Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Health Care Of Glendale during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, post‑stroke deficits, dysphagia, and a primary language other than English experienced multiple falls, refusals of care and therapy, and behavioral symptoms while staff documented ongoing communication barriers and did not use interpreter services. The care plan noted communication and behavioral issues but lacked specific language‑access interventions, and a psychiatric consult ordered for behaviors was never completed before discharge. Therapy notes showed limited participation and refusals, yet discharge documentation conflicted on whether skilled services were completed or the resident’s needs could not be met, and physician documentation did not support an inability to meet needs. The resident’s son reported being told on short notice that the resident could no longer stay unless a family member or private sitter stayed overnight, leading him to hire a sitter and then take her home. Although facility policy and leadership interviews confirmed that a NOMNC must be given at least 48 hours before Medicare‑covered services end, the NOMNC in this case was dated with coverage ending the same day it was purportedly discussed and was actually signed by the son on the day of discharge, with no clear evidence that the required advance notice and appeal information were provided within the mandated timeframe.
A resident with multiple complex cardiac, respiratory, and metabolic conditions was admitted without any documented wrist or elbow wounds in the admission assessment or care plan. Later, the resident was observed with dressings on both wrists and one elbow that were not dated or initialed, and a review of the EHR showed no corresponding wound care orders or progress notes for these areas at that time. An RN subsequently obtained an order only for the right wrist before additional orders were later entered for all three sites, but the left wrist and elbow dressings continued to lack dates and initials. Interviews with RNs, the ADON, and the wound care nurse confirmed that facility policy requires wound care orders for each wound, documentation of all wounds and treatments in the EHR, and dated/initialed dressings, and that these requirements were not met for the resident’s wrist and elbow wounds.
A resident with severe cognitive impairment, post-stroke deficits, and a primary language other than English was admitted with documented communication barriers and behavioral symptoms. The care plan noted altered communication and a language barrier but did not include use of a communication board or translation app. Over several days, the resident repeatedly refused meds and blood glucose checks, had multiple unwitnessed falls, and exhibited escalating behaviors such as screaming, striking staff, throwing equipment, and barricading in the room, often without provider notification or care plan revision. Documentation showed no use of interpreter or translator services and no addition of 1:1 supervision to the care plan, even after three unwitnessed falls in one evening and a psychiatric consult order. The administrator and nursing leadership acknowledged the resident needed a sitter, stated the facility could not provide ongoing 1:1 care, and directed the family to hire a private caregiver, resulting in the resident receiving 1:1 supervision from a privately paid sitter while the facility’s own staffing and sitter resources, described in its policy, were not implemented.
Surveyors found that a resident had ZAL cream and Baqsimi (glucagon) stored on the room sink counter without a lockbox and without provider orders for either the medications themselves (for part of the review period) or for self-administration. The resident reported independently applying the ZAL cream since admission and stated staff were aware, but the care plan contained no self-medication focus and the record lacked a completed self-medication assessment. A CNA stated medications and creams should not be left at bedside, while an LPN acknowledged there were no self-administration orders and that Baqsimi should have been kept in the med cart. The DON confirmed that policy requires a provider order, documented assessment, and locked storage for self-administered meds, none of which had been implemented for this resident.
A resident reported a breach of privacy when staff entered the bathroom without knocking and experienced confusion due to staff's refusal to disclose their role, citing HIPAA incorrectly. The resident also faced issues with obtaining herbal tea, highlighting communication gaps and inconsistencies in staff understanding of resident rights and facility policies.
A resident experienced a breach of privacy when staff entered the bathroom without knocking and faced communication issues with staff who incorrectly cited HIPAA as a reason for not disclosing their role. The resident also encountered problems with meal service, highlighting inconsistencies in staff adherence to facility policies on resident interaction and privacy.
A resident with multiple health issues, including acute respiratory failure, received oxycodone outside the prescribed pain level parameters on six occasions without physician notification or documentation. The facility's policy requires adherence to physician orders and documentation of any changes, which was not followed in this case.
A CNA in the facility failed to treat residents with dignity and respect, as reported by multiple residents. One resident felt violated when the CNA checked his brief without waking him, while another resident filed a grievance due to the CNA's inappropriate comments and uncaring demeanor. A third resident described the CNA as rude and questioned his attitude. The facility's response was limited to reassigning the CNA without further investigation or direct communication with the residents.
