Glenfields Living With Care

In the surveyor’s words

From the most serious findings on record at Glenfields Living With Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Aug 30, 2023

  Based on observation and interview, the facility failed to ensure staff were following standard precaution guidelines to prevent the spread of infection by wearing personal protective equipment (PPE), while processing contaminated linens. This had the potential to affect all 80 resident who resided within the facility. Finding include: On 8/29/23 at 1:04 p.m., nursing assistant (NA)-D provided a tour of the soiled utility room and described the process for rinsing out heavily soiled linen in the hopper. It was observed that the hopper did not have a protective splash screen on the hopper, it was on the floor next to the hopper. NA-D stated she would use gloves to rinse and soak the heavily soiled linens in the hopper. […]

• No harm, potential for more than minimal, widespreadF812Jul 22, 2021

  Based on observation, interview and document review, the facility failed to maintain clean and sanitary conditions in the main kitchen. This practice had the potential to affect all residents, staff and visitors who ate at the facility. Findings include: On 7/19/21, at 12:53 p.m. the initial tour of the kitchen was completed with the dietary director (DD). The following areas of concern were identified. -walk in cooler floor was observed to have food debris and plastic items on the floor. A light fixture hanging from the ceiling in front of fans had approximately one quarter inch layer of black fluffy debris between the inner glass cover and the outer cage. The debris at the bottom of the light fixture was waving in the breeze from the fans. […]

• No harm, potential for more than minimal, patternF550Aug 20, 2026

  Based on observation, interview, and document review, the facility failed to ensure residents were treated with dignity and respect for 6 of 6 residents (R76, R83, R46, R63, R67, and R6) when a nurse directed them to remain in the dining room until medications were administered. Findings included: During an observation on 8/19/26 at 8:20 a.m., R76 and R83 stood from the dining room table after finishing breakfast and began walking out of the dining room. Registered nurse (RN)-A told R76 and R83 they could not leave because she still needed to administer their medications. […]

• No harm, potential for more than minimal, patternF880Jun 5, 2025

  Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 2 of 2 residents (R8, R63) observed for wound care and failed to properly implemented enhanced barrier precautions (EBP) for 4 of 4 residents (R8, R63, R66, R73)) reviewed for contact precautions. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE], included R8 was cognitively intact, was able to make self be understood and was able to understand others. R8 had a diagnosis of stage 4 pressure ulcer on her sacral region (a wound caused by pressure extending to underlying tissue like muscle, bone or tendon), multiple sclerosis (MS)(a disease that can cause weakness, pain, fatigue and impaired coordination), and malnutrition (a lack of proper nutrition). […]

• No harm, potential for more than minimal, isolatedF604Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to assess the use of a wheelchair seatbelt to determine whether the seatbelt restricted the resident's freedom of movement and constituted a physical restraint for 1 of 1 resident (R81) reviewed for physical restraints.Findings included:R81's admission Minimum Data Set (MDS), dated [DATE], identified R81 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R81's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by an injury), vascular dementia with agitation (a decline in thinking and memory caused by reduced blood flow to the brain, accompanied by agitation), and non-Alzheimer's dementia (a decline in memory, thinking, and ability to… […]