Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Glenhaven Healthcare during CMS and state inspections, most recent first.
A CNA was observed handling meal trays and providing resident assistance without performing hand hygiene between resident contacts, despite acknowledging she forgot and should have done so before and after care. In the kitchen, a cook prepared and plated food with an uncovered mustache, while the DS was unsure of the requirement and the DON confirmed the facility policy required facial hair to be covered during food preparation. The affected residents included individuals with diabetes, hypertension, schizoaffective disorder, CKD, and osteomyelitis, with varying cognitive status and care needs.
A resident’s chart lacked the name of an antidepressant on the CAR consent even though consent was obtained for psychotropic use and Zoloft was later ordered. Another resident’s RNA weekly restorative assessment was missed because of a date miscount, and an LVN incorrectly documented metoprolol as given on the MAR even though the dose was held for low BP and remained in the bubble pack. The DON and staff confirmed the documentation errors.
Infection control lapses were observed with oxygen equipment for several residents. Two residents had humidification bottles in their room without a date or resident name, an RN stated the bottles should be dated and labeled, and the facility policy required labeling and routine replacement. Another resident was receiving O2 via NC without a label or date of last change, and the DON stated the NC should be changed weekly. A fourth resident’s NC was found on the floor while the resident was in bed without oxygen, and the DON identified this as an infection control issue.
Resident Found in Soiled Gown: A resident with dementia, diabetes, and HF who was dependent on staff for most ADLs was observed wearing a gown soiled with food and liquid. RN confirmed the resident should not have been left in the soiled gown and stated it could cause embarrassment. The facility policy required residents to be cared for in a manner that promotes dignity, respect, and individuality.
A resident with CHF, anemia, osteoarthritis, bilateral artificial knee joints, weak extremities, and high fall risk did not have her call light within reach. During an observation with the DON, the call light was found on the floor while the resident was awake and unable to reach it. The DON stated call lights are expected to be within reach, especially for residents who need assistance.
Advance directive documentation was incomplete for two residents. One resident with ESRD on HD had an Advance Directive acknowledgment form that was not dated, not signed, and missing the intensity-of-care authorization, while another resident admitted for respite hospice care had a POLST noting an advance directive but no copy of the directive in the chart. The DON and DSS confirmed the missing documentation and stated the POLST and advance directive are separate legal documents.
A resident who required dependent assistance for personal hygiene and shaving was observed with thick facial hair during the morning and remained unshaven later that day. The resident, who had CHF, acute respiratory failure, and generalized muscle weakness, agreed to be shaved when asked, but routine nursing care did not include the needed grooming assistance. RN stated that morning care should ensure residents needing ADL help are clean and well-groomed, including shaving.
A resident with dysphagia and a GT was observed receiving Jevity 1.5 calorie at 45 mL/hr even though the physician ordered Jevity 1.2 via feeding pump. The LVN confirmed the resident was receiving the wrong formula, and the DON stated the incorrect formula can cause nutritional deficiencies or surpluses, slow wound healing, weight gain, and electrolyte imbalances. The facility policy required tube feedings to be compared against the physician’s order.
Failure to Maintain Ordered Continuous Oxygen Therapy: A resident with CHF, anemia, and sleep apnea was ordered continuous O2 at 2 to 4 L/min via NC, but surveyors observed the NC on the floor and not connected for at least five minutes while the resident was in bed with eyes closed. The DON confirmed the resident needed continuous oxygen, stated the resident should have been receiving O2 as ordered, and noted the facility policy required oxygen support to maintain adequate oxygenation.
A facility failed to ensure multiple-occupancy resident bedrooms met the required 80 sq ft per resident. A review of the room accommodation analysis showed 12 rooms were below the minimum size, including rooms with two or four occupied beds. During observation and interview, residents, a CNA, an LVN, and the MS stated they had no concerns with the room sizes and were able to provide or receive care, and the MS confirmed the measured room sizes and bed counts.