Failure to Provide Timely NOMNC and Consistent Discharge Notice for a Cognitively Impaired, Non‑English‑Speaking Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s representative in accordance with federal requirements and the facility’s own NOMNC policy. The resident was admitted with significant neurologic and functional impairments, including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, metabolic encephalopathy, type 2 diabetes, and gait abnormalities. Early assessments documented that the resident’s preferred language was not English, that staff were unable to determine if an interpreter was needed, and that the resident had slurred, sometimes understandable speech and severe cognitive impairment as evidenced by very low BIMS scores. A baseline care plan identified an alteration in communication, a language barrier, and aphasic, disorganized, and slurred speech, but did not include checked interventions such as a communication board, written communication, or translation applications. Throughout the stay, multiple therapy and nursing notes documented the resident’s limited cooperation, refusals of care and therapy, falls, and behavioral symptoms, often in the context of a language barrier and confusion. Nursing and therapy documentation repeatedly showed that staff attempted to communicate verbally or with a language board but were unable to verify understanding due to the language barrier, and there was no evidence of attempts to use an interpreter or translator application. The resident experienced several unwitnessed falls, episodes of combative behavior, refusal of medications, blood glucose checks, and care, and was at times described as barricading herself in her room. A psychiatric consult was ordered but there was no evidence in the clinical record that a psychiatric evaluation was ever completed before discharge. The care plan for behavioral symptoms did not include specific interventions addressing the resident’s primary non‑English language or use of interpreter services. As the stay progressed, therapy records showed that the resident participated in some OT, PT, and ST sessions but also refused multiple sessions, with therapy staff documenting refusals and minimal progress. Despite speech therapy documentation on one day recommending continuation of the plan of care, PT and ST discharge summaries were later completed indicating dates of service over a short period and noting minimal progress or refusal. Nursing and administrative notes indicated that staff communicated with the resident’s son about concerns for the resident’s safety at night and the need for a caregiver or private sitter, and the son ultimately arranged and paid for a private sitter overnight and then took the resident home. The discharge planning note stated that the NOMNC was signed by the son on a specific date and that discharge home was discussed, but the NOMNC form itself showed Medicare coverage ending on that same date and was actually signed by the son the following day, the day of discharge. There was no documentation that the NOMNC timeframe was waived, that appeal information was provided at the time of the initial notification, or that the discharge was resident‑ or family‑driven or due to the facility’s inability to meet needs as documented by a physician. Interviews with staff and the resident’s son confirmed that the son was informed of discharge plans only shortly before discharge, that he did not receive 48‑hour advance notice or appeal information, and that the facility’s own policy required the NOMNC to be delivered at least two days before Medicare‑covered services ended, which did not occur for this resident. Additionally, discharge documentation contained conflicting information about the reason and timing of discharge. The Discharge Instructions and Summary listed the reason for discharge as completion of skilled services and stated that the resident participated in therapy as tolerated, while the Notice of Transfer or Discharge cited that the resident’s needs could not be met in the facility and included appeal and Ombudsman information. The notice of transfer or discharge also contained inconsistent dates for when the notice was given. The clinical record lacked a physician note stating that the resident was unsafe to remain in the facility or that her needs could not be met there. Interviews with the LPN discharge nurse, DON, administrator, and other staff showed inconsistent explanations regarding whether the resident met therapy goals, whether she refused therapy, whether the discharge was rushed due to safety concerns, and whether 48‑hour advance notice of Medicare coverage termination and discharge was provided. The facility’s NOMNC policy required delivery of the NOMNC at least two days before Medicare‑covered services end, with proper documentation of communication and appeal rights, but the record for this resident did not show that these requirements were met.
Failure to Obtain Orders and Document Wound Care for Wrist and Elbow Dressings
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician orders and corresponding wound documentation for dressings applied to a resident’s wrists and elbow. The resident was admitted with multiple complex medical conditions, including pleural effusion, acute respiratory failure with hypoxia, syncope and collapse, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, sick sinus syndrome, left bundle branch block, endocarditis, metabolic encephalopathy, acute embolism and thrombosis of the left peroneal vein, long-term anticoagulant use, and a cardiac pacemaker. The 5‑day MDS showed no BIMS score, but the admission assessment documented the resident as alert, cooperative, oriented, and with clear comprehension, and showed no evidence of wounds to the wrists or elbow. The admission care plan also contained no documentation of wounds or wound care to these areas. During an observation, the resident was seen in a wheelchair with bandages on both wrists and the left elbow, none of which were dated or initialed. The resident’s daughter reported that the right wrist bandage was coming off, and nursing staff were notified. A review of the physician’s orders at that time revealed no wound care orders for either wrist or the left elbow, and there were no progress notes documenting wounds to these areas. Later that same day, an initial wound care order was entered only for the right wrist. On a subsequent observation, the right wrist dressing was dated and initialed, but the left wrist and left elbow dressings still lacked dates and staff initials. A follow‑up review of physician orders then showed wound care orders for the right wrist, left elbow, and left wrist, specifying cleansing with wound cleanser, patting dry, and applying a foam dressing twice daily as needed. Interviews with nursing staff and leadership confirmed that facility expectations and policies required wound care orders for each wound, documentation of all wounds and treatments in the electronic health record, and that all dressings be dated and initialed by the nurse providing care. The RN who identified the loose bandage stated she had requested a wound care order for the right wrist and later noticed additional areas without knowing how long the dressings had been in place, and confirmed there were no orders for the left wrist or elbow at that time. The ADON verified that wounds present on admission should be identified in the admission assessment with corresponding orders, and that any bandaging must have matching orders and documentation. The wound care nurse stated she was not aware when the wrist and elbow injuries occurred and acknowledged that orders, wound documentation, and dated/initialed dressings were expected. Facility policies on wound documentation, standards of nursing practice, and charting requirements all required comprehensive assessment, daily monitoring, and treatment documentation, which were not followed for these wrist and elbow wounds.
