| RNC | Regional Nurse Consultant | Named in smoking policy oversight and infection control |
| RDO | Regional Director of Operations | Named in smoking policy oversight and staff education |
| VP of Quality | Vice President of Quality | Named in smoking policy education and QAPI meeting |
| Medical Director | Medical Director | Named in QAPI meeting and policy oversight |
| ADON | Assistant Director of Nursing | Named in smoking policy education and assessments |
| LPN UM IIII | Licensed Practical Nurse Unit Manager | Named in smoking assessments and staff education |
| CNA MMMM | Certified Nursing Assistant | Named in smoking policy education and supervision |
| Receptionist ZZZ | Receptionist | Named in smoking break announcements |
| Receptionist YYY | Receptionist | Named in smoking break announcements |
| RT JJ | Respiratory Therapist | Named in tracheostomy care infection control |
| RT KK | Respiratory Therapist | Named in tracheostomy care infection control |
| Housekeeping Director | Housekeeping Director | Named in toilet brush handling and infection control |
| LPN HHH | Licensed Practical Nurse | Named in medication administration and hand hygiene |
| CNA SSS | Certified Nursing Assistant | Named in hand hygiene and ice handling |
Inspection Report
Life Safety
Census: 225
Capacity: 211
Deficiencies: 15
Sep 23, 2024
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including aisle clearance, emergency lighting documentation, fire alarm system testing, sprinkler system maintenance, fire extinguisher accessibility, smoke compartment door functionality, smoke barrier construction and door maintenance, electrical safety, fire drill documentation, smoking regulations, soiled linen and trash container limits, door maintenance documentation, storage of gas-operated equipment, and gas cylinder storage safety.
Severity Breakdown
SS= D: 6
SS= E: 4
SS= F: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to keep the hall leading out of the kitchen clear and free of storage and debris. | SS= D |
| Failed to properly document Emergency Lighting Testing. | SS= F |
| Failed to have the Fire Alarm checked annually and the Smoke Detectors sensitivity checked. | SS= F |
| Failed to have the sprinkler system Green Tagged, 5-year internal completed, and Backflow Preventer annually tested. | SS= F |
| Fire extinguishers blocked in the kitchen office and maintenance room off the dining room. | SS= D |
| Patient room doors (Rooms 136, W144, W141) not properly closing. | SS= E |
| Failed to properly seal most smoke and fire walls; holes/penetrations in patient room doors D209, E101, E111, M107. | SS= F |
| Most smoke and fire doors not closing properly (rooms E113, G218, M107, West wing Soiled Linen room). | SS= F |
| Failed to keep electrical panels from being blocked in kitchen and West Wing Hall (corrected on site), open electrical circuits in Elevator Maintenance Room, and missing globes in patient rooms M108, M109. | SS= E |
| Failed to properly document monthly fire drills. | SS= F |
| Failed to have a metal container with a self-closing lid on site for smoking areas. | SS= D |
| Exceeded 64 gallons of soiled linen and trash receptacles in some areas. | SS= D |
| Failed to maintain and document door maintenance, inspection, and testing. | SS= F |
| Stored gas operated equipment in the Maintenance room of the dining room. | SS= D |
| Unsecured O2 tanks in West Wing on floor under crash cart (fixed on site) and in East Wing O2 Storage room on top shelf. | SS= E |
Report Facts
Census: 225
Total Capacity: 211
Smoke Compartments Affected: 7
Soiled linen and trash receptacles capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour |
Inspection Report
Follow-Up
Census: 210
Deficiencies: 0
Apr 26, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/11/2024 Complaint Only Survey.
Findings
All deficiencies cited as a result of the 3/11/2024 Complaint Only Survey were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint investigation on 3/11/2024; all cited deficiencies were corrected.
Report Facts
Census: 210
Inspection Report
Follow-Up
Census: 210
Deficiencies: 0
Apr 26, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in a prior complaint survey concluded on March 11, 2024.
Findings
All deficiencies cited in the previous complaint survey were found to be corrected during this revisit survey.
Complaint Details
This visit was a follow-up to a complaint survey concluded on March 11, 2024, verifying correction of cited deficiencies.
Inspection Report
Annual Inspection
Census: 209
Deficiencies: 1
Mar 11, 2024
Visit Reason
A State Licensure survey was conducted to assess compliance with state health regulations at Glenwood Health Center by Harborview.
Findings
The facility failed to ensure full visual privacy for residents on three of five halls due to missing, improperly sized, or non-functional privacy curtains in multiple resident rooms, potentially diminishing residents' quality of life.