A resident with a history of aggressive behavior was involved in multiple altercations, including kicking another resident's wheelchair and later striking a different resident during an activity. Despite internal reporting, the incidents were not reported to external authorities within the required timeframe, and the resident was not placed under increased supervision as indicated by policy. The care plan lacked interventions for monitoring aggressive behavior, and staff interviews confirmed the failure to follow abuse reporting protocols.
A resident tested positive for influenza and required droplet precautions, but the facility failed to ensure the bedside curtain was fully closed, increasing the risk of infection spread. The resident, who had Diabetes Mellitus and Chronic Kidney Disease, was in a shared room with two other residents. The infection preventionist confirmed that guidelines required the curtain to be fully closed, but it was found partially open due to it being stuck. The DON acknowledged the issue, noting the lack of a single room for the resident.
A resident with limited mobility and incontinence developed a Stage 2 pressure injury that progressed to Stage 4 due to the facility's failure to consistently implement care interventions such as repositioning and incontinence management. Despite being at high risk, the resident's care plan was not effectively followed, and there was inadequate monitoring and communication among staff, leading to the worsening of the resident's condition.
The facility failed to properly dispose of garbage, resulting in an overflowing dumpster and trash on the ground, which could attract pests and pose health risks. The Maintenance Supervisor, Dietary Service Supervisor, and Administrator acknowledged the issue, and the housekeeping supervisor admitted responsibility for maintaining cleanliness. The facility's policy requires safe disposal and a clean area around the dumpster.
The facility failed to ensure call lights were within reach for three residents, impacting their ability to signal for assistance. A resident with dementia and blindness had a call light tucked between the mattress and bed rail, making it inaccessible. Another resident with dementia and Parkinson's disease had a call light placed out of reach, and a third resident with COPD and muscle weakness had a call light hanging on the side of the bed, unreachable. Staff confirmed the call lights were not accessible, contrary to facility policy.
The facility failed to follow food storage policies, leading to expired and unlabeled food items in the kitchen. Observations revealed 15 ham sandwiches and six breaded fish with expired use-by dates, and two hotdog buns and a pitcher of prune juice without labels or dates. The Dietary Service Supervisor and Director of Nurses acknowledged the importance of labeling and discarding expired food to prevent contamination and health risks to residents.
A facility failed to implement its infection control policy, leading to a deficiency in preventing infection spread. A CNA did not wear appropriate PPE or practice hand hygiene when entering a resident's room under contact precautions for a multi-drug-resistant organism infection. Despite a contact precaution sign, the CNA entered the room without a gown or gloves and did not sanitize hands before entering another resident's room. The facility's policies required PPE use and hand hygiene, which were not followed.
A CNA failed to maintain a resident's dignity by standing over them while providing feeding assistance, contrary to facility policy. The resident, diagnosed with dementia and hemiplegia, required full assistance with eating. The CNA admitted the oversight, and the DON confirmed the importance of sitting at eye level with residents during meals.
A facility failed to ensure an advance directive and POLST were accessible in a resident's medical records. The resident, with a history of dementia and other conditions, had severely impaired cognitive skills and required significant assistance. Staff interviews confirmed the absence of these documents in the chart, which was against facility protocol. The Director of Nursing acknowledged the importance of having these documents readily available to prevent delays in care.
Two residents at high risk for falls were inadequately supervised, leading to potential injury. One resident was observed without a required floor mat, and another fell in a room not his own, with no staff monitoring. The facility failed to implement care plan interventions and lacked documentation of required supervision.
A facility failed to use appropriate alternative interventions before installing bilateral 1/4 siderails for a resident with impaired cognition and mobility issues, risking entrapment and injury. The resident's records showed siderails were used for bed mobility without prior alternative methods. The DON admitted the facility did not follow its policy for bedside rail assessment, which required alternate methods and least restrictive measures before siderail use.
The facility failed to maintain accurate medical records for two residents. One resident's wound care treatment was not documented by the IP, leading to potential inconsistencies in care. Another resident's discharge disposition was incorrectly recorded by the MDS Nurse, contradicting the facility's documentation guidelines.
