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 Glendale Healthcare Center during CMS and state inspections, most recent first.
Dishwashing Machine Operated Below Required Temperature: A dietary aide was observed washing dishware in a low-temp dishwasher while the reservoir thermometer read 98 F, below the manufacturer’s and facility’s stated minimum temperatures. The DSS stated the water should be at least 120 F, and on a later observation another dietary aide again operated the machine at 98 F until the DSS and maintenance staff drained and refilled it to reach the required inlet temperature.
Incomplete Annual Nursing Competency Assessments: The facility failed to ensure annual skills competency assessments were completed for an LPN and three CNAs. Record review showed the staff had competency evaluations completed in 2024 for some topics, but the facility assessment required annual evaluation of ADLs, hand hygiene, and VS/I&O for CNAs and LNs. The DSD and DON stated annual skills competencies were done, but they were not aware of the facility assessment requirements, and the DON was unsure whether makeup sessions were completed for staff who missed the Skills Fair.
Low Air Loss Mattress Set Incorrectly for Resident With Pressure Injuries: A resident with multiple pressure injuries, severe cognitive impairment, and dependence for turning and most cares had a LAL mattress ordered at Setting 3 based on a weight of 161 lbs. During observation, the pump label indicated Setting 3, but the mattress was actually set to 4, and the DON confirmed the setting did not match the resident’s weight or the manufacturer’s guidelines.
Two residents with G-tubes, dysphagia, and severe cognitive impairment were observed receiving continuous enteral feedings with their HOB below the ordered and policy-required 30-degree minimum. One resident’s HOB measured 19 degrees and the other 22 degrees, despite care plans and orders directing elevation of 30 to 45 degrees during feeding. An LVN and the DON acknowledged the HOB was too low, and the facility policy required at least 30 degrees during tube feeding and for 1 hour afterward.
Failure to use gown during EBP care: A CNA changed a resident’s incontinent brief without wearing an isolation gown even though the resident was on EBP for an unhealed sacro coccyx wound. The resident had a pressure ulcer, anemia, ESRD, and moderately impaired cognition, and the care plan and doorway signage both directed gown use for brief changes. The CNA said she forgot the gown, and the DON confirmed awareness of the event.
A resident with multiple medical conditions, including Parkinson's disease and heart disease, was prescribed apixaban and clopidogrel bisulfate, but the facility did not develop or implement a person-centered care plan addressing the use of these medications. Staff confirmed that no individualized care plan or interventions were in place, and the facility's policy requiring comprehensive care planning was not followed.
The facility failed to assess and monitor two residents' conditions adequately. One resident developed a self-inflicted wound under the eye, which was not treated or reported to a physician, while another experienced daily vomiting episodes without proper documentation or physician notification. Staff interviews confirmed the lack of documentation and monitoring, contrary to facility policies.
A facility failed to obtain informed consent for a resident before administering Amitriptyline, a medication for depression and neuropathic pain. The resident, with moderately impaired cognitive skills, received the medication without documented consent from May 2024 to January 2025. Facility policies require informing residents about treatment risks and benefits, but this was not adhered to, violating the resident's rights.
The facility failed to ensure that two residents had their call light devices within reach, which is essential for calling for assistance. One resident, with conditions like rheumatoid arthritis and a risk for falls, was found with the call light on the floor beneath the bed. Another resident, with a history of falling and dementia, also had the call light out of reach. Staff confirmed the importance of having the call light accessible to prevent falls and ensure timely assistance, as per the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses experienced daily vomiting episodes, but the facility failed to document these occurrences or notify the primary physician, delaying treatment and monitoring. Staff interviews confirmed the lack of documentation and notification, contrary to facility policy.
Two residents in an LTC facility had inadequate care plans. One resident's plan for weight loss lacked measurable objectives and target weights, while another resident's plan failed to address IV catheter care and monitoring. These omissions did not align with the facility's policy requiring comprehensive, person-centered care plans.
A resident with a malignant brain tumor and other serious conditions was found to have dirt under their nails, indicating a failure in maintaining personal hygiene. Despite being alert and oriented, the resident required substantial assistance for personal hygiene, which was not provided as per the facility's policy. The facility's policy required daily cleaning and regular trimming of nails, but the care plan only mandated weekly maintenance by the Activities Department.