Deficiencies (1)
| Description |
|---|
| Failure to ensure full visual privacy due to missing or inadequate privacy curtains in twenty-one resident rooms on Magnolia Hall, one room on Dogwood Hall, and one room on East Hall. |
Report Facts
Residents affected: 209
Rooms with privacy curtain issues: 23
Rooms with missing or inadequate curtains on Magnolia Hall: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RR | Assistant Director of Nursing | Interviewed regarding housekeeping awareness of privacy curtain problems |
| WW | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues | |
| A3 | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| AA | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| A16 | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| A17 | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| A18 | Certified Nurse Assistant | Observed providing incontinence care without full visual privacy due to curtain issues |
| Administrator | Interviewed regarding curtain removal and renovation status | |
| Director of Nursing | Interviewed regarding privacy provision and housekeeping responsibilities | |
| Housekeeping Supervisor | Participated in walk-through revealing curtain issues | |
| Maintenance Director | Participated in walk-through revealing curtain issues |
Inspection Report
Complaint Investigation
Census: 209
Deficiencies: 2
Mar 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Number GA00244436, which was substantiated with deficiencies cited.
Findings
The facility failed to protect residents from neglect by not ensuring timely provision of Activities of Daily Living care, including briefs and bed linen changes, for seven sampled residents. Additionally, the facility failed to ensure full visual privacy for residents due to missing, improperly sized, or non-functional privacy curtains in multiple rooms across three halls.
Complaint Details
Complaint Number GA00244436 was substantiated with deficiencies cited related to neglect and privacy issues.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide necessary Activities of Daily Living care such as briefs and bed linen changes for seven residents. | SS=E |
| Failure to ensure full visual privacy due to missing, too short, or non-functional privacy curtains in twenty-one rooms on Magnolia Hall, one room on Dogwood Hall, and one room on East Hall. | SS=F |
Report Facts
Residents sampled: 29
Residents with neglect issues: 7
Resident census: 209
Rooms with privacy curtain issues: 23
Staff signatures: 31
Staff signatures: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RR | Assistant Director of Nursing | Interviewed regarding in-service training and staff responsibilities for incontinence care and privacy curtain issues |
| DON | Director of Nursing | Interviewed regarding staff in-service training, monitoring of incontinence care, and privacy curtain monitoring |
| Administrator | Interviewed regarding facility renovations and housekeeping responsibilities for privacy curtains |
Inspection Report
Deficiencies: 0
Aug 24, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Glenwood Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 203
Deficiencies: 0
Aug 24, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2023-07-21.
Findings
All deficiencies cited as a result of the 7/21/2023 complaint survey were found to be corrected.
Complaint Details
This was a follow-up to a complaint survey conducted on 7/21/2023; all cited deficiencies were corrected.
Inspection Report
Annual Inspection
Census: 202
Capacity: 184
Deficiencies: 2
Jul 21, 2023
Visit Reason
A State Licensure survey was conducted at Glenwood Health Center by Harborview from July 20, 2023 through July 21, 2023 to assess compliance with state health regulations.
Findings
The facility failed to ensure opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry. Additionally, the kitchen environment was unsafe due to towels stored inside a non-working oven with active burners and unclean equipment surfaces.
Deficiencies (2)
| Description |
|---|
| Opened food items were not properly dated and labeled in the cooler, freezer, and dry food pantry. |
| Top of the oven and fryer were not clean, and towels were stored inside a non-working oven with functioning burners, creating an unsafe kitchen environment. |
Report Facts
Residents receiving oral diet: 184
Total residents in facility: 202
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed expired food and kitchen safety issues during tour on 7/18/2023 | |
| Corporate Administrator | Discussed discrepancies and discarded open container of pureed fruit on 7/18/2023 |
Inspection Report
Complaint Investigation
Census: 202
Deficiencies: 2
Jul 21, 2023
Visit Reason
A complaint survey was conducted from July 20, 2023 through July 21, 2023 to investigate multiple complaint intake numbers related to the facility.
Findings
The investigation found some complaints unsubstantiated, one substantiated without federal deficiency, and one substantiated with federal deficiencies cited. Deficiencies included failure to ensure food served was palatable for some residents and failure to properly date and label opened food items, as well as cleanliness and safety issues in the kitchen.
Complaint Details
Complaint Intake Numbers GA00234239, GA00234276, GA00235242, GA00235848, GA00236788, and GA00237185 were investigated. Complaints GA00234239, GA00235242, GA00237185, and GA00235848 were unsubstantiated. Complaint GA00236788 was substantiated without federal deficiency cited. Complaint GA00234276 was substantiated with federal deficiencies cited.