The facility failed to meet the required minimum room size of 80 square feet per resident in 12 out of 16 rooms. Despite this, residents and staff reported no issues with space for care or privacy. The facility submitted a Room Waiver Request to monitor room capacity.
A resident with a history of respiratory issues experienced chest pain and difficulty breathing, requesting transfer to a hospital. The LVN on duty, unfamiliar with facility protocols, delayed the transfer for over four hours, despite the resident's and emergency contact's requests. The LVN failed to document the situation using the SBAR form, and the DON did not respond promptly, leading to a deficiency in care.
A resident with respiratory issues and anxiety disorder experienced chest pain and difficulty breathing. The LVN on duty, from a Nursing Registry, failed to act promptly due to a lack of protocol awareness and inability to contact the DON. The resident's emergency contact's request for hospital transfer was initially denied, leading to a delayed 911 call. The LVN had not completed the facility's competency checklist, contributing to the deficiency.
A resident with dementia and combative behavior was improperly restrained by an LVN, leading to physical injury and psychosocial harm. The facility failed to implement care plan interventions and develop a comprehensive plan to address the resident's behaviors, resulting in the unnecessary use of physical restraints. The facility's actions violated their policy on Physical Restraint Management.
Hand Hygiene and Food Preparation Hygiene Lapses
Penalty
Summary
The facility failed to follow its hand hygiene and personal hygiene policies during meal service and resident care. A CNA was observed bringing meal trays to residents, assisting one resident into a sitting position with physical contact, touching another resident’s blankets while setting up the meal tray, and removing a meal tray from a resident’s bedside table, but leaving the room each time without performing hand hygiene. When interviewed, the CNA stated she had been too busy and forgot to perform hand hygiene, and acknowledged she should have done so before and after providing care to each resident. The deficiency involved three sampled residents. Resident 6 was admitted with diabetes, heart disease, and hypertension; the H&P stated the resident had the capacity to understand and make decisions, and the MDS described the resident as cognitively intact but requiring maximum assistance with most activities of daily life, including oral hygiene, toileting, and showering. Resident 10 was admitted with diabetes, hypertension, and schizoaffective disorder; the H&P stated the resident had the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment. Resident 29 was admitted with diabetes, chronic kidney disease, and osteomyelitis; the H&P stated the resident had the capacity to understand and make decisions, and the MDS described the resident as cognitively intact and able to complete eating, personal hygiene, and oral hygiene by self. Food preparation practices were also not followed in the kitchen. A cook was observed preparing resident food and placing food on meal plates without covering a thick mustache. The Dietary Supervisor stated she was unsure whether facial hair had to be covered and needed to check the policy. The DON reviewed the facility policy and stated the mustache was body hair that required covering during food preparation to prevent hair from dropping into food and causing contamination. The facility policy on personal hygiene stated beards or any exposed body hair must be covered, and the hand hygiene policy stated hand hygiene methods should be followed between contact with residents.
Inaccurate documentation of psychotropic consent, restorative nursing assessment, and MAR entry
Penalty
Summary
Resident 1’s medical record did not accurately document informed consent for psychotropic medication use. The resident was admitted with pneumonia and depressive episodes, and the MDS dated 10/2/2025 indicated moderate cognitive impairment and a need for maximum assistance with most ADLs. The H&P dated 12/9/2025 stated the resident did not have the capacity to make own decisions. The CAR consent dated 12/8/2025 did not include the name of the antidepressant medication, even though the physician order summary dated 12/8/2025 indicated informed consent was obtained for administration of an antidepressant and the order summary dated 12/24/2025 showed Zoloft was ordered for depression. RN 2 reviewed the consent and verified that the medication name was missing from the form. Resident 33’s restorative nursing documentation was not completed as required on the weekly summary. The resident was admitted and readmitted with diagnoses including CVA and aphasia, and the MDS dated 10/31/2025 indicated severe cognitive impairment and dependence for oral hygiene, toileting hygiene, bathing, dressing, and transfers. The order listing report dated 12/9/2025 showed the resident was to receive a restorative nursing program with bilateral locked knee splints, bilateral hand splints, and bilateral PRAFOs. RNA 1 stated weekly assessments were done every Friday and acknowledged that the assessment due on 1/2/2026 was missed because of confusion about the dates. The DON stated the weekly assessment documentation due on 1/2/2026 was missed due to a miscount of days. Resident 45’s MAR was documented inaccurately for metoprolol tartrate. The resident had diagnoses including atherosclerotic heart disease, paroxysmal atrial fibrillation, hypertension, and cerebral ischemia, and the MDS dated 2/24/2025 indicated severely impaired cognitive skills and dependence for all listed ADLs and transfers. The physician order dated 11/29/2025 directed metoprolol tartrate twice daily for hypertension and to hold it if systolic blood pressure was less than 110. The MAR dated 1/7/2026 showed the evening dose was given on 1/6/2026 even though the blood pressure was 102/66. LVN 1 stated the medication was not actually administered and that the MAR entry was made in error; the DON also confirmed the medication should not have been documented as given and observed that the bubble pack still contained the evening dose.
