Glenflora

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 4, 2023

  Based on record review, observation, staff and Physician interviews, the facility failed to provide a safe transfer when the Transportation Aide did not ensure a resident's lower extremities were raised during a transfer onto the wheelchair lift platform of the facility van for 1 of 1 resident reviewed for supervision to prevent accidents (Resident #1). During a facility van transport on 10/31/23, Resident #1 was assisted onto the wheelchair lift platform by the facility Transportation Aide when she fell forward from the wheelchair resulting in a laceration to the head, fractures of cervical (neck) 1 and 2 vertebrae, fractures of the right tibia and fibula (bones of the lower leg), and fracture of the femur (hip). […]

• Actual harm, isolatedF684May 28, 2026

  Based on record review and staff, Nurse Practitioner, Medical Director, and Responsible Party interviews, the facility failed to provide ongoing assessments after a fall and failed to communicate effectively to provide medical diagnostics and treatment for 1 of 3 residents reviewed for assessment after a fall (Resident #1). Resident #1 was found on the floor mat beside her bed by Nurse #1 on 4/27/26 at approximately 4:30 AM. Nurse #1 stated Resident #1 did not have any apparent injury and she and Nursing Assistant (NA) #1 picked the resident up and placed her back in her bed. Nurse #1 did not report the fall to the oncoming nurse for the 7:00 AM to 7:00 PM shift, Nurse #2. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  Based on observations and staff interviews, the facility failed to maintain hot pureed food at 135 degrees Fahrenheit (F) or higher for 1 of 1 tray line observation. This practice has the potential to affect residents on a pureed diet. The findings included: An observation of the lunch meal tray line in progress was conducted in the main kitchen on 02/09/26 at 11:30 AM, with three lunch trays plated, covered and ready to be placed into the tray carts. Temperature monitoring was requested and performed by the Dietary Manager (DM) on 02/09/26 at 11:30 AM. The following temperatures were obtained: pureed chicken alfredo 128 degrees F and pureed spinach 130 degrees F. The temperatures of these items were taken using the facility's electronic food thermometer. […]

• No harm, potential for more than minimal, isolatedF761Apr 14, 2022

  Based on observations and staff interviews the facility failed to dispose of expired medications from the medication storage cabinet and medication refrigeration storage in one of 2 medication storage rooms observed and failed to date an inhalation medication when opened on 2 of 3 medication carts reviewed. Findings Included: On 04/12/22 at 9:00 AM an unopened bottle of Aspirin 81 milligrams with an expiration date of 01/21/22 was found in the stock medication cabinet in the medication storage room. […]

• No harm, potential for more than minimal, isolatedF849Apr 14, 2022

  Based on record review and staff interviews, the facility failed to have all hospice information including progress notes and care plan available in the medical record to assure that the services provided were coordinated for 1of 2 residents (Resident #7) reviewed. The findings included: Resident #7 was readmitted to the facility from the hospital on 10/25/21. Resident #7 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7 ' s medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/21 Hospice services which included skilled nursing, chaplain, nursing assistant (NA) and social worker began. Review of Resident #7 ' s medical record revealed a hospice plan of care for period of 10/26/21 through 1/23/22. […]