Severity Breakdown
D: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure food served was palatable for three of 14 sampled residents, potentially impeding recovery from illness or injury. | D |
| Facility failed to ensure opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry, and failed to maintain cleanliness and safety in the kitchen environment. | F |
Report Facts
Resident census: 202
Sampled residents: 14
Residents affected: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Glenwood Health Center by Harborview following a survey completed on 07/21/2023.
Findings
The document does not contain any detailed deficiencies or findings; it is a form prepared for reporting deficiencies and corrective actions but no specific deficiencies are listed.
Inspection Report
Re-Inspection
Census: 202
Deficiencies: 0
Jul 21, 2023
Visit Reason
A revisit survey was conducted from July 18 through July 21, 2023, to investigate multiple complaint intake numbers and verify correction of previous deficiencies.
Findings
All deficiencies cited in the April 13, 2023 Recertification and Complaint survey were found to be corrected. Four complaint investigations were unsubstantiated, one was substantiated without deficiency, and one was substantiated with deficiencies cited.
Complaint Details
Complaint Intake Numbers GA00234239, GA00235242, GA00237185, and GA00235848 were unsubstantiated. GA00236788 was substantiated without deficiency. GA00234340 was substantiated with deficiencies cited.
Report Facts
Complaint Intake Numbers investigated: 6
Inspection Report
Follow-Up
Deficiencies: 0
Jun 27, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies.
Findings
All tags were found in compliance during the follow-up survey.
Inspection Report
Routine
Census: 193
Deficiencies: 6
Apr 13, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including rehabilitation services, infection control, environmental safety, resident privacy, and water temperature safety.
Findings
The facility failed to re-evaluate a resident for rehabilitation services after a hospital stay, did not ensure proper infection control practices during tracheostomy care and linen handling, maintained an unsafe and unclean environment in some areas, failed to provide privacy curtains in one resident room, and did not maintain safe water temperatures below 110 degrees Fahrenheit in several rooms.
Deficiencies (6)
| Description |
|---|
| Failed to re-evaluate one of two residents reviewed for rehabilitation services after a seven-day hospital stay. |
| Failed to implement effective Infection Control Program by not ensuring staff perform hand hygiene and maintain appropriate precautions during tracheostomy care. |
| Failed to implement effective Infection Control Program by not ensuring proper storage, handling, transport, and processing of linens. |
| Failed to maintain a safe, clean, and comfortable home-like environment on one wing including dirty equipment, scuffed walls, broken furniture, dirty curtains, soiled mattress, dusty vents, slow draining sink, and holes in sheetrock. |
| Failed to ensure privacy for one resident room by not providing a privacy curtain for bed B. |
| Failed to maintain safe water temperatures below 110 degrees Fahrenheit in four resident rooms and one shower room. |
Report Facts
Facility census: 193
Water temperature: 116
Water temperature: 119
Water temperature: 120
Water temperature: 111.4
Water temperature: 111.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SS | Registered Nurse | Named in infection control deficiency related to tracheostomy care |
| NN | Licensed Practical Nurse | Confirmed absence of privacy curtain in resident room 127 |
| Director of Rehab | Director of Rehabilitation | Confirmed missed re-evaluation of resident after hospital stay |
| Vice President of Rehab | Vice President of Rehabilitation | Confirmed resident was not re-evaluated by therapy upon return from hospital |
| Administrator | Facility Administrator | Acknowledged multiple deficiencies including missed therapy re-evaluation, infection control, environment cleanliness, privacy curtain absence, and water temperature issues |
| DON | Director of Nursing | Stated expectations for nursing staff to follow infection control policies |
| Director of Plant Services | Director of Plant Services | Responsible for water temperature monitoring and maintenance |
| Regional Nurse Consultant | Regional Nurse Consultant | Verified no incidents of burns from hot water |
| Housekeeping Supervisor | Housekeeping Supervisor | Confirmed environmental cleanliness issues and responsibility |
Inspection Report
Routine
Census: 193
Deficiencies: 10
Apr 13, 2023
Visit Reason
A standard survey was conducted from 4/11/2023 through 4/13/2023, including investigation of multiple complaint intake numbers, with one complaint substantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to assess resident self-medication, environmental cleanliness issues, inaccurate MDS assessments, incomplete care plans, lack of physician orders for protective equipment, improper respiratory equipment care, unsecured medication carts, failure to re-evaluate therapy needs after hospital stay, infection control lapses during tracheostomy care, and failure to provide privacy curtains.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Complaint GA00229357 was substantiated with deficiency cited; all other complaints were unsubstantiated.
