Glenbrook

In the surveyor’s words

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

• Actual harm, isolatedF692Aug 24, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure the nutritional status was monitored and acceptable parameters were maintained for one of one resident, (Resident 23), with unintended, unplanned severe weight loss of 16.43% in six months (9/4/22-2/4/23) when: 1) The resident's nutritional status was not reassessed, the laboratory values were not drawn, or the interventions were modified after five, ten, or fifteen percent of weight loss occurred, according to facility policy and standards of practice. […]

• No harm, potential for more than minimal, widespreadF800Aug 24, 2023

  Based on observations, interview and record review, the facility failed to ensure overall systems were met for the Food and Nutrition Services in the kitchen when: a resident experienced an unplanned insidious severe weight loss of 16% in a six months; residents' food temperatures were not monitored for safety and palatability; kitchen staff did not perform tasks competently for food safety in food preparation, food storage, and sanitation for dishwashing and dish storage; kitchen staff did not monitor the temperatures in the dry storage room and emergency food supply room closet to ensure safe quality of the food supply; recipes were not followed for time and temperature control for food safety foods (TCS); and fruit fly pests were found in the kitchen. […]

• No harm, potential for more than minimal, widespreadF802Aug 24, 2023

  Based on observations, interview and record review, the facility failed to ensure kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Kitchen staff did not correctly label and date TCS (Time/Temperature Controlled for food safety) foods in a walk-in refrigerator and did not monitor the dry storage room by correctly labeling, dating, and checking the quality of the food supply. 2. A Lead Cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 3. A Dishwasher did not enter the dish machine wash and rinse temperatures on a log in a timely manner. These failures placed all residents at risk of cross contamination and the potential to acquire food-borne illnesses. […]

• No harm, potential for more than minimal, widespreadF812Aug 24, 2023

  Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. An ice scooper was left inside the ice machine. 2. The kitchen's clean dish storage area had dirty serving utensils and debris in tray with clean dishes. 3. A Lead cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 4. The floor in the walk-refrigerator and freezer had dirty label, brown stains, trash and other debris on the floor. 5. […]

• No harm, potential for more than minimal, patternF605Sep 19, 2025

  Based on interview and record review the facility failed to initiate nonpharmacological or behavioral intervention before initiating antipsychotic medications (medication to treat psychosis [mental disorder characterized by disconnection from reality]) for two of five sample residents (Residents 31 and 49).This deficient practice had the potential for Resident 31 and 49 to receive unnecessary antipsychotic medication or inappropriate dose for behavioral treatment.Findings:1. A review of Resident 31's admission Record indicated the resident was readmitted on [DATE] with diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory and other cognitive decline), dementia (loss of mental function such as thinking, memory and reasoning skills), delusional… […]