Infection Control Lapses With Oxygen Equipment
Penalty
Summary
The facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for four sampled residents. The deficiency was identified during observation, interview, and record review and involved respiratory equipment used for oxygen therapy. The facility's policy and procedure titled Scope of Infection Control Program stated the infection prevention and control program was to provide a safe, sanitary, and comfortable environment and help prevent communicable diseases and infections. Resident 8 was admitted with diagnoses including sepsis, diabetes, and dementia, and records showed the resident was unable to make own decisions and was dependent for all activities of daily living. Resident 2 was admitted with diagnoses including diabetes, dementia, and heart failure, and records showed the resident lacked capacity to understand and make decisions and was dependent for most ADLs. During observations in the shared room, both residents' humidification bottles were observed without a date and without the resident's name. RN1 stated the humidification bottles should be dated and labeled with the resident's name, and if not dated it could be old and an infection control issue because staff would not know when to change it. The facility policy for disposable respiratory equipment stated opened solutions were to be discarded after 24 hours and labeled with the resident's name, room number, and date changed. Resident 27 was admitted with diagnoses including chronic heart failure, acute respiratory failure, and generalized muscle weakness, and the MDS showed the resident required substantial to maximal assistance with eating and was dependent for toileting, bathing, dressing, and personal hygiene. During a concurrent observation and interview, Resident 27 was receiving oxygen via NC without a label or date of the last time it was changed. The DON stated the NC was not labeled with the date it was last changed to identify whether it was new or old and that it was changed weekly per policy. Resident 39 was admitted and readmitted with diagnoses including chronic heart failure, anemia, and sleep apnea, and the MDS showed the resident required substantial to maximal assistance with personal hygiene and dressing and was dependent for toileting and bathing. During observation, Resident 39 was in bed with eyes closed and was not receiving oxygen because the NC was on the floor for at least five minutes. The DON stated the NC on the floor was an infection control issue and could be contaminated with virus and/or bacteria. The facility policies for disposable respiratory equipment and oxygen administration indicated humidifiers and NCs were to be labeled and NCs changed every 7 days.
