Complete Care at Glendale West

In the surveyor’s words

From the most serious findings on record at Complete Care at Glendale West, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Oct 24, 2022

  Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure injuries, promote healing of pressure injuries, and prevent infection of pressure injuries for 4 (R274, R57, R63, and R55) of 6 residents reviewed for pressure injuries. *R274 developed a Moisture Associated Skin Damage (MASD) area to the sacrum on 9/8/2022 and the Care Plan was not revised with interventions to prevent further damage. The MASD progressed into an Unstageable pressure injury on 10/3/2022. […]

• Immediate jeopardy, isolatedF692Mar 31, 2021

  Base on interview and record review the facility did not ensure 1 (R6) of 3 residents reviewed maintained acceptable parameters of nutritional status. R6 was noted to have a significant weight loss of 5.4 lbs. (pounds) within the first month of admission to the facility. R6's physician and family were not notified and interventions were not put into place to prevent further weight loss. R6 continued to lose weight and the physician and family were not notified timely, lab tests were ordered but not obtained timely and speech therapy recommendations were not identified on the care plan. R6 became unresponsive at the facility and was sent to the hospital via 911, where R6 weighed 77 lbs (a 30 lb. weight loss in 5.5 months). R6 passed away 18 days later. […]

• Actual harm, isolatedF689Nov 29, 2023

  Based on record review and interview, the facility did not ensure 1 of 4 sampled residents (R13) reviewed for falls failed to provide adequate assistance during a transfer. R13 was to be transferred with the assist of 2 staff and per a therapy recommendation, those staff were to use a gait belt and pivot transfer. On 8/12/23, staff transferred R13 with a sit to stand lift without assistance. R13 fainted and fell out of the sit to stand lift resulting in a laceration to the head requiring sutures. Findings include: R13 was admitted to the facility on [DATE] with diagnoses that included syncope (fainting) and collapse. […]

• Actual harm, isolatedF686Jul 13, 2021

  Based on observation, interview, and record review the facility did not provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -R48 was at risk for the development of pressure injuries. The facility did not put interventions in place to offload pressure to R48's heels prior to R48 developing a pressure injury that developed necrotic tissue. -R62 was at risk for the development of pressure injuries. The facility did not put interventions in place to offload pressure to R62's heels following R62 having a fracture to their left femur. R62 developed an unstageable pressure injury to the left heel. The facility stated R62 refused offloading measures to his heel, but did not develop a plan of to address R62's refusals. -R66 has an unstageable pressure injury. […]

• No harm, potential for more than minimal, patternF550May 22, 2025

  Based on observation and interviews, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 4 (R65, R68, R173, and R174) of 10 Residents reviewed for dignity. *R65 was observed to be in a gown during 3 days of the survey process and prefers to be dressed. *R68 was observed to be in the hallway by the nurse's station in a gown during the survey process. *R173 was observed to be in the dining room eating lunch in a gown. *R174 was observed walking down the hallway with therapy in a gown. […]