Glen Meadows Retirement Com.

In the surveyor’s words

From the most serious findings on record at Glen Meadows Retirement Com., in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 31, 2025

  Based on review of medical records and other pertinent documentation, interview with facility staff, and observations, it was determined that the facility failed to have an effective system in place to prevent residents with cognitive impairments from leaving the facility without appropriate supervision. This failure led to 1) Resident #16, who was known to have exit-seeking/elopement behaviors with previous two elopement incidents, found outside of the building on 12/13/24 around 6 PM, and 2) Resident #20, who had a wanderguard placed due to high risk of elopement since May 2024, found in the Assisted Living (AL) library on 3/20/25 around 9 AM. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2025

  Based on observation and interview with facility staff, it was determined the facility failed to: 1) ensure expired food items were discarded 2) ensure the ice machine's filtration cartridge was replaced timely and 3) ensure required temperature levels were consistent for dishwashing sanitization. These deficient practices have the potential to affect all facility residents. The findings include: On [DATE] at 7:53 AM, the surveyor conducted an initial tour of the facility's kitchen. […]

• No harm, potential for more than minimal, patternF867Mar 31, 2025

  Based on staff interviews, review of pertinent documentation, and survey findings, it was determined that the facility staff failed to ensure that an effective Quality Assurance Performance and Improvement (QAPI) program was in place to identify quality concerns and have a system in place to correct identified concerns. This was found to be evident while conducting the facility's recertification/complaint survey. The findings include: The facility's annual and complaint surveys, including investigations of self-reported incidents, conducted from 3/24/25 to 3/31/25, identified non-compliance regarding Resident Abuse, free of accident hazards (elopement), and pharmacy service (related document of controlled medication use), and so on. […]

• No harm, potential for more than minimal, patternF657May 12, 2021

  Based on resident and staff interview and medical record review, it was determined the facility failed to have documentation which indicated care plans were reviewed and evaluated. This was evident for 1 (#1) of 1 residents reviewed for [CONDITION(S)], and 2 (#10, #5) of 5 residents reviewed for unnecessary medication. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 5/4/21 at 1:35 PM, a review of Resident #7's medical record was conducted. […]

• No harm, potential for more than minimal, patternF880May 12, 2021

  Based on observation, interview, and documentation review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to implement an effective system to ensure that symptomatic staff, visitors and vendors did not enter the facility during a declared health emergency. The findings include: According to the Centers for Disease Control and Prevention (CDC) published updated guidance on COVID-19 symptoms. In addition to fever, cough, and shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, persistent pain or pressure in the chest, trouble breathing, new confusion, inability to arouse, and bluish lips or face, the CDC added gastrointestinal symptoms including nausea,… […]