Resident Found in Soiled Gown
Penalty
Summary
The facility failed to promote dignity and respect for one resident who was observed wearing a soiled gown. Resident 2 was admitted with diagnoses including diabetes, dementia, and heart failure. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognition and dependence on staff for most ADLs, including toileting hygiene and showers. The care plan identified altered cognition, impaired ability to communicate and understand others, inability to make needs known, and the need for assistance with ADLs and anticipation of needs. During an observation, Resident 2 was seen in the room wearing a gown soiled with oatmeal-colored food and liquid on the chest area. In a concurrent observation and interview, RN1 confirmed the resident was wearing a gown soiled with food and liquid stains and stated the resident should not have been left in a soiled gown and that it should have been changed as soon as possible. RN1 further stated that leaving the resident in a soiled gown had the potential to cause embarrassment. The facility policy on dignity stated that residents shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Call Light Not Within Reach
Penalty
Summary
The facility failed to keep a resident’s call light within reach. Resident 39 was admitted and readmitted to the facility with diagnoses including chronic heart failure, anemia, osteoarthritis, and bilateral artificial knee joints. The resident’s H&P dated 6/16/2025 indicated she was alert and oriented to person and place and had weak extremities. The MDS dated 12/15/2025 showed she was sometimes able to make herself understood and understand simple communication, required substantial/maximal assistance with personal hygiene and dressing, and was dependent for toileting and bathing. Her care plan for fall risk, revised 11/17/2024, included placing the call light within reach and prompting response to requests for assistance. Her fall risk assessment dated 12/16/2025 indicated she could not walk unassisted and was at high risk for falls. During a concurrent observation and interview on 1/8/2026 at 8:12 AM, the DON observed Resident 39 awake and, when asked where her call light was, the resident touched her chest area. The call light was on the floor and not within reach. The DON stated the resident was not able to reach the call light, which had the potential for staff not being able to attend to her needs, especially during an emergency. In a later interview on 1/8/2026 at 11:48 AM, the DON stated he expected call lights to be within reach of residents, especially those who could use them, and that for Resident 39, who was at high risk for falls, not being able to use the call light for assistance had the potential for fall and/or injury. The facility’s Fall Prevention Program and Answering Call Lights policies both stated that resident care articles and call lights should be placed within reach or easy reach.
Advance Directive Documentation Not Completed or Obtained
Penalty
Summary
The facility failed to inform and obtain an Advance Directive acknowledgment form, or properly complete the form, for two sampled residents. Resident 9 was admitted and later readmitted with end stage renal disease and dependence on hemodialysis. The resident’s H&P dated 12/23/2025 indicated the resident had capacity to understand and make decisions, and the MDS dated 12/23/2025 indicated the resident was cognitively intact but required maximal assistance with most ADLs. Review of the medical chart showed the Advance Directive Acknowledgment Form was not dated or signed by Resident 9 and did not include the resident’s preferred intensity of care for authorization for treatment. During a concurrent interview and record review on 1/6/2026 at 11:10 AM, the DSS confirmed the form was not dated, not signed by the physician, and missing the authorization for intensity of care, and stated it should have been completed upon admission. Resident 53 was admitted for respite hospice care with diagnoses including malignant neoplasm of the bladder, hypertension, and anxiety disorder. The resident’s POLST dated 10/23/2025 indicated an advance directive dated 9/29/2018, but the medical record did not contain a copy of the advance directive. During an interview on 1/8/2026 at 2:45 PM, the DON stated the POLST and advance directive are different legal documents and that Social Services should obtain a copy of the advance directive. During an interview on 1/9/2026 at 9:35 AM, the DSS stated the copy was not in the chart and that the facility should have obtained it. The facility policy titled Advanced Directives, dated February 2017, stated a copy of the advance directive must be obtained from the resident or legal representative and placed in the clinical record, and that the facility must document whether the resident has issued an advance directive.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary assistance with grooming and personal hygiene during routine nursing care for one resident who was unable to complete these activities independently. Resident 27 was admitted with chronic heart failure, acute respiratory failure, and generalized muscle weakness. The MDS dated 12/22/2025 indicated the resident was sometimes able to make self-understood and understand simple communication, but required substantial/maximal assistance with eating and was dependent for toileting, bathing, dressing, personal hygiene, and shaving. The care plan revised on 1/3/2026 identified a need for assistance with ADLs, including personal hygiene, with staff to provide assistance as needed. During observation on 1/6/2026 at 9:51 AM, Resident 27 was lying in bed rubbing thick facial hair and agreed when asked if he wanted his facial hair shaved. During a later observation the same day at 3:45 PM, the resident was still observed with thick facial hair and remained unshaven. RN 1 stated that routine morning care should ensure residents needing ADL assistance are clean and well-groomed, including shaving facial hair, and that not providing grooming assistance during morning care could negatively affect the resident's self-esteem. The facility policy stated residents are to receive necessary assistance to maintain good grooming and personal hygiene, and that staff should assist residents to remain clean, neat, and well-groomed, including shaving.
