The inspection revealed systematic medication administration failures affecting multiple residents with diabetes, including one patient who routinely travels for dialysis three times weekly.
Resident C's medication records from August showed a pattern of missing documentation. Staff failed to record whether the resident received or refused Lantus insulin on August 1st and 10th. Blood glucose wasn't measured on August 31st at 6 PM, yet 42 units of Lantus were administered between 7 PM and 10 PM without any recorded glucose reading.
The resident's fast-acting Lispro insulin was also mishandled. When blood glucose reached 272 on August 1st at 6 PM, no documentation showed whether Lispro was given or refused. The same documentation gap occurred on August 4th when glucose hit 255 at noon, and again on August 31st with no record of administration or refusal.
Staff also failed to document whether Resident C received prescribed hydrocodone-acetaminophen on August 21st at midnight.
Resident D presented more complex medication management challenges. The cognitively intact patient with type 2 diabetes, diabetic peripheral angiopathy with gangrene, and chronic kidney disease had undergone right leg below-the-knee amputation. The resident travels to dialysis every Monday, Wednesday, and Friday.
Physician orders required blood glucose measurements four times daily and 18 units of insulin glargine once daily. The orders contained no parameters for holding insulin doses or special instructions for dialysis days.
Despite clear physician orders, staff routinely withheld the morning insulin dose based on their own judgment. Records from October showed staff held the 8 AM insulin on multiple occasions: October 6th for glucose of 120, October 10th for glucose of 93, October 12th for glucose of 132, October 13th for glucose of 121, October 23rd for glucose of 124, October 26th for glucose of 100, October 28th for glucose of 95, and October 30th for glucose of 108.
On October 14th, staff noted they didn't measure glucose before the resident left for a procedure, then held the insulin anyway.
The medication administration record revealed staff routinely skipped insulin doses on dialysis days. Resident D typically didn't receive the prescribed insulin on Mondays, Wednesdays, and Fridays, with one exception on Monday, October 27th when insulin was given before dialysis.
Staff also missed required blood glucose measurements. Documentation gaps appeared on Sunday, October 5th at 8 AM, Tuesday, October 7th at 5 PM, and Tuesday, October 14th at 8 AM, with no record of completion or refusal.
LPN 4 explained the facility's routine during a November 19th interview. Staff obtained blood sugar measurements within an hour before meals and bedtime. When insulin was required within ordered parameters, a qualified medical assistant would ask a nurse to administer the dose. All actions required documentation on the medication administration record.
The nurse said when residents weren't in the building, staff would document they were "not available" or "LOA" (leave of absence).
However, the facility's own policies contradicted staff practices. A procedure from February 2010 required documenting medications held or refused on the medication administration record. It specified that medication administration should only be documented after actually giving the medication, and insulin type and units should be checked against physician orders at least three times for accuracy.
A separate policy from February 2003 instructed staff to administer medications and meals before or after dialysis "as ordered" — not based on staff judgment.
The administrator provided both policies to inspectors, acknowledging the facility's written standards for medication management.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to few residents. The citation relates to two separate complaint investigations conducted at the facility.
The medication errors affected residents requiring precise diabetes management, with one patient navigating the additional complexity of regular dialysis treatments that can affect blood sugar levels and medication timing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenbrook Rehabilitation & Skilled Nursing Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
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