Glenvue Health & Rehab

Based on observations, staff interview, and record review, the facility failed to ensure that the preplanned menu portion serving sizes and standardized recipes were followed. Failure to meet these requirements altered the intended calorie and nutritional content of the meal offered and could place residents at risk for weight loss and health complications associated with malnutrition. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: On 04/15/25 at 4:45 PM, [NAME] (C) 3 was observed setting up the tray line for the meal service. After removing the main entrée from the oven, C3 tested the temperature, and stated the menu included chicken pot pie, and could be served without any alteration to the residents with altered textured diets. C3 then stated he needed to prepare the casserole for puree foods. When asked if a standardized recipe was used to prepare the casserole, C3 explained he had added cheese to the recipe and provided assurance the resident really liked it. It was also noted that biscuits had been…

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 observations, staff interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions; as evidenced by failure to ensure food preparation equipment was stored under sanitary conditions; and ensure food storage areas were kept clean and sanitary. In addition, the facility failed to ensure foods were cooked to the appropriate temperature before placing them in a warmer (a low temperature oven intended to hold hot food), and failure to ensure ready to eat foods were handled in a manner that prevented contamination. The deficient practice increased the risk for all residents residing in the facility who receive a diet from the kitchen could experience a food borne illness. Findings include: On 04/14/25 at 9:20 AM, during the initial tour of the kitchen, the following observations for food preparation equipment, and food storage areas were kept in a clean and sanitary manner. The floor in the kitchen was soiled with food crumbs, and particulate matter, broken linoleum tiles were observed exposing the sub-floor. Food…

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 record review, interviews, and policy reviews, the facility failed to ensure five of 10 residents and their representatives (Resident (R) 8, R7, R23, R45, and R74) reviewed for facility initiated emergent hospital transfer from a total sample of 31 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred, and/or how to appeal a transfer, if desired. Findings included: Review of the facility policy titled, Transfer or Discharge, Facility Initiated, dated 10/2022, revealed, .Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer is provided to the resident and representative as…

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 staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living for one of four residents (Resident (R) 244) reviewed for activities of daily living out of a total sample of 24 residents. This failure had the potential to lead to a decline in activities of daily living. Findings include: Review of R244's admission Record located under the Profile tab in the electronic medical record (EMR), revealed R244 was initially admitted on [DATE] with diagnoses including acute respiratory failure, epilepsy, cerebral palsy, cognitive communication deficit, bipolar, and intellectual disabilities. The resident went out to the hospital on 2/28/29, readmitted on [DATE], and discharged on 03/15/25. Review of R244's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/28/24 revealed the resident was unable to complete a Brief Interview of Mental Status (BIMS) assessment. A Staff Assessment for Mental Status was…

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 record reviews, and staff interviews, the facility failed to ensure physician orders were followed related to laboratory monitoring for one of one (Resident (R)45) residents reviewed for laboratory services. Specifically, the facility failed to ensure that R45's HbA1c (blood test measuring average blood sugar levels over the past two to three months) labs were drawn in October 2024 and January 2025. Findings included: Review of R45's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, showed an admission date of 12/15/20 with a primary medical diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R45's Care Plan revised 04/11/25 located in the EMR under the Care Plan tab included diabetic status and .labs as ordered . Review of R45's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 01/07/25 revealed a Brief Interview for Mental…

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 staff interview and record review, the facility failed to maintain a complete and accurate medical record for one of 31 sampled residents (Resident (R) 8). Specifically, the facility failed to include the physician order for metoprolol tartrate 25 milligrams (mg) into the electronic medical record (EMR) following a readmission after hospital discharge. This failure had the potential to cause a medication error that could be harmful to the resident. Findings include: Review of R8's admission Record located in the EMR under the Profile tab indicated R8 was readmitted to the facility on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Review of R8's Order Summary Report, dated 04/17/25, did not include orders for metoprolol 25mg tablets. An order for gabapentin 100mg capsule, give 2 capsules by mouth twice daily for neuropathy was ordered 08/01/24 and atorvastatin 20mg tablet, give one tablet by mouth every evening for hyperlipidemia was…

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 observations, staff interviews, record review, and facility policy review, the facility failed to ensure infection control was maintained for five of 31 sampled residents (Resident (R) 17, R53, R59, R61, and R84). Specifically, the facility failed to ensure that hand hygiene was completed during medication administration, meal service, and housekeeping tasks. Additionally, a personal drink was on top of the medication cart during medication pass which increased the risk for cross contamination and infections. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene provided by the facility and revised 08/2019 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub .before preparing or handling medications .before handling clean or soiled dressings .after handling used dressings, contaminated equipment .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . 1.…