Incorrect Tube Feeding Formula Administered
Penalty
Summary
Resident 52, who was admitted with diagnoses including dysphagia and a gastrostomy tube, had the capacity to understand and make decisions according to the history and physical. During an observation in the resident’s room, Resident 52 was receiving Jevity 1.5 calorie at 45 milliliters per hour through the GT, with the tubing dated 1/5/2026. During a concurrent interview and record review, the physician’s order for Resident 52 indicated Jevity 1.2 via feeding pump. The LVN stated the resident was receiving the wrong tube feeding formula and that it can lead to weight gain. The DON stated that providing the incorrect tube feeding formula can lead to nutritional deficiencies or surpluses, slow wound healing, weight gain, and electrolyte imbalances. The facility policy titled Enteral Feeding Via Pump Administration stated that all tube feedings should be compared against the physician’s order.
Failure to Maintain Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous supplemental oxygen therapy as ordered for one resident who was prescribed oxygen at 2 to 4 liters per minute via nasal cannula continuously. The resident’s record showed diagnoses including chronic heart failure, anemia, and sleep apnea. The resident’s H&P indicated the resident was alert and oriented to person and place, and the MDS showed the resident sometimes could make self-understood and understand simple communication, but required substantial to maximal assistance with personal hygiene and dressing and was dependent for toileting and bathing. The care plan for risk for ineffective airway clearance related to sleep apnea included administering oxygen 2 to 4 liters per minute via nasal cannula continuously. During observation in the resident’s room, the resident was in bed with eyes closed and was observed for at least five minutes without receiving oxygen because the nasal cannula was on the floor and not connected to the resident. The DON observed the same condition and stated the resident needed continuous oxygen due to sleep apnea and that the resident did not know why the nasal cannula was on the floor. The DON also stated that if the resident did not receive oxygen for five minutes, the resident had the potential to experience respiratory distress. In interview, the DON stated it was the facility’s policy to provide oxygen support to maintain adequate oxygenation for respiratory compromised residents and acknowledged the resident should have been receiving oxygen as ordered. The facility policy on oxygen administration stated oxygen support should be provided when indicated via the appropriate delivery device to achieve or maintain adequate oxygenation, maintain tissue oxygenation in chronically hypoxic residents, and that the oxygen setup should be checked regularly to ensure proper functioning.
Resident Bedrooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that resident bedrooms measured at least 80 square feet per resident in multiple-occupancy rooms. A review of the Client Accommodation Analysis dated 1/6/2026 showed that 12 resident bedrooms did not meet the required space per resident, including rooms with two beds and rooms with four beds. The listed rooms included rooms 2, 3, 4, 7, 8, 9, 10, 11, 12, 14, and 15, with room sizes ranging from about 155.6 square feet to 292.4 square feet while occupied by two or four residents. During observations and interviews, residents and staff stated they had no concerns about the room sizes and were able to move around and provide care. Resident 40 was observed in a wheelchair and able to propel self in the room, and Resident 16 and Resident 10 stated they were fine with their room sizes. CNA 2 and LVN 4 stated they had enough space to care for residents, including those using wheelchairs. The Maintenance Supervisor measured sampled rooms and confirmed the room sizes and bed counts. The facility’s Room Waiver Request stated the Administrator and DON would screen admissions and complete room rounds to ensure only the allowed capacity of residents were placed in the listed rooms, and that the rooms were inspected for equipment such as wheelchairs, guest chairs, and a Hoyer lift.