A facility failed to label an IV catheter dressing with the date, time, and nurse's initials, as required by policy. This oversight involved a resident with a history of surgical amputation, diabetes, and osteomyelitis, who was receiving IV Meropenem. The lack of labeling was confirmed by RN 1, who noted no documented dressing change in the past three days, contrary to the policy of changing gauze dressings every 48 hours.
A resident with multiple serious health conditions experienced difficulty breathing, prompting an emergency call. However, discrepancies were found in the timing and accuracy of the facility's documentation of the resident's vital signs and the sequence of events. The Director of Nurses acknowledged the inaccuracies, which could lead to miscommunication and affect care delivery.
Dishwashing Machine Operated Below Required Water Temperature
Penalty
Summary
The facility failed to properly wash dishware when the low-temperature dishwasher was operating below the manufacturer’s specified water temperature. During an observation on 2/18/2026 at 8:51 AM, Dietary Aide 1 was washing plate ware from breakfast service while the dishwasher’s water reservoir thermometer read 98 F. The Dietary Services Supervisor stated that water temperature varies during use and should be 120 F at the beginning of dishwashing. A manufacturer poster on the wall indicated that 140 F water is recommended and that staff should report temperatures lower than 120 F or higher than 160 F. On 2/19/2026 at 8:30 AM, Dietary Aide 2 was operating the dishwashing machine while the sink reservoir thermometer again showed 98 F. The Dietary Services Supervisor performed a drain-and-fill and the temperature increased to 105 F, then Maintenance Staff drained the reservoir longer until the inlet thermometer reached 140 F and the reservoir reached 133 F. The Dietary Services Supervisor stated staff had been educated on the procedure but was unable to provide in-service records at the time of request. Facility policy dated 11/2022 stated dishwashing machines are operated according to manufacturer instructions and indicates a wash temperature of 120 F, and the manufacturer’s service manual stated that if the water temperature gauge has not reached 120 F, water should be drained and the machine continued to fill until proper temperature is attained.
Incomplete Annual Nursing Competency Assessments
Penalty
Summary
The facility failed to ensure annual skills competency assessments were completed for four of seven sampled nursing staff, including an LVN and three CNAs. Record review showed the last competency evaluations for the LVN and CNAs were completed in 2024, while the facility assessment revised in 1/2026 required competencies on activities of daily living, infection control hand hygiene, and measurements of vital signs and intake/output to be evaluated upon hire, annually, and as needed for CNAs and licensed nurses. Review of the DSD and IP in-service binder showed the listed staff had competency evaluations completed in 2024 for some required topics, but not as required by the facility assessment. During interviews, the DSD stated nursing staff skills competencies were done upon hire and once a year, but she was not aware of the facility assessment or the competency requirements outlined in it. The DON stated the facility held an annual Skills Fair to assess nursing staff competencies, but she was not aware that the facility assessment included the required topics, and she was unsure whether a makeup day had been completed for staff who missed the Skills Fair. The ADM stated the facility assessment was revised annually by the IDT and that there would be a concern if staff competency was not completed based on the facility assessment.
Low Air Loss Mattress Set Incorrectly for Resident With Pressure Injuries
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for one resident with multiple pressure injuries when the resident’s low air loss mattress was set to the wrong comfort setting. The resident was admitted with a Stage 3 pressure injury of the right lower back and unstageable pressure injuries of the left heel and sacrum. The MDS indicated the resident had severely impaired cognition, required maximal assistance for turning, was dependent on staff for most cares, and was at risk for pressure injuries. The care plan identified the resident as at risk for pressure injury development related to fragile skin, immobility, aging process, and disease process, and directed use of a low air loss mattress at Setting 3 for residents weighing 135 to 170 lbs. The resident’s weight was documented as 161 lbs, and the manufacturer’s guidelines for the low air loss mattress indicated that residents weighing 135 to 170 lbs should be set at level 3. During observation, the mattress pump label indicated Setting 3, but the Comfort Adjust setting on the machine was lit at level 4. The DON stated the label indicated what setting the mattress should be on and confirmed the resident’s mattress was set to 4 instead of 3 based on the resident’s weight and the manufacturer’s guidelines. The DON also stated she usually checked residents’ low air loss settings to ensure they were appropriate, but did not do so that day.
