Inspection Report Summary
The most recent inspection on January 3, 2025, found the complaint GA00253135 substantiated but cited no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to dietary service and food safety, medication storage security, and physical plant maintenance including cleanliness issues in resident areas and shower rooms. Prior complaint investigations were mostly unsubstantiated, with one substantiated complaint in late 2024 that resulted in cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated correction of previously cited deficiencies in follow-up surveys, indicating some improvement over time despite recurring issues.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
42 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints intake GA00253135 in conjunction with a revisit survey for the same complaint.
Complaint Details
Complaint GA00253135 was substantiated with no deficiencies cited.
Findings
The complaint GA00253135 was substantiated with no deficiencies cited during the investigation.
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints intake GA00253135 in conjunction with a revisit survey.
Complaint Details
Complaint GA00253135 was substantiated with no deficiencies cited.
Findings
Complaint GA00253135 was substantiated with no deficiencies cited.
Report Facts
Facility census: 42
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints intake GA00253135 in conjunction with a revisit survey.
Complaint Details
Complaint GA00253135 was substantiated with no deficiencies cited.
Findings
Complaint GA00253135 was substantiated with no deficiencies cited.
Report Facts
Facility census: 42
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints intake GA00253135 in conjunction with a revisit survey.
Complaint Details
Complaint GA00253135 was substantiated with no deficiencies cited.
Findings
Complaint GA00253135 was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 42
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints intake GA00253135 in conjunction with a revisit survey.
Complaint Details
Complaint GA00253135 was substantiated with no deficiencies cited.
Findings
The complaint GA00253135 was substantiated with no deficiencies cited during the survey.
Report Facts
Facility census: 42
Inspection Report
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Glenwood Healthcare, 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
Follow-Up
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the November 10, 2024 recertification survey.
Findings
All deficiencies cited in the November 10, 2024 recertification survey were found to be corrected during the revisit survey.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 4
Date: Nov 10, 2024
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with State Long Term Care Requirements at Glenwood Healthcare Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including dietary service preparation, medication storage security and expired medications, physical plant maintenance with plumbing and cleanliness issues, improper food storage and temperature control, and cluttered shower rooms.
Deficiencies (4)
Dietary staff failed to follow recipes and measure ingredients when preparing puree food, compromising nutritive value and flavor for one resident.
Medication storage room was not secure and contained expired medications.
Resident living areas and shower rooms were not clean or in good repair, including brown rust-colored water from faucets and cluttered shower rooms.
Food items were not removed by discard date, not labeled or dated for storage, dented cans were not removed, food stored on the floor, and steam table food temperatures were below required levels.
Report Facts
Residents on puree consistency diet: 1
Residents receiving oral diet: 42
Rooms with living area deficiencies: 7
Shower rooms with deficiencies: 2
Expired medication items: 10
Steam table food temperatures: 121
Steam table food temperatures: 116
Steam table food temperatures: 94
Steam table food temperatures: 103
Cases of bottled water stored on floor: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Dietary Cook | Named in findings related to improper puree food preparation and food storage practices |
| AA | Registered Nurse | Confirmed observations of expired medications in medication storage room |
| DM | Dietary Manager | Provided multiple confirmations and interviews regarding dietary deficiencies and food storage |
| DON | Director of Nursing | Confirmed medication storage room door was not locked during observation |
| Maintenance Director | Interviewed regarding physical plant deficiencies and water issues | |
| Corporate Maintenance Director | Interviewed regarding facility maintenance and water system management | |
| VP | Vice President of Environmental Services | Interviewed regarding water system management and environmental concerns |
| Administrator | Interviewed regarding expectations for facility cleanliness and repair |
Inspection Report
Routine
Census: 42
Deficiencies: 6
Date: Nov 10, 2024
Visit Reason
A standard survey was conducted from November 8 through November 10, 2024, including investigation of two complaints (GA00252246 unsubstantiated, GA00243278 substantiated). The survey assessed compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Two complaints were investigated: GA00252246 was unsubstantiated; GA00243278 was substantiated with deficiency cited.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including poor maintenance and cleanliness of resident rooms and shower areas, failure to submit required PASRR Level II for a resident with new mental health diagnosis, improper cleaning and storage of nebulizer equipment, unsecured medication storage with expired medications, improper preparation of pureed foods, and multiple food safety violations including unlabeled and expired food items, dented cans, food stored on the floor, and inadequate hot food temperatures.