Failure to Timely Report and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and immediately report, within the required two-hour timeframe, an alleged abuse incident involving verbal and physical altercations between residents. On the morning of 6/5/2025, a resident with a history of aggressive behavior kicked another resident's wheelchair and engaged in a verbal altercation. Despite this incident being witnessed and reported internally, it was not reported to the appropriate external agencies as required by facility policy and state regulations. The Director of Nursing (DON) acknowledged that the incident was not reported because there was no physical injury, contrary to the policy that mandates reporting all alleged abuse regardless of injury. The resident involved in the altercations had a documented history of schizoaffective disorder, bipolar disorder, and anxiety, and was noted to lack capacity to make decisions. This resident had previously exhibited aggressive behavior, including hitting an LVN on 6/2/2025. Despite these prior incidents, the care plan did not include specific interventions for supervision or monitoring to address the resident's aggressive behavior. On 6/5/2025, after the initial altercation in the hallway, the same resident later struck another resident in the activity room during a BINGO game, again without having been placed on increased monitoring or supervision. Interviews with staff confirmed that the incidents were reported internally but not to the required external authorities within the mandated timeframe. Staff members, including the Activity Director, DON, and others, stated that the policy required immediate reporting of all alleged abuse, but this was not followed. The facility's own policy emphasized prevention, identification, and timely reporting of abuse, but these procedures were not adhered to, resulting in a failure to protect residents from further harm.
Failure to Implement Proper Droplet Precautions for Influenza-Positive Resident
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for a resident who tested positive for influenza and required droplet precautions. During an observation, it was noted that the bedside curtain for the resident was partially open, despite the presence of two other residents in the same room. A certified nurse assistant (CNA) was observed wearing only a simple face mask, and the curtain was reported to be stuck, which prevented it from being fully closed. The infection preventionist confirmed that guidelines required the curtain to be fully closed to maintain droplet precautions. The resident in question was admitted with medical diagnoses including Diabetes Mellitus and Chronic Kidney Disease and was cognitively intact. The resident tested positive for influenza, and Tamiflu was prescribed. The Director of Nursing acknowledged that no single room was available for the resident, but emphasized that the curtain should have been fully closed to prevent the spread of infection. The failure to close the curtain as required by guidelines increased the risk of influenza spreading to other residents and staff in the facility.
Failure to Prevent and Manage Pressure Injuries in Resident
Penalty
Summary
The facility failed to provide necessary care and interventions to prevent pressure injuries for a resident, leading to the development and worsening of pressure ulcers. The resident, who was admitted with conditions such as Parkinson's Disease, spondylosis, and dementia, was assessed to be at high risk for pressure injuries due to limited mobility and incontinence. Despite being identified as high risk, the resident was not consistently turned, repositioned, or kept clean and dry, resulting in the development of a Stage 2 pressure injury on the sacrococcyx, which progressed to Stage 3 and eventually Stage 4. The facility's care plan for the resident included interventions such as offloading, repositioning every two hours, and using a Low Air Loss mattress. However, these interventions were not effectively implemented or monitored. The Treatment Nurse admitted to relying on staff reports without daily follow-up, and the Director of Staff Development did not maintain logs or provide specific training to CNAs after the resident developed pressure injuries. The Director of Nursing acknowledged the lack of a system to ensure consistent repositioning and incontinence management, and there was a delay in notifying the wound consultant about the reopening of the pressure injury. The facility's policy on skin breakdown prevention and management was not adequately followed. The policy required daily skin inspections, frequent incontinence care, and specific care plans for each resident, but these measures were not consistently applied. The lack of documentation and communication among staff contributed to the resident's deteriorating condition, as evidenced by the progression of the pressure injury and the eventual need for hospital transfer due to complications.
