Glasgow State Nursing Facility

In the surveyor’s words

From the most serious findings on record at Glasgow State Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jul 10, 2024

  Based on interview, record review and review of facility's policy, the facility failed to implement the care plan for one of nine sampled residents (Resident #1) R1. The facility assessed R1 as a high risk for wandering and developed a care plan with interventions that addressed that behavior. The facility failed to ensure the care plan interventions were implemented. On 06/24/2024 at 6:09 AM, R1 exited Pod 2 (where he resided), a secured unit, behind a kitchen staff member, who did not ensure the door was secured after going through the doors. A Housekeeper passed R1 in the hall; the Housekeeper failed to intervene. R1 proceeded to the front lobby where the Security Guard was stationed and also failed to intervene when R1 went out the front door. […]

• Immediate jeopardy, isolatedF689Jul 10, 2024

  Based on observation, interview, record review, facility document and policy review, and Google Maps, the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of nine (9) sampled residents assessed for high elopement risk Resident #1 (R1). The facility assessed R1 as being at risk for wandering and care planned the resident for being a wandering risk. R1's care plan interventions included: ensuring all doors were closed securely when entering or exiting the resident's pod (unit), redirecting the resident away from doors, and observing for wandering behavior with redirection as needed. […]

• Actual harm, isolatedF600Dec 21, 2023

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for two (2) of six (6) sampled residents, Resident #45 and Resident #39. 1. On 11/23/2023 at 3:50 PM, it was noted Certified Nurse Aide (CNA) #4 abused Resident #45. The facility investigated the incident, and CNA #4 was suspended pending the outcome of the investigation. Resident #45 was noted to have behaviors the day of the incident, and tried to get up into other people's personal space. CNA #4 pushed Resident #45's chair under the table in the common area of the Pod which resulted in the resident sustaining a skin tear. […]

• Actual harm, isolatedF609Dec 21, 2023

  Based on interview, record review and facility policy review it was determined, the facility failed to ensure violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for two (2) of six (6) sampled residents, Resident #39 and Resident #45. 1. An incident involving Resident #45 occurred on 11/23/2023 at 3:50 PM, when CNA #4 was observed by CNA #1 and CNA #5 to push Resident #45's chair up to the table during which the resident sustained a skin tear. […]

• Actual harm, isolatedF656Dec 21, 2023

  Based on interview, record review and review of facility's policy it was determined, the facility failed to follow the care plan for one (1) of fifteen (15) residents, Resident #45. On 11/23/2023 at 3:50 PM, Certified Nurse Aide (CNA) #4 abused Resident #45. The incident was investigated by the facility and CNA #4 was suspended pending the outcome of the investigation. On the day of the incident Resident #45 had behaviors and was trying to get up into other people's space. CNA #4 pushed Resident #45's chair under the table with the resident sustaining a skin tear on his/her hand. It was also reported CNA #4 hit Resident #45's arm twice and poked her index finger over and over just beneath the resident's shoulder. […]