Failure to Provide Facility-Staffed 1:1 Supervision and Communication Support for a High-Acuity Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and appropriate staffing, including provision of a caregiver/sitter, to meet the individualized needs of a resident with significant cognitive impairment, language barriers, and behavioral symptoms. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, dysphagia, metabolic encephalopathy, diabetes, and gait abnormalities. On admission, the nursing assessment documented that the resident’s preferred language was not English, that it was unclear whether an interpreter was needed, and that the resident had slurred, sometimes understandable speech and could only sometimes understand others. A BIMS score of 1 indicated severe cognitive impairment. The baseline care plan identified an alteration in communication, language barrier, and aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult, but did not include use of a communication board, written communication, or translation application. Over the following days, the resident exhibited repeated refusals of medications and blood sugar checks, falls, and escalating behavioral symptoms, while documentation showed limited or no use of interpreter tools and no timely care plan revisions. On one date, a provider notification note documented that the resident refused medications and blood sugar checks despite use of a language communication board, and staff were unable to verify understanding due to the language barrier; there was no evidence of attempts to use an interpreter or translator application. The resident experienced an unwitnessed fall and was unable to describe the event, yet the care plan showed no updates or added interventions after this fall. A second fall occurred with similar inability to describe the event, again without evidence of care plan revision. Subsequent nursing notes described the resident screaming, kicking, scratching staff, refusing care and medications, attempting to get out of bed unassisted, smacking staff, throwing equipment (including leg brace and sensor pad), and remaining combative and refusing all care and medications, with multiple entries lacking evidence of provider notification of these behaviors. Later documentation showed that the resident had three unwitnessed falls in one evening, was very distressed, would not allow staff to touch her, and seemed unable to be safe, prompting provider notification and a psychiatric consult order. Notes indicated the resident barricaded herself in her room, staff had difficulty accessing her, and the physician ordered transfer to the hospital. After return from the hospital with no acute findings, the administrator documented a conversation with the resident’s son stating concerns about the resident’s safety and a need for a caregiver from late afternoon to early morning, and provided information for a private caregiver company. The care plan still contained no revision or intervention specifying a need for 1:1 sitter or caregiver during those hours. A later nursing note documented that the resident had direct 1:1 supervision with a private sitter, paid for by the family, with continued refusal of medications and assessments and no evidence of use of a communication board, interpreter, or translator application. Interviews with staff and the administrator confirmed that the facility did not have an interpreter or translator service, relied on a basic picture sign for communication, and that the administrator believed the resident required care above what the facility could provide, specifically 1:1 sitter care. The administrator stated the facility could provide a sitter only for a very short period and otherwise referred families to private caregiver companies, and that he informed the resident’s son that the facility could not provide a sitter. The ADON stated that the facility did have staff who could act as sitters but that additional staffing required administrator approval, and that based on the record, the resident needed a sitter. Other nursing staff reported that the resident could sometimes be calmed and redirected and appeared appropriate for the facility, but also acknowledged uncertainty about the extent of the language barrier. The facility’s staffing policy stated that staffing is based on census and acuity, that the facility has the ability to hire sitters as needed, and that additional staff or agency personnel can be brought in when events require extra resources. Despite this policy, the record and interviews showed no evidence that the facility implemented or provided a facility-funded sitter or adjusted staffing to meet this resident’s identified need for 1:1 supervision, instead directing the family to hire and pay for a private sitter and proceeding with discharge while documenting that the resident’s needs could not be met in the facility.