Inadequate Head-of-Bed Elevation During Continuous Tube Feedings
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feedings for two residents who were receiving continuous G-tube feedings. Resident 36 was admitted with diagnoses including attention to gastrostomy, GERD, dysphagia, and generalized muscle weakness, and the MDS indicated severely impaired cognitive skills and dependence for all ADLs. Resident 36’s care plan and order summary directed continuous formula via G-tube at 60 cc/hour for 20 hours a day with the head of bed elevated 30 to 45 degrees during feeding. Resident 25 was originally admitted and later readmitted with diagnoses including attention to gastrostomy tube, dysphagia, and hemiplegia/hemiparesis, and the MDS indicated severely impaired cognitive skills and dependence for all ADLs. Resident 25’s care plan and order summary directed continuous formula via G-tube at 65 cc/hour for 20 hours a day with the head of bed elevated 30 to 45 degrees during feeding. During a concurrent observation and interview, both residents were observed receiving continuous enteral feedings with their head of bed elevated less than 30 degrees; an angle measuring device confirmed Resident 36 at 19 degrees and Resident 25 at 22 degrees. The LVN stated the head of bed should be elevated at least 30 degrees during enteral feeding, and the DON stated it was unacceptable for the residents to be below that level. The facility policy titled Enteral Feedings - Safety Precautions required elevating the head of bed at least 30 degrees during tube feeding and for at least 1 hour after feeding.
Failure to Use Gown During Enhanced Barrier Precautions Care
Penalty
Summary
The facility failed to ensure CNA 1 donned an isolation gown while providing high-contact care to Resident 7, who was on Enhanced Barrier Precautions due to an unhealed sacro coccyx wound. Resident 7 was originally admitted with diagnoses including a pressure ulcer of the sacral region, anemia, and end stage renal disease. The MDS dated 11/19/2025 indicated the resident had moderately impaired cognitive skills and required assistance with eating, toileting, bathing, and personal hygiene. The care plan dated 11/24/2025 directed use of a gown during high-contact care activities such as brief changes, and the EBP signage posted at the resident’s doorway also indicated to use a gown for brief changes. During observation on 2/18/2025, CNA 1 entered Resident 7’s room and changed the incontinent brief without wearing an isolation gown. CNA 1 stated she forgot to wear a gown during the care, although she knew the resident was on EBP isolation, and stated that wearing a gown during brief changes is important to prevent infection in the facility. The DON later stated she was aware CNA 1 changed the brief without wearing an isolation gown and confirmed the resident was on EBP isolation because of the unhealed sacro coccyx wound. The facility policy on Enhanced Barrier Precautions, revised 4/2022, states that EBP uses isolation gown use during high-contact resident care activities, including hygiene and changing briefs.
Failure to Develop Person-Centered Care Plan for Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was prescribed both apixaban (an anticoagulant) and clopidogrel bisulfate (an antiplatelet medication). Despite the resident's medical history, which included Parkinson's disease, atherosclerotic heart disease, and other vein disorders, there was no care plan initiated to address the use of these medications. The resident's records, including the admission record, order summary reports, and comprehensive care plan, did not reflect any individualized plan or interventions related to the administration of apixaban or clopidogrel bisulfate. Interviews with facility staff, including an LVN and the DON, confirmed that no resident-specific care plans were in place for the use of these medications. Both staff members acknowledged that the absence of such care plans meant there were no established goals or interventions to guide care related to the medications, and that this was not in accordance with facility policy. The staff recognized that the resident was at risk for issues such as bruising and skin discoloration, as noted in the resident's skin assessments, but these risks were not addressed in a care plan. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives, timeframes, and interventions based on the resident's needs and conditions. However, the care plans for this resident did not include any information or interventions related to the use of anticoagulant or antiplatelet therapy, despite the resident's moderate cognitive impairment and ongoing use of these medications.
