Aliya of Glenwood

In the surveyor’s words

From the most serious findings on record at Aliya of Glenwood, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 13, 2025

  Based on observation, interview, and record review, the facility failed to follow their abuse policy and failed to protect one resident (R1) from repeated verbal and psychological abuse by R2. This failure affected one (R1) of three residents reviewed for abuse. These failures resulted in R1 experiencing ongoing fear and anxiety related to being R2's roommate. Findings include: R2's face sheet documents and admission date of [DATE] and diagnoses that include but are not limited to asthma, type 2 diabetes mellitus, and chronic kidney disease.R2's BIMS (brief interview mental status), dated [DATE] is 12 which indicates R2's cognition is moderately impaired.On [DATE] at 9:31am, R2 said, We (R1 and R2) had a disagreement a few days ago. […]

• Actual harm, isolatedF684Apr 3, 2025

  Based on interview and record review, the facility failed to ensure that staff administer prescribed PRN (as needed) blood pressure medication for a resident; failed to assess and document vital signs for a resident with a change in condition; and failed to monitor and document a resident's blood sugar as ordered. This failure affected one (R2) of three residents reviewed for nursing care and resulted in R2 becoming unresponsive while at the facility and required hospitalization and treatment that included intubation and being admitted to the intensive care unit (ICU) for treatment of septic shock and healthcare associated pneumonia. […]

• Actual harm, isolatedF689Oct 4, 2024

  Based on interview and record review, the facility failed to supervise one resident (R2) who was diagnosed with Dementia, cognitively impaired with a history of falls and identified as high fall risk from sustaining three falls within forty-five days. This affected one of three residents (R2) reviewed for falls. This failure resulted in R2 sustaining an unwitnessed fall with a laceration to the back of the head injury requiring suture and staple repair and sustaining another fall with a laceration to the back of the head requiring staples. Findings include: R2 was admitted to the facility on [DATE]with a diagnosis of type II diabetes, dementia, psychosis, Alzheimer's disease, anemia, encephalopathy, and history of falling. […]

• Actual harm, isolatedF684Sep 10, 2024

  Based on interviews and record reviews, the facility failed to follow its skin care prevention policy and implement effective interventions and monitoring to prevent one resident developing three facility acquired non-pressure wounds to the right foot and ankle. This affected one of three R1 residents reviewed for non-pressure wounds in a sample of 11. This failure resulted in R1 presenting to the hospital emergency roiagnom on [DATE] with sepsis secondary to a right heel wound that was infected and with acute osteomyelitis (bone infection). Findings include: On 9/5/24 at 1:40 PM, V11 (wound care nurse) stated that the staff nurses are responsible for monitoring residents' skin for any breakdown. […]

• Actual harm, isolatedF686Sep 10, 2024

  Based on interviews and record reviews, the facility failed to implement effective pressure relieving interventions to prevent one resident, who's lower extremities are severely contracted, at very high risk for skin breakdown, and dependent on staff for all ADLs (activities of daily living), from developing a facility acquired pressure ulcer on the left posterior distal thigh due to pressure from posterior mold splint on the left lower leg. This affected one of three residents R1 reviewed for pressure ulcers in a sample of 11. […]