Severity Breakdown
D: 8
E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to assess one resident (R#76) for safe self-administration of medications. | D |
| Failure to maintain a safe, clean, and comfortable environment on one wing, including dirty equipment, scuffed walls, broken furniture, soiled mattress, and dusty vents. | E |
| Failure to ensure accurate MDS assessment for smoking status for one resident (R#172). | D |
| Failure to develop person-centered comprehensive care plans with measurable objectives for four residents (R#56, R#31, R#172, R#144). | D |
| Failure to obtain a physician order for use of a soft helmet for one resident (R#31) with seizure activity. | D |
| Failure to properly care for, clean, and store nebulizers and BiPAP equipment for three residents (R#144, R#121, R#127). | D |
| Failure to ensure medications were secure and locked on two treatment carts when not in use. | D |
| Failure to re-evaluate one resident (R#128) for rehabilitation services after a seven-day hospital stay. | D |
| Failure to implement effective infection control program including hand hygiene and proper linen handling and storage; lapses observed during tracheostomy care and in laundry area. | E |
| Failure to ensure privacy for one resident room (room 127) due to missing privacy curtain for bed B. | D |
Report Facts
Resident Census: 193
Number of residents sampled for self-medication assessment: 68
Number of residents reviewed for smoking: 41
Number of residents sampled for comprehensive care plans: 66
Number of residents reviewed for respiratory care: 8
Number of treatment carts observed unlocked: 2
Hospital stay duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in medication self-administration deficiency for resident R#76. |
| Director of Nursing | Director of Nursing | Confirmed no residents assessed for self-medication; confirmed care plan and order deficiencies. |
| RN CC | Registered Nurse | Confirmed resident R#31 wears soft helmet but no order or care plan present. |
| RN SS | Registered Nurse | Observed tracheostomy care with improper hand hygiene and glove use. |
| LPN YY | Licensed Practical Nurse | Observed unlocked treatment cart and confirmed leaving it unattended. |
| Administrator | Facility Administrator | Confirmed expectations for locked medication carts and privacy curtain responsibility. |
| Director of Reimbursement | Director of Reimbursement | Verified inaccurate MDS smoking assessment for resident R#172. |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided physician progress note regarding soft helmet use for resident R#31. |
| Vice President of Rehab | Vice President of Rehab | Confirmed resident R#128 was not re-evaluated for therapy after hospital stay. |
Inspection Report
Life Safety
Census: 194
Capacity: 225
Deficiencies: 1
Apr 12, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance at Glenwood Health Center.
Findings
The facility was found not in substantial compliance due to failure to maintain the sprinkler system during the annual inspection. The sprinkler system was yellow-tagged for violations as of 11/11/2022, which need to be repaired and green-tagged to ensure resident safety.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain the sprinkler system during the annual inspection; sprinkler system was yellow-tagged for violations. | SS=F |
Report Facts
Census: 194
Total Capacity: 225
Date of last sprinkler system violation tag: Nov 11, 2022
Inspection Report
Deficiencies: 0
Nov 30, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Glenwood Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 199
Deficiencies: 0
Nov 30, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/9/22 recertification survey.
Findings
All deficiencies cited as a result of the 10/9/22 recertification survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 29, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple previous survey citations.
Findings
The survey was initiated on 2022-09-27 and concluded on 2022-09-29 with no State Licensure deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Sep 29, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints, some substantiated with deficiencies, others unsubstantiated or substantiated without deficiencies.
Findings
The facility failed to report alleged violations involving abuse, neglect, and injuries of unknown origin within required timeframes for three residents. Investigations of alleged abuse were not thorough, lacking complete interviews and documentation. Resident-to-resident verbal altercations were not reported timely to the State Agency. The facility also failed to conduct a thorough investigation related to an injury of unknown origin for one resident.
Complaint Details
The investigation was complaint-driven, involving multiple complaints. Some complaints were substantiated with deficiencies (G00227345, G00224741, G00225257), some substantiated without deficiencies, and others unsubstantiated. Resident-to-resident verbal altercations and injuries of unknown origin were key complaint issues.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, and injuries of unknown origin within required timeframes for three residents. | SS= D |
| Failure to provide evidence that all alleged violations of abuse were thoroughly investigated for three residents. | SS= D |
Report Facts
Number of residents sampled for abuse and neglect review: 10
Dates of incidents: May 18, 2022
Dates of verbal altercations: Sep 22, 2022
Dates of verbal altercations: Sep 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Cared for resident R#8 on 5/18/22 and reported resident's pain but resident was non-verbal. |
| JJ | Office Staff | Witnessed verbal altercation between residents R#6 and R#15 on 9/22/22 but did not report it. |
| SSM | Social Services Manager | Filed grievance and reported verbal altercation between residents R#6 and R#15 to Administrator. |
| Administrator | Facility Administrator | Responsible for reporting incidents to State Agency and conducting investigations; admitted failure to report resident-to-resident altercation timely. |
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