Failure to Monitor and Document Resident Conditions
Penalty
Summary
The facility failed to adequately assess, monitor, and intervene in the care of two residents, leading to deficiencies in their treatment. Resident 28, who was admitted with obstructive pulmonary disease and a malignant brain tumor, developed a self-inflicted wound under the left eye. Despite the presence of a care plan indicating the need for monitoring and intervention, there was no evidence of assessment or treatment for the wound. Observations revealed active bleeding and an open tear, with the resident reporting no treatment had been provided for four days. Interviews with staff confirmed the lack of documentation and notification to the physician regarding the resident's condition. Resident 31, admitted with gastroesophageal reflux disease and intervertebral disc degeneration, experienced daily episodes of vomiting. The care plan required monitoring for fluid volume depletion and notifying the physician as needed. However, there was no documentation of the root cause of the vomiting or evidence that the physician was informed. Observations and interviews indicated frequent vomiting, yet staff failed to document the frequency or duration of these episodes, and the resident's electrolytes were not monitored. The facility's policies on skin care and changes in a resident's condition were not followed, as evidenced by the lack of timely notification to physicians and inadequate documentation of the residents' conditions. These deficiencies in care and communication could potentially lead to further health complications for the residents involved.
Failure to Obtain Informed Consent for Amitriptyline Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 19, received informed consent prior to the administration of Amitriptyline, a medication used to treat depression and neuropathic pain. The resident was admitted with diagnoses including polyneuropathy and pyogenic arthritis and was noted to have moderately impaired cognitive skills for daily decision-making. Despite these conditions, there was no documentation indicating that the resident or a responsible party was informed about the risks and benefits of Amitriptyline before its administration began on May 24, 2024. The medication was administered nightly from January 1, 2025, to January 22, 2025, without documented informed consent. During a review of the facility's policies, it was noted that federal and state laws require residents to be informed and participate in their care planning and treatment. The facility's policy on psychotropic medication use also emphasized the importance of understanding the benefits and risks of medication therapy. However, the clinical record review with an LVN confirmed the absence of informed consent documentation for Amitriptyline until January 23, 2025. This oversight violated the resident's rights to make informed decisions about their treatment, as confirmed by interviews with facility staff.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 15 and 195, had their call light devices within reach, which is crucial for them to call for assistance when needed. Resident 15, admitted with conditions such as rheumatoid arthritis, contracture of the left knee, and a tear of the meniscus, was observed with the call light on the floor beneath the bed. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills and a need for substantial assistance with daily activities, along with a risk for falls. A Certified Nurse Assistant (CNA) confirmed the call light was out of reach, which could lead to the resident falling and injuring themselves. The resident's care plan emphasized the importance of having the call light within reach to anticipate and meet needs promptly. Similarly, Resident 195, who had a history of falling, muscle weakness, dementia, and rheumatoid arthritis, was found with the call light on the floor beside the bed. The MDS for Resident 195 also showed severely impaired cognitive skills and a risk for falls, requiring partial assistance with daily activities. A CNA acknowledged the call light was out of reach, posing a risk of injury if the resident attempted to get out of bed independently. The care plan for Resident 195 included interventions to attend to needs promptly. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), highlighted the importance of having the call light within reach to prevent falls and ensure timely assistance, as per the facility's policy and procedure on call lights.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the primary physician of a significant change in condition for a resident who experienced daily episodes of vomiting over an unknown period. This oversight resulted in a delay in treatment and monitoring, which could have prevented fluid loss, discomfort, and weight loss for the resident. The resident, admitted with diagnoses including gastro-esophageal reflux disease, intervertebral disc degeneration, and kidney disease, had severely impaired cognition and required maximal assistance with activities of daily living. Interviews and record reviews revealed that there was no documentation of the resident's daily vomiting episodes in the progress notes, nor was there evidence that the primary physician was informed. A registered nurse confirmed the lack of documentation and notification, while a licensed vocational nurse observed the resident using a bucket for vomiting. The facility's policy mandates prompt notification of the resident's physician and representative in case of changes in the resident's medical or mental condition, which was not adhered to in this instance.