Deficiencies (6)
Resident living areas and shower rooms were not clean or in good repair, including missing floor tiles, missing baseboards, brown rust colored water from faucets, and cluttered shower rooms.
Failure to submit PASRR Level II after new mental health diagnosis and behavioral changes for one resident.
Nebulizer mask for one resident was not cleaned, bagged, or labeled properly, risking infection spread.
Medication storage room was not secure and contained expired medications.
Dietary staff failed to measure ingredients and follow recipes when preparing pureed foods, compromising nutritive value and consistency.
Food safety violations including failure to remove expired food, unlabeled and undated food items, dented cans not removed, food stored on the floor, and hot foods held below required temperatures.
Report Facts
Census: 42
Expired medications: 10
Food temperatures: 121
Food temperatures: 116
Food temperatures: 94
Food temperatures: 103
Residents reviewed: 19
Residents affected: 1
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director | Responsible for PASRR process; admitted PASRR Level II was not submitted for resident R37 |
| Director of Nursing | Director of Nursing | Confirmed PASRR responsibility and deficiencies; confirmed nebulizer mask storage issues |
| Maintenance Director | Maintenance Director | Unaware of water issues and repairs initially; confirmed brown water and needed repairs during interviews |
| Vice President of Environmental Services | Vice President of Environmental Services | Verified city manages water system and facility completes annual Legionella testing |
| Registered Nurse AA | Registered Nurse | Assigned nurse for resident R43; confirmed responsibility for cleaning and bagging nebulizer masks; confirmed expired medications |
| Dietary Cook BB | Dietary Cook | Observed preparing pureed foods improperly; confirmed not measuring ingredients; confirmed food storage violations |
| Dietary Manager | Dietary Manager | Confirmed expectations for measuring ingredients and food safety; confirmed food storage and temperature violations |
Inspection Report
Life Safety
Census: 43
Capacity: 62
Deficiencies: 3
Date: Nov 9, 2024
Visit Reason
The 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 with fire safety requirements, including improperly installed sprinkler heads, unsealed penetration fire walls, and unauthorized use of extension cords as permanent fixtures.
Deficiencies (3)
Sprinkler head in room 203 was not properly installed.
Firewalls were not properly sealed on Hallway 200.
Unauthorized extension cord used as a permanent fixture.
Report Facts
Census: 43
Total Capacity: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Follow-Up Survey.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous 7/23/23 survey.
Findings
All deficiencies cited in the 7/23/23 survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous survey dated 7/23/23.
Findings
All deficiencies cited as a result of the 7/23/23 survey were found to be corrected during the revisit survey conducted on 9/11/23 and concluded on 9/12/23.
Inspection Report
Life Safety
Census: 37
Capacity: 62
Deficiencies: 5
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to review Glenwood Healthcare's Emergency Preparedness Program and compliance with life safety code requirements, including fire safety and emergency plan testing.
Findings
The facility was found not in substantial compliance with 42 CFR § 483.73 and NFPA 101 Life Safety Code 2012 edition. Deficiencies included lack of documentation for a full-scale community-based emergency exercise, patient room door malfunction, excessive grease buildup in kitchen hood ventilation, missing fire alarm inspection and repair documentation, and severely oxidized sprinkler system components in the kitchen.
Deficiencies (5)
No documentation available for a full-scale community-based emergency preparedness exercise.
Patient room 206 door was difficult to open and close, failing to ensure free egress.
Excessive grease buildup on kitchen hood nozzles and ventilation compartment.
Missing fire alarm testing and inspection reports for 2021 and 2022; no documentation of repairs performed.
Severe oxidation and rust on every sprinkler and escutcheon in the kitchen area.
Report Facts
Certified beds: 62
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness, door obstruction, kitchen hood grease buildup, fire alarm documentation, and sprinkler system condition. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Jul 23, 2023
Visit Reason
A State Licensure survey was conducted from 7/21/2023 through 7/23/2023, including investigation of Complaint Intake Number GA00225231, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00225231 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with deficiencies including failure to follow up on Registered Dietician recommendations for nutritional assessments for one resident, failure to address a resident's pain during wound treatment resulting in harm, and failure to implement a care plan related to oxygen tubing storage for another resident.