Unsecured Bedside Medications and Lack of Self-Administration Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly stored and not left unattended at the bedside, and failure to follow its own self-medication policies. During an observation of one resident’s room, two containers of ZAL cream with pharmacy labels were found on the counter next to the sink, with no lockbox present. The resident reported that she had been self-applying the ZAL cream to her buttocks and labia since admission, that staff were aware she was using it, and that one container was empty. Review of the clinical record from admission through the observation dates showed no provider orders for ZAL cream and no orders authorizing self-administration of any medications or treatments. The resident had diagnoses including Sjogren syndrome, urinary tract infection, and Type 2 diabetes mellitus, and an admission assessment showed she was alert and oriented, with a BIMS score of 13 indicating she was cognitively intact. The care plan included focuses on altered skin integrity and an indwelling catheter but did not include any focus or interventions related to self-administration of medications or treatments. Although provider orders were later written for a compounded topical preparation and ZAL cream, there was no evidence of any order permitting these medications to be stored at the bedside or self-administered by the resident during the period reviewed. A subsequent room observation found a container of ZAL ointment and a box of Baqsimi (glucagon) on the sink counter, again without a lockbox. Staff interviews revealed inconsistent understanding and implementation of facility policy: a CNA stated that medications and creams should not be left at the bedside and should be reported to the nurse, while an LPN stated that ointments could be left at the bedside only if there was a provider order for self-administration, and confirmed there were no such orders for this resident. The LPN acknowledged that Baqsimi should have been kept in the medication cart and that he had not been aware these medications were in the room. The DON stated that residents requesting to self-administer must be assessed using a Self-Medication Administration Assessment form, require a provider order, and that medications must be kept in a lockbox; review of the record showed no such assessment or orders for bedside storage or self-administration, despite the presence of ZAL cream and Baqsimi in the resident’s room. Facility policies required medications to be administered only on clear provider orders and required staff to remove any unauthorized medications found at the bedside, which had not occurred in this case.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident #338, who was admitted with multiple diagnoses including pneumonia, type 2 diabetes mellitus, depression, and anxiety. The resident reported that staff entered the bathroom without knocking, which violated her privacy. Additionally, the resident experienced confusion and frustration when staff, specifically Staff #27, refused to disclose their role or shift, citing HIPAA as the reason, which is a misinterpretation of the regulation. This lack of transparency and communication contributed to the resident's anxiety and dissatisfaction with the care provided. Furthermore, the resident expressed dissatisfaction with the availability of herbal tea, which was initially denied by Staff #27 but later found in the dining room. Interviews with staff, including a CNA and the Director of Nursing, revealed inconsistencies in communication and understanding of resident rights and facility policies. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance, leading to the deficiency noted in the report.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident #338, who was admitted with multiple diagnoses including pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. The resident reported an incident where staff entered the bathroom without knocking, which compromised her privacy. Additionally, during an interaction, Staff #27 incorrectly cited HIPAA as a reason for not disclosing their role or shift to the resident, which led to confusion and a lack of transparency in communication. The resident also experienced issues with meal service, specifically not receiving herbal tea as requested, which was later found to be available in the dining room. Interviews with staff, including a CNA and the Director of Nursing, revealed inconsistencies in communication and adherence to facility policies regarding resident interaction and privacy. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance.
Failure to Adhere to Opioid Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident's opioid medication regimen was administered according to the physician's ordered parameters. The resident, who was admitted with multiple diagnoses including acute respiratory failure and dementia, had a physician's order for oxycodone to be administered only when the pain level was between 8-10 on a scale of 1-10. However, the medication was administered six times outside of these parameters, with pain levels ranging from 5 to 7, without notifying the physician or documenting any changes in the medication administration record (MAR) or progress notes. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the facility's policy requires adherence to physician orders, including pain level parameters, and mandates documentation of any changes or notifications to the physician. Despite this policy, there was no evidence of physician notification or documentation of order changes for the six instances where oxycodone was administered outside the prescribed parameters. This oversight could potentially lead to serious side effects, such as respiratory distress, due to the inappropriate administration of opioids.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple incidents involving a CNA, identified as Staff #42. Resident #20 reported that the CNA entered his room and changed his brief without providing peri care, and later checked his brief without waking him, which made the resident feel violated. The resident expressed that the CNA lacked compassion and did not communicate appropriately during care. Despite reporting these incidents to the charge nurse, the resident felt that the administration did not follow up adequately. Additionally, Resident #60 filed a grievance after an interaction with the same CNA, who made an inappropriate comment about getting paid to provide care. The resident felt the CNA was uncaring and only interested in money. The CNA's demeanor and comments led the resident to distrust him, prompting a request for the CNA not to return to his room. The facility's response was to reassign the CNA to another hallway without further investigation or direct communication with the affected residents. Resident #4 also expressed dissatisfaction with the CNA's attitude, describing him as rude and uncaring. The resident recounted an incident where the CNA questioned her about not wearing a fall bracelet, which the facility did not even provide. This pattern of behavior by the CNA, coupled with the facility's inadequate response to grievances, highlights a failure to uphold residents' rights to dignity and respect, as outlined in the facility's policy on Resident Rights.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 241 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Arrowhead, Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of North Glendale | 2.4 mi | ★★★★★ | 1 | 0 |
| Sierra Winds | 2.9 mi | — | 0 | 0 |
| Freedom Plaza Care Center | 4 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 4.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Advanced Health Care Of Glendale.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.