Deficient Care Plans for Weight Loss and IV Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific health needs. Resident 6, who was admitted with a history of neck fracture, falls, and malnutrition, had a care plan for weight loss that lacked measurable objectives and time frames, such as target weights. The care plan was incomplete as it did not specify the resident's baseline weight, which is crucial for monitoring progress. Despite the resident's severely impaired cognition and poor appetite, the care plan did not provide clear guidelines for achieving weight stability. Resident 39, who was readmitted with conditions including surgical amputation, diabetes mellitus, and osteomyelitis, did not have a care plan addressing the care and monitoring of an intravenous (IV) catheter. The absence of a care plan for the IV catheter meant that staff lacked guidance on how to manage the IV site, which is essential for preventing complications such as bleeding, infiltration, and infection. The facility's policy requires care plans to include measurable goals and reflect the resident's current condition, but this was not adhered to in the case of Resident 39.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure proper grooming and personal hygiene for one of the sampled residents, identified as Resident 28. The deficiency was observed when a Licensed Vocational Nurse (LVN) noted that Resident 28 had dirt under their nails. This observation was made during an interview and concurrent observation in the resident's room. The facility's policy and procedure on nail care, revised in February 2018, requires daily cleaning and regular trimming of nails to prevent skin problems and infections. However, the care plan for Resident 28, which was revised in January 2025, indicated that the Activities Department was responsible for maintaining and cleaning the resident's nails at least once a week, which was not adhered to. Resident 28 was admitted to the facility in September 2020 with diagnoses including a malignant brain tumor, acute respiratory failure, and paralysis of the vocal cords and larynx. Despite these conditions, the resident was alert and oriented, with intact cognition as per the Minimum Data Sheet dated December 2024. The resident required substantial assistance for personal hygiene tasks, including nail care. The failure to maintain the resident's nails in a clean condition was a deviation from the facility's policy and posed a potential risk for skin infection and poor body image.
Failure to Label IV Dressing as per Policy
Penalty
Summary
The facility failed to ensure proper labeling of an intravenous (IV) catheter dressing for a resident, which is a requirement according to the facility's policy. During an observation, it was noted that the IV dressing on the resident's right hand was not labeled with the date, time, or the initials of the nurse who applied it. This lack of labeling was confirmed by RN 1, who also stated that there was no documented evidence of the dressing being changed in the past three days, despite the facility's policy requiring gauze dressings to be changed every 48 hours or when soiled. The resident involved had a medical history that included surgical amputation, diabetes mellitus, and osteomyelitis, and was receiving intravenous Meropenem as part of their treatment. The resident was capable of understanding and making decisions, as indicated by their intact cognition. The failure to label the IV dressing as per the facility's policy placed the resident at risk for complications, as staff would not be able to determine when the dressing needed to be changed, potentially leading to infection at the site.
Inaccurate Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, which is a violation of accepted professional standards. The incident involved a resident who was admitted with multiple serious health conditions, including respiratory failure, heart failure, sepsis, gastrostomy, dementia, and epilepsy. The resident was dependent on assistance for daily activities and lacked the capacity to make decisions. On the day of the incident, the resident experienced difficulty breathing, and emergency services were called. However, discrepancies were found in the timing and accuracy of the documentation of the resident's vital signs and the sequence of events leading to the emergency call. The progress notes indicated that the resident was in distress at 1:00 AM, but the paramedic report showed that the emergency call was made at 12:25 AM, and the paramedics arrived shortly after. The facility's documentation of the resident's vital signs at 3:42 AM did not match the paramedic's report, which recorded different vital signs at an earlier time. The Director of Nurses acknowledged that the timing of the documentation was inaccurate. This inconsistency in record-keeping could lead to miscommunication and affect the delivery of care, as per the facility's policy, which requires objective, complete, and accurate documentation of any changes in a resident's condition.
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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.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenhaven Healthcare | 0.1 mi | ★★★★★ | 14 | 0 |
| Chestnut Ridge Post Acute Llc | 0.5 mi | ★★★★★ | 35 | 1 |
| Leisure Glen Post Acute Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Broadway Manor Care Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 1.2 mi | ★★★★★ | 35 | 0 |
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