Glades Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that clinical nutritional assessments were completed within the scope of practice for 1 of 1 sampled resident reviewed for nutrition (Resident #30). This had the potential to affect 51 out of 60 residents on the facility's current census. The findings included: A review of the Certified Dietary Manager (CDM) scope of practice dated 01/20/20 showed the following: Gather Nutrition Data. Interview and identify client-specific nutritional needs/problems. Review nutrition screening data and calculate nutrient intake. Document in the medical record. Identify food customs and nutrition preferences based on race, culture, religion, and food intolerances. Utilize standard nutrition care procedures following ethical and confidentiality principles and practices. Participate in care conferences and review the effectiveness of nutrition care. Provide nutrition education. A Review of the Revised 2024 Scope and Standards of Practice for the Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, menu review, and interview, the facility failed to follow their approved menu for 1 of 2 meals observed, as evidenced by the failure to prepare all foods on the lunch menu on 12/04/24, and substituted with foods not on the menu, affecting sampled Residents #13 and #2, with the potential of affecting 4 of 56 residents who consume food. The findings included: Review of the approved lunch menu for 12/04/24 documented, in part, the provision of an alternate vegetable of corn on the cob, the mechanical soft vegetable of cooked carrots, and the alternate mechanical soft vegetable of lima beans. An observation of the posted lunch meal for 12/04/24 docmented the meat as BBQ ribs with a side of baked beans. The alternate meal was listed as fried fish with corn on the cob. During an observation of the lunch meal service on 12/04/24 beginning at 11:20 AM, Staff G, lead cook for the day, placed the prepared food on the steam table, to include in part, chicken thighs, green beans, pureed chicken, and pureed green beans. After completion of the the food temperatures at 11:35…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy, centers for disease control (CDC) review, observations and record review, the facility failed to ensure appropriate infection control practices by failure to implement enhanced barrier precaution (EBP) process for residents with wounds, and indwelling medical devices including feeding tubes, and foley catheter for 4 of 4 sampled residents, with the potential to affect 6 residents identified as needing EBP. This involved Resident #1, #20, #22, and #44. The facility failed to ensure appropriate hand hygiene during wound care. This involved (Resident #22). The facility failure to ensure appropriate hand hygiene during perineal/catheter care. This involved Resident #44. The findings included: The Policy reviewed, titled handwashing practices dated March 19, 2020, indicated handwashing shall be regarded by this organization as the single most important means of preventing the spread of infections. 1) all personnel shall follow our establishing procedures to prevent the spread of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure of accurate Minimum Data Set (MDS) assessments for 3 of 3 sampled residents (Resident #33, #15, and #8), specifically a resident with hearing loss, this involved Resident #33; a resident with limited range of motion, this involved Resident #15; and a resident for medication usage, this involved Resident #8. The findings included: 1) Clinical record review revealed that Resident #15 was admitted to the facility on [DATE] with diagnosis that included: Dementia. Review of the quarterly MDS assessment, reference date 10/08/24, indicated Resident #15 was rarely/never understood. No moods or behaviors were recorded in this MDS. Under section GG for functional abilities and goal. It was documented Resident #15 had no impairment in his upper extremity (shoulder, elbow, wrist, and hand). Review of Therapy evaluation/summary dated 04/10/24 revealed Resident #15's proper hand function and skin integrity were impacted by the need for a right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for 2 of 17 sampled residents (Resident #58 related to an actual fall and Resident #17 for use of bed rails). The findings included: 1) Resident #58 was admitted to the facility on [DATE] with diagnoses that included Falls, General weakness, Hypertension, and Rhabdomylosis (a breakdown of skeletal muscle). Record review revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 5 on the annual Minimum Data Set (MDS) assessment dated [DATE]. This indicated the resident had severe cognitive impairment. Further record review revealed on 10/05/24, the resident sustained a fall when he was walking to the bathroom, felt dizzy and fell on his side. A review of the resident's care plans revealed a care plan with a start date of 01/09/24 for potential for significant injury related to fall (edited 10/07/24). Approaches included: redirect prn (as needed) (created on 10/07/24) and keep call light and personal items within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, interview, and record review, the facility failed to ensure complete and proper personal care for 1 of 1 sampled resident who had an urinary drainage device, as evidenced by the failure to perform hand hygiene prior to donning gloves, failed to provide peri-care (personal care) during catheter care, and failed to ensure proper catheter care for Resident #1. The findings included: Review of the policy titled, Foley Catheter Care and Maintenance revised 05/19/22, documented in part, Procedures: Foley (urinary drainage device) Catheter Maintenance . 4. Wash your hands with soap and water for at least 20 seconds, then apply gloves. 5. Using mild soap and water, or approved cleaner, clean your genital area. 8. Clean your urethra (urinary opening), which is where the catheter enters your body. 9. Clean the catheter from where it enters your body and then down, away from your body. Review of the record revealed Resident #1 was admitted to the facility on [DATE]. The record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on recipe review, observation, and interview, the facility failed to follow cooking instructions and ensure prepared fried fish was at a safe temperature, for 1 of 1 sampled resident who ordered that meal (Resident #13). The findings included: Review of the Production Recipe for the breaded cod, the fried fish on the lunch menu for 12/04/24, documented in part, Crunchy Breaded Cod Fillet 1. Deep fry from frozen at 360 degrees F for 3 to 5 minutes. Final internal cooking temperature must reach a minimum of 145 degrees F, held for a minimum of 15 seconds. Hot foods held for later service must maintain a minimum internal temperature of 135 degrees F. An observation of the lunch meal service was made on 12/04/24 beginning at 11:20 AM. Staff G, lead cook for the day, placed the prepared foods into the steam table and took the food temperatures. When asked about fried fish, the cook stated it would be fried a little later, as the resident who requested it was served on the last cart. At about 12:00 PM, Staff H, assistant cook for the day, fried three pieces of fish and placed them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, interview, and record review, the facility failed to act upon a grievance voiced by a resident regarding care for 1 of 2 sampled residents (Resident #266). The findings included: Policy titled complaints/grievances of resident/family member. Revised date January 2018. Department approval: Director of social services. The objective included: to ensure that all residents have complaints addressed to their satisfaction; to provide a mechanism for residents to access a grievance process. The procedure included: Complaints received by social services or staff member: 1.the staff member brings the complaint to their department manager immediately. 2.the social service director or department manager arranges a meeting with the involved discipline and the resident and/or family member where attempts shall be made to resolve the issues. 3.a resident/family complaint/grievance resolution form is completed and forwarded to the director of social services who will present the data at the quality assurance/performance improvement committee meeting. Record review revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record review, observation, and interview, the facility failed to maintain in-dwelling urinary catheters according to facility policy for 2 of 2 sampled residents (#44 and #54). The findings included: Facility policy titled: Foley Catheter Care and Maintenance effective date 01/01/2020 reads, 1. Keep the drainage bag below the level of your bladder and off the floor at all times. 2. Keep the catheter secured to your thigh to prevent it from moving. 1). Record review revealed Resident #44 was admitted to the facility on [DATE], with diagnosis that include Cerebral Vascular Accident (stroke) and Dementia. The quarterly assessment on 04/09/2022 documented the resident as being severely cognitively impaired and having a functional status of total dependence on staff performance for all activities of daily living and care. A Physicians order dated 03/22/2022 documented,, Foley catheter care every shift per facility protocol Care Plan dated 01/26/2022 documented, Catheter care per facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.