Deficiencies (3)
Failed to follow-up on Registered Dietician recommendations related to nutritional assessments for resident #28.
Failed to stop and address resident #39's expression of pain during wound treatment, resulting in severe pain and harm.
Failed to implement care plan for resident #7 regarding proper storage of oxygen tubing, which was found touching the ground and wrapped around bed rails.
Report Facts
Resident census: 40
Weight measurements: 166
Weight measurements: 143
Weight measurements: 147.2
Weight measurements: 146
BIMS score: 13
BIMS score: 12
BIMS score: 15
Pain medication dosage: 50
Pain medication dosage: 500
Pain medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Failed to administer pain medication prior to wound care for resident #39 and continued treatment despite resident's pain expressions |
| LPN BB | Licensed Practical Nurse | Administered pain medication to resident #39 after wound care started and stated she ensures pain medication is given before wound care |
| GG | Licensed Practical Nurse | Interviewed regarding resident #28's supplement intake and care |
| FF | Certified Dietary Manager | Acting CDM who received RD recommendations and forwarded them but did not receive approved orders |
| EE | Certified Dietary Manager | Being trained as CDM and confirmed no approved orders received for RD recommendations |
| DON | Director of Nursing | Interviewed about follow-up on RD recommendations and expectations for pain management and care plan adherence |
| UM | Unit Manager | Interviewed about RD recommendations process and lack of received recommendations for resident #28 |
| CC | Certified Nursing Assistant | Provided information about resident #39's pain behaviors and communication |
| MDS Coordinator | Reported on oxygen use coding and care plan adherence for resident #7 | |
| RD | Registered Dietician | Made recommendations for resident #28's nutritional supplements in May and July 2023 |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Date: Jul 23, 2023
Visit Reason
A standard survey was conducted from 7/21/2023 through 7/23/2023, including investigation of Complaint Intake Number GA00225231. The complaint investigation was conducted in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00225231 was investigated and found not substantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Complaint GA00225231 was not substantiated. Deficiencies included failure to implement care plans, failure to follow up on dietitian recommendations, improper oxygen equipment cleaning and storage, failure to address resident pain during wound care resulting in actual harm, and lack of evidence of RN coverage for certain days.
Deficiencies (5)
Failed to implement the care plan for resident R#7 related to oxygen tubing storage and care.
Failed to follow-up on Registered Dietician recommendations for resident R#28 related to nutritional assessments and supplements.
Failed to ensure oxygen machine was clean and oxygen tubing stored properly to prevent cross contamination for resident R#7.
Failed to stop and address resident R#39's expression of pain during wound treatment, resulting in severe pain and actual harm.
Failed to provide evidence of Registered Nurse coverage for eight consecutive hours on multiple days in the last quarter.
Report Facts
Resident census: 40
Weight measurements: 146
Weight measurements: 147.2
Weight measurements: 143
Weight measurements: 144
Weight measurements: 166
Weight measurements: 166
Dates lacking RN coverage: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Failed to administer pain medication prior to wound care for resident R#39, causing severe pain. |
| LPN BB | Licensed Practical Nurse | Administered pain medication to resident R#39 after wound care was started without pain control. |
| Director of Nursing | Interviewed regarding oxygen tubing storage and pain management expectations. | |
| Regional Nurse Consultant | Acting Director of Nursing | Reported oxygen machine cleanliness and tubing storage issues. |
| Unit Manager | Interviewed about Registered Dietician recommendations and staffing. | |
| Certified Dietary Manager FF | Certified Dietary Manager | Confirmed receipt of Registered Dietician recommendations for resident R#28. |
| Certified Dietary Manager EE | Certified Dietary Manager | Confirmed not receiving approved orders for dietitian recommendations. |
| Registered Dietician | Made nutritional recommendations for resident R#28. | |
| HR Director | Confirmed not responsible for PBJ data reporting. | |
| Administrator | Confirmed not responsible for PBJ data reporting and lack of knowledge on reporting system. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00226952, #GA00225683, #GA00224431, and #GA00224186.
Complaint Details
Complaints #GA00226952, #GA00225683, #GA00224431, and #GA00224186 were unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a required seven-day reporting period from 07/25/2022 to 07/31/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day reporting period from 07/18/2022 to 07/24/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day reporting period from 07/11/2022 to 07/17/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00221551 from March 7, 2022 to March 9, 2022.