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 record review, staff interviews, and review of the facility policy titled, Discharging the Resident the facility failed to complete a recapitulation of stay and discharge summary for one resident (R) R#92 of 11residents discharged from the facility in the last three (3) months. The deficient practice had the potential to affect the continuance of care for R#92 after being discharged from the facility. Findings include: Review of the facility policy titled; Discharging the Resident revised 10/2010 revealed: Documentation-The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individuals who assisted in the discharge. 3. All assessment data obtained during the procedure, if possible. R#92 was discharged from the facility on 9/14/2022 with return not anticipated. Diagnoses included but not limited to hypertension, COVID-19, diabetes, chronic kidney disease and dementia. Review of the quarterly Minimum Data Set…

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 observations, record review, staff interviews and review of the facility policy titled, Medication Monitoring and Management, the facility failed to ensure that a psychotropic medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one (1) resident (R) R#33 of five (5) residents reviewed for unnecessary medications. Specifically, the facility failed to ensure that there was a stop order date for Klonopin prescribed for R#33. Finding include: Review of the facility policy titled, Medication Monitoring and Management effective 5/1/2020 revealed: A. 6) As needed (PRN) orders include an indication for use. a. If the PRN medication is used to modify behavior, the indication for use is clearly defined in objective terms, what specific symptom is being addressed. b. The resident is monitored for the effectiveness of the medication or possible adverse consequence. the results are documented in the medical record. Diagnoses for R#33 included but not limited to upper respiratory infection, ortho aftercare, weight loss, atrial fibrillation,…

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, record review, staff interview, and review of the policy titled, Important Dietary Instruction Guide: Labeling and Dating, the facility failed to ensure opened and canned food items in the dry storage area were properly labeled and dated. This had the potential to affect 111 out of 120 residents receiving an oral diet. Findings include: 1. Review of the facility policy titled Important Dietary Instruction Guide: Labeling and Dating, revealed All Foods Must Have a Date Grocery truck opened times: Any items that have been opened but will be used again. During the initial tour on 01/27/2020 at 11:10 a.m. with the Dietary Manager revealed the following: (3) gallon-sized cans of ketchup not labeled for receiving date, (2) gallon-sized cans of whole kernel corn not labeled for receiving date, (7) gallon-sized cans of beets not labeled for receiving date, (1) gallon-sized can of apple sauce not labeled for receiving date, (1) 16 oz. bag of marshmallows opened with no opening date, (1) 16 oz. container of All Spice Seasoning opened with no opening date, and (1) 16 oz.…

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, staff interview, and review of the facility policy titled, Ice Machine and Ice Storage Chests the facility failed to provide a sanitary ice scoop for an ice machine serving five of five halls and failed to ensure a soap dispenser was working in one of three shower rooms. Findings include: Review of the Ice Machine and Ice Storage Chests policy dated January 2012 revealed to keep ice scoop/bin in a covered container when not in use. During an interview on 1/30/2020 with the Maintenance Assistant he reported that the ice scoop should be kept on the outside of the ice machine. During an observation on 1/27/2020 at 11:20 a.m. of the ice machine on the F hall there was a blue scoop inside of the ice machine. During an observation on 1/27/2020 at 11:57 a.m. in the shower room on F hall the hand soap dispenser was not functioning. During an observation and interview on 1/30/202 at 11:45 a.m. Licensed Practical Nurse DD confirmed there was a scoop hanging in the ice machine. LPN DD also revealed that the ice scoop should be kept in the ice machine to keep residents…

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 2. Review of medical record for R#21 revealed diagnosis of acute chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The Minimum Data Set annual assessment dated [DATE] section O revealed oxygen therapy. Record review of the medical record revealed a care plan for R#21 being at risk for ineffective breathing due to COPD and acute chronic respiratory failure with an intervention that included oxygen as ordered. There was no Physician's order for oxygen. During observations on 1/27/2020 at 3:17 p.m., 1/28/2020 at 4:28 p.m., and 1/29/2020 at 8:45 a.m. R# 21 was observed wearing oxygen. During an interview with Licensed Practical Nurse (LPN) CC on 1/29/2020 at 1:40 p.m. she confirmed that R#21 wears oxygen but was unable to find the orders for oxygen. Based on observation, record review, and staff interviews the facility failed to follow the care plan for two of 24 residents (R#82, R#21) reviewed for care plans. Findings include: 1. Record review revealed that R#82 was admitted to the…

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, staff interviews, record review, and review of the facility policy titled, Oxygen Administration the facility failed to ensure that the Physician's order for oxygen administration was followed for one resident (R#82) and failed to obtain an order for oxygen administration for one resident (R#21) for 18 residents reviewed for oxygen administration. Findings include: 1. A review of the policy titled, Oxygen Administration under subtitle 1. Preparation reveals that there was to be verification of the Physician's order. Record review revealed that R#82 was admitted to the facility with diagnoses that included: sepsis and paroxysmal atrial fibrillation. A review of the Physician Orders revealed an order for oxygen at 3 LPM via nasal cannula as tolerated by the resident. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation also revealed that oxygen concentrator was on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m.…

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.