Ahc of Glendale LLC

Violation cited

Violation cited

Violation cited

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338). Findings include: Resident #338 was admitted on September 19, 2024 with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. A review of clinical record Minimum Data Set (MDS) is still in process. During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking. A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand. During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea. An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the res

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338). Findings include: Resident #338 was admitted on September 19, 2024 with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. A review of clinical record Minimum Data Set (MDS) is still in process. During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking. A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand. During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea. An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the res

Based on observations, staff interview, and policy review, the facility failed to ensure opioid medication regimen was administered according to physician's ordered parameters for one patient (#8). Findings: The subacute rehab patient (#8) was admitted on September 03, 2024 with diagnoses of GLF-ground level fall, acute respiratory failure with hypoxia, lobar pneumonia, single subsegmental thrombotic pulmonary embolism, gastrostomy, acute embolism and thrombosis of right distal lower extremity, edema, acute post hemorrhagic anemia, adult failure to thrive, dementia. History of breast cancer. An Admission 5-day Minimum Data Set (MDS) included the patient's Brief Interview for Mental status (BIM) score of 12 out of 15 which indicated the resident was moderately impaired. The MDS also included the resident experienced frequent pain and was receiving (PRN) as needed pain medication. A physician's order dated September 03, 2024 included oxycodone 5 mg tablet every 6 Hours PRN 5 mg, gastric tube, Every 6 Hours PRN, Pain parameters 8-10/10 Review of the Medication Administration Record (MAR) and the opioid oxycodone PRN pain management treatment was administered to patient outside of the provider's ordered pain level parameters of 8-10 of a pain scale 1-10. There is no evidence or documentation within the clinical records that the physician had been notified when oxycodone was administered outside of ordered perimeters on dates: 9/04/2024 at 19:09 for pain level 7 9/11/2024 at 19:41 for pain level 7 9/12/2024 at 19:33 for pain level 6 9/16/2024 at 21:04 for pain level 5 9/18/2024 at 19:14 for pain level 7 9/19/2024 at 02:16 for pain level 7 An interview was conducted on September 26, 2024 12:51 PM with nurse (#28) who stated about pain management opioid treatment, that if a patient has an order for pain medication, the patient has a related pain scale with parameters, and it is the facility policy and procedures to follow physician orders as written including parameters. Nurse referred to patient #8's oxycodone order having the pain scale of 1-10, and she stated that the opioid is prescribed for 8-10 pain level treatment on patient provider's order and that the floor nurse would only administer that opioid treatment if the patient's pain is within that range of 8-10 parameters. But, if the patient requested the opioid medication and their pain level is not within the prescribed 8-10 perimeters, then the nurse would call the patient's physician for clarification, then put in a new order or parameter change and document the change in either the MAR or progress note, or both locations. Nurse #28 stated patient #8's oxycodone, that the oxycodone was given outside of provider's 8-10 pain level perimeters order and she counted six times this occurred from 9/4/24-9/19/24. She stated that the order is written for the pain scale of 8-10 and the medication should have been administered only for the pain levels in that range. She further stated, that when a medica

Based on resident and staff interviews, review of clinical records and facility policies and procedure, the facility failed to ensure one resident (#27) is served and provided with resident's food preferences. Findings include: Resident #27 was admitted on August 12, 2024 with diagnoses of type 2 diabetes mellitus, hypertension, fibrillation, and hydronephrosis. A review of resident's comprehensive care plan dated August 31, 2024 revealed resident is at risk for alteration in nutrition status due to increased nutrition risk secondary to recent history of unintentional weight loss due to inadequate and impaired by mouth intake requiring tube feeding during hospitalization with difficulty cutting and feeding self. Alteration in carbohydrate metabolism with diagnoses of: type 2 diabetes, therapeutic diet in place. The interventions include facility will honor resident requests and preferences. A review of clinical record, "New Admission Nutrition Services Review", dated August 14, 2024 revealed a documentation of no fish/seafood for the question "are there any meats/poultry/fish/proteins you avoid?". During an interview with resident #27 on September 24, 2024 at 11:48 am, resident stated that most part the staff treats him well, the staff are fairly responsive, they come within few minutes sometime and up to 30 minutes especially during lunch, dinner or breakfast time, but the rest of the time, they are responsive. Resident stated that the food is not too bad, he fills out the menu, and resident stated that for dinner yesterday, they were served tuna melt, then resident was given the alternate meal, and sometimes they wonder who is reading the menu. Resident was served seafood even though their meal ticket states "No Seafood". And, his meal sometimes is served cold by the time it gets to his room. An interview was conducted on September 25, 2024 at 9:40 am with a certified nursing assistant (CNA)/Staff #6. Staff #6 stated that the process for taking meal orders is when he gets to work in the morning, he checks the halls, give residents fresh water, he grabs the iPad/tablet, he logs in then go to the dietary tab. He goes to each resident's room, give them the menu including the alternate menu. Their iPad/tablet, their system, has each resident's diet order, allergies, for instance. He stated that the Monday's menu on September 23, 2024 for dinner included a corn chowder and tuna melt sandwich. He types in in the iPad what resident requested. Staff #6 also stated that the resident's trays comes with a meal ticket that has a date, percent eaten, and they can write what resident requested and get sent back in the kitchen. An interview was conducted with pastry cook/Staff #96 on September 26, 2024 at 11:17 AM. Staff #96 stated that there is a sheet that has a texture diet that tells him what to do for each diet, then he plates the regular diet, place texture diet separate, and during the food service , one of the dietary aid will match the diet with the

Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect. The deficient practice could lead to residents suffering from psychosocial harm. Findings include: Resident #4 was admitted to the facility on August 17, 2024 with a diagnosis of orthostatic hypotension and fracture of vertebrae. Resident #20 was admitted to the facility on August 19, 2024 with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease. Resident #60 was admitted to the facility on August 29, 2024 with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia. An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied "you're dry" and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, "if you don't do things at his pace then he just does if for you". "Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over". There really isn't any compassion from him and that is a real problem". Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care. An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's, Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated "that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway". When asked if she had personally interviewed the resident, she stated "no, I didn't have to because my nurse reported it to me". When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 "I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said "that's what I get paid

Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect. Findings include: Resident #4 was admitted to the facility on August 17, 2024 with a diagnosis of orthostatic hypotension and fracture of vertebrae. Resident #20 was admitted to the facility on August 19, 2024 with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease. Resident #60 was admitted to the facility on August 29, 2024 with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia. An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied "you're dry" and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, "if you don't do things at his pace then he just does if for you". "Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over". There really isn't any compassion from him and that is a real problem". Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care. An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's, Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated "that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway". When asked if she had personally interviewed the resident, she stated "no, I didn't have to because my nurse reported it to me". When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 "I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said "that's what I get paid to do". Resident didn't like that he said it and he didn't want the CNA in his ro