Complaint Details
Complaint #GA00221551 was substantiated with no regulatory violations cited.
Findings
The complaint #GA00221551 was substantiated but no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
A revisit survey was conducted on 2/23/2022 through 2/24/2022 to verify correction of deficiencies cited during the 12/2/2021 Recertification Survey.
Findings
All deficiencies cited in the prior 12/2/2021 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Glenwood Healthcare, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Dec 2, 2021
Visit Reason
A State Licensure survey was conducted at Glenwood Healthcare from 11/30/2021 through 12/2/2021, including investigation of Complaint Intake Number GA00218093, which was substantiated with a deficiency cited.
Complaint Details
Complaint Intake Number GA00218093 was investigated in conjunction with the standard survey and was substantiated with a deficiency cited related to restraint use and care planning.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including failure to assess and care plan for use of restraints (Geri chair and lap tray) for one resident, failure to follow care plans for divided plates and anticoagulant monitoring for other residents, and failure to maintain effective infection control practices including sanitizing shared equipment and proper mask use by staff.
Deficiencies (3)
Failure to assess the use of a Geri chair in a reclining position and a lap tray as restraint devices for one resident (R#3).
Failure to follow care plan for one resident (R#36) requiring a divided plate and failure to develop/implement person-centered care plans for two residents (R#339, R#3), including monitoring for anticoagulant medication and use of possible restraints.
Failure to provide an effective infection control program by not sanitizing shared resident equipment between use and failure of staff to properly wear face masks.
Report Facts
Residents present: 37
BIMS score: 7
BIMS score: 1
BIMS score: 4
BIMS score: 9
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant EE | CNA | Provided information about resident #3's use of Geri chair and lap tray |
| Director of Nursing | DON | Interviewed regarding restraint orders, care plans, and infection control |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed about care plans and restraint assessments |
| Medical Director | MD | Provided clinical opinion on restraint use and care planning |
| Certified Nursing Assistant GG | CNA | Provided information on resident #3's mobility and lap tray use |
| Licensed Practical Nurse DD | LPN | Provided observations on resident #3's mobility and lap tray |
| Certified Nursing Assistant HH | CNA | Observed using shared mechanical lift and lift pad without disinfecting between residents |
| Administrator | Administrator | Interviewed regarding expectations for care plan adherence and mask use |
| Dietary Manager | Dietary Manager | Confirmed resident #36 was not served on divided plate as ordered |
| Dietary Aide | Dietary Aide | Verified failure to serve resident #36 on divided plate |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 10
Date: Dec 2, 2021
Visit Reason
A standard annual survey was conducted at Glenwood Healthcare from 11/30/2021 through 12/2/2021, including investigation of a substantiated complaint intake number GA00218093.
Complaint Details
Complaint Intake Number GA00218093 was investigated in conjunction with the standard survey and was found to be substantiated with a deficiency cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure resident privacy, maintain a safe and clean environment, properly assess and document use of restraints, timely submit MDS data, develop baseline and comprehensive care plans, provide appropriate ADL care, maintain infection control practices, and ensure qualified infection preventionist oversight.
Deficiencies (10)
Failure to ensure staff provided full visual privacy while weighing residents and administering medication.
Failure to maintain a safe, clean, comfortable, and homelike environment including stained ceiling tiles, peeling wallpaper, dust-covered vents and ceiling fans, and holes in walls.
Failure to assess and document use of physical restraints including a Geri chair in reclined position and lap tray for one resident.
Failure to timely submit a Discharge Minimum Data Set (MDS) for one discharged resident, 120 days past due.
Failure to develop and implement baseline and comprehensive care plans for residents including failure to follow divided plate order and failure to develop care plan for Geri chair and lap tray use.
Failure to follow physician orders for administration of Ativan medication resulting in missed doses.
Failure to maintain kitchen cleanliness and food safety including unclean oven, expired food in walk-in cooler, and unlabeled food items.
Failure of Medical Director to attend required quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings.
Failure to maintain an effective infection prevention and control program including failure to disinfect shared equipment between residents and improper mask use by staff and residents.
Failure to ensure Infection Preventionist is qualified, trained, and actively involved in infection control program and reporting.
Report Facts
Resident census: 37
MDS Discharge submission delay: 120
Missed medication doses: 4
Facility census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) HH | Observed failing to disinfect mechanical lift and lift pad between resident use | |
| Certified Nursing Assistant (CNA) GG | Observed failing to disinfect mechanical lift and lift pad between resident use | |
| Director of Nursing (DON) | Interviewed regarding privacy, care plans, infection control, medication administration, and infection preventionist role | |
| Administrator | Interviewed regarding expectations for privacy, care plans, infection control, and QAPI meetings | |
| Licensed Practical Nurse (LPN) AA | Observed failing to provide privacy during medication administration | |
| Certified Nursing Assistant (CNA) EE | Interviewed regarding use of Geri chair and lap tray for resident R#3 | |
| Minimum Data Set (MDS) Coordinator | Interviewed regarding care plans and assessments for residents | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and food safety | |
| Registered Dietician | Interviewed regarding divided plate order for resident R#36 | |
| Medical Director | Interviewed regarding medication administration and infection preventionist role | |
| Regional Nurse Coordinator (RNC) | Infection Control Preventionist with limited involvement and training |
Inspection Report
Life Safety
Census: 37
Capacity: 62
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 0
Date: Mar 18, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 4, 2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on February 4, 2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the February 4, 2021 Complaint Survey were found to be corrected.
Inspection Report
Routine
Deficiencies: 1
Date: Feb 4, 2021
Visit Reason
The inspection was conducted as a routine survey to assess the environmental sanitation and housekeeping conditions of the facility.
Findings
The facility failed to maintain a safe, clean, and comfortable home-like environment in two resident rooms (102 and 107), one hallway (100 hall), and two shower rooms (100 and 200 Halls). Observations included dark rings, brown substances, black streaks, and debris on walls, floors, and bathroom fixtures. Interviews with staff and administration confirmed these cleanliness concerns.
Deficiencies (1)
Environmental sanitation and housekeeping deficiencies including dark rings and brown substances in bathrooms and resident rooms, black streaks on walls, and debris in shower rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Interviewed regarding environmental cleanliness concerns and monitoring of housekeeping staff. | |
| Administrator | Confirmed environmental cleanliness concerns in shower rooms and resident rooms. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted on February 4, 2021, to investigate complaint intake GA00211598, which was substantiated.
Complaint Details
Complaint Intake GA00211598 was substantiated.
Findings
The facility failed to maintain a safe, clean, and comfortable home-like environment in two resident rooms (102 and 107), one hallway (100 hall), and two shower rooms, with observations of dark rings, brown substances, black streaks, and debris on walls, floors, and fixtures. Interviews with residents, housekeeping supervisor, and administrator confirmed the cleanliness issues and the need for improved monitoring of housekeeping.
Deficiencies (1)
Facility failed to ensure a safe, clean, and comfortable home-like environment in resident rooms, hallways, and shower rooms, evidenced by dark rings, brown substances, black streaks, and debris on walls and fixtures.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Interviewed regarding environmental cleanliness concerns and monitoring of housekeeping staff. | |
| Administrator | Interviewed and confirmed environmental cleanliness concerns in multiple areas. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208303.
Complaint Details
Complaint #GA00208303 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Glenwood Healthcare, 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: 43
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the complaint survey conducted on 2020-07-30.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 7/30/2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 7/30/2020 complaint survey were found to be corrected.
Report Facts
Census: 43
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate cases GA00202235 and GA00206544.
Findings
The survey was completed with no State Health Deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 3
Date: Jul 30, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00202235 and GA00206544.
Complaint Details
The survey was initiated based on complaints GA00202235 and GA00206544. GA00202235 was substantiated with deficiencies; GA00206544 was not substantiated.
Findings
The facility was found deficient for failing to repair or replace broken vertical blinds in three resident rooms, compromising resident privacy and dignity, and for failing to timely repair or replace a leaking roof that affected all residents. The facility also lacked an effective Quality Assurance program to address these issues promptly.
Deficiencies (3)
Broken vertical blinds in rooms 204, 207, and 211 did not provide full visual privacy for residents.
Leaking roof causing water intrusion, evidenced by two bath basins on the floor and a bulging ceiling tile, was not repaired or replaced in a timely manner.
Failure to have an effective Quality Assurance program to develop and implement plans to correct the leaking roof issue timely.
Report Facts
Resident census: 46
Rooms with broken blinds: 3
Total rooms on hall: 12
Date of Performance Improvement Plan: May 2, 2020
Date of Capital Expenditure Request: May 11, 2020
Date of Accounting Department approval: Jun 30, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Head of Maintenance | Reported knowledge of broken blinds and budget constraints; confirmed blinds in rooms 204, 207, and 211 were broken. | |
| Administrator | Agreed blinds needed replacement and approved expenditure to order new blinds; approved roof repair after surveyor inquiry. | |
| Director of Nursing | DON | Confirmed presence of bath basins on floor due to roof leaks and bulging ceiling tile; participated in interviews regarding facility conditions. |
Inspection Report
Routine
Census: 44
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant federal regulations and preparedness for COVID-19.
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: 45
Deficiencies: 0
Date: Oct 3, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2019-08-07.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 2019-08-07; deficiencies were corrected.
Findings
All deficiencies cited as a result of the 8/7/19 complaint survey were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
A complaint survey was conducted from 1/7/19 through 1/8/19 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility.
Complaint Details
Complaint survey conducted with no deficiencies cited.
Findings
The complaint survey revealed that there were no deficiencies cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
A Revisit Survey was conducted on 1/7/19 through 1/8/19 to verify correction of deficiencies cited in the standard survey of the 11/16/18 Recert survey.
Findings
All deficiencies cited as a result of the 11/16/18 Recert survey were found to be corrected during the revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00193061.
Complaint Details
Complaint GA00193061 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Inspection Report
Life Safety
Census: 45
Capacity: 62
Deficiencies: 0
Date: Nov 14, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan was also in substantial compliance with Appendix Z requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 17, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00190093 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00190093 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186023 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186023 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 16, 2018
Visit Reason
A Revisit Survey was conducted at Glenwood Healthcare to verify correction of deficiencies cited during the standard survey on 12/21/17.
Findings
All deficiencies cited as a result of the standard survey on 12/21/17 were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 7, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 40
Capacity: 62
Deficiencies: 2
Date: Dec 18, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code 2012 edition, specifically failing to properly separate hazardous areas with fire barriers and smoke barriers with required fire resistance ratings, and lacking self-closing doors on certain hazardous rooms. These deficiencies could place residents at risk in the event of a fire.
Deficiencies (2)
Failed to separate hazardous areas from other areas in a sprinkled building with smoke rated partitions and doors, including a medical records storage room door lacking a self-closing device.
Failed to provide smoke barriers with at least a 1/2 hour fire resistance rating; smoke barrier wall had unsealed conduit, plumbing, copper pipe, and roof joist penetrations.
Report Facts
Residents at risk: 20
Census: 40
Total licensed beds: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Aug 24, 2017
Visit Reason
A complaint standard survey was conducted on August 24, 2017 to investigate allegations related to the facility.
Complaint Details
The complaint survey was conducted and the facility was found to be in substantial compliance with no deficiencies.
Findings
The complaint survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, with no deficiencies found during the standard survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 18, 2017
Visit Reason
The inspection was conducted to investigate complaint GA00175056.
Complaint Details
Complaint GA00175056 was investigated and found to have no deficiencies.
Findings
No deficient practice was cited during the complaint investigation.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 15, 2017
Visit Reason
An unannounced revisit survey was conducted in conjunction with the investigation of Complaint Intake Number GA00171612.
Complaint Details
Complaint Intake Number GA00171612 was investigated in conjunction with the revisit survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities. No federal deficiencies were cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 15, 2017
Visit Reason
An unannounced revisit survey was conducted in conjunction with the investigation of Complaint Intake Number GA00171612.
Complaint Details
Complaint Intake Number GA00171612 was investigated in conjunction with the revisit survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. No federal deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 7, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 40
Capacity: 50
Deficiencies: 1
Date: Nov 9, 2016
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility failed to ensure that the automatic sprinkler system was inspected, tested, and maintained in accordance with NFPA 25 standards, specifically the 5-year internal inspection had not been completed, placing residents at risk in the event of a fire.
Deficiencies (1)
Failure to complete the 5-year internal inspection for the automatic sprinkler system as required by NFPA 25.
Report Facts
Census: 40
Total Capacity: 50
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