Improper Garbage Disposal and Overflowing Trash
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. A metal dumpster was found with its lid open due to overflowing trash bags, and additional trash bags, boxes, and an old mattress were left on the ground in the garbage area. This situation was noted during an observation and interview with the Maintenance Supervisor, who acknowledged the responsibility of the housekeeping supervisor to ensure the trash bin was emptied and the area kept clean. The Dietary Service Supervisor also confirmed that the kitchen shared the same trash bin and emphasized the importance of maintaining cleanliness to prevent pest infestation. The Administrator was unaware of the overflowing trash and surrounding debris until the survey and acknowledged the potential for pest infestation and health risks. The housekeeping supervisor admitted responsibility for maintaining the cleanliness of the garbage area and planned to request additional trash pickups. The Director of Nursing also recognized the risk of infection from pests attracted by the overflowing trash. The facility's policy on garbage disposal, dated August 2017, mandates that garbage and refuse be collected and disposed of safely, and the area around the dumpster be kept free of debris.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by not ensuring that their call lights were within reach, which is crucial for them to signal for assistance. Resident 9, who was admitted with dementia and blindness in the left eye, was observed with a call light tucked between the mattress and bed rail, making it inaccessible. The CNA confirmed that due to Resident 9's blindness and weakness, they would not be able to locate or use the call light. Resident 45, diagnosed with dementia and Parkinson's disease, was found with a call light placed at the top of the bed over the pillow, out of reach. The resident, who experienced tremors and was unable to lift their arms over their head, stated they did not know where the call light button was. The CNA acknowledged that the call light was not within reach and should be accessible to ensure residents can request help. Resident 1, with a history of COPD, anxiety disorder, and muscle weakness, was observed with a call light hanging on the right side of the bed, pointing towards the floor and unreachable. The LVN noted that Resident 1 could use a call light if it were reachable. The facility's policy, as stated by the DON, requires call lights to be within reach to meet residents' needs and ensure their safety, especially in emergencies. The facility's policy and procedure document also indicated that call lights should be placed within easy reach of residents.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure for food storage and professional standards for food service safety. During an observation and interview with the Dietary Service Supervisor (DSS), it was noted that 15 ham sandwiches were stored in a refrigerator with an expired use-by date. Additionally, two hotdog buns were found in a clear plastic bag without a label or use-by date, and six breaded fish were in an open plastic bag in the freezer with an expired use-by date. A pitcher of prune juice was also found in the refrigerator without a label or use-by date. The DSS acknowledged that foods should be labeled with a use-by date and that expired foods should be discarded immediately to prevent potential contamination and health risks to residents. The Director of Nurses (DON) confirmed the importance of labeling food with a current use-by date as per policy to ensure kitchen staff know when to discard items and prevent serving expired food to residents. The facility's policy titled "Food Storage Principle" emphasizes preserving food quality, labeling packages with expiration dates, and discarding foods that exceed their expiration date or have not been used within 48 hours of preparation. The Food Code 2022 also requires ready-to-eat, time/temperature control for safety food to be clearly marked with a date or day by which it should be consumed, sold, or discarded when held at a temperature of 5°C (41°F) or less for a maximum of 7 days.
Infection Control Deficiency Due to Improper PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection control policy and procedures, leading to a deficiency in preventing the spread of infection among residents. Specifically, the facility did not ensure that a Certified Nurse Assistant (CNA) practiced proper hand hygiene and wore appropriate personal protective equipment (PPE) such as gloves and gowns when entering a resident's room under contact precautions. This lapse was observed when CNA 6 entered Resident 5's room, who was on contact precautions due to a multi-drug-resistant organism (MDRO) infection, without wearing a gown or gloves and without performing hand hygiene before and after the visit. Resident 5, who was admitted with conditions including Chronic Obstructive Pulmonary Disease (COPD) and metabolic encephalopathy, required maximal assistance for activities of daily living and was unable to make decisions. Despite the presence of a contact precaution sign outside Resident 5's room, CNA 6 failed to adhere to the facility's infection control policies. This included not using alcohol-based hand rub or washing hands with soap and water after leaving Resident 5's room and before entering another resident's room, Resident 42, who also had enhanced barrier precautions in place. The facility's policies clearly outlined the need for staff to wear appropriate PPE and practice hand hygiene to prevent the spread of infections, which was not followed in this instance.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that a certified nurse assistant (CNA) was seated while assisting a resident during mealtime, which compromised the resident's dignity. The incident involved a resident who was originally admitted to the facility in 2016 and readmitted in 2024, with diagnoses including dementia and hemiplegia. The resident was dependent on assistance for eating, oral hygiene, bathing, toilet hygiene, and transfers. During an observation, the CNA was seen standing over the resident while feeding her, rather than sitting at eye level as required by the facility's policy. The CNA acknowledged during an interview that she should have been seated to maintain the resident's dignity. The Director of Nursing confirmed that staff should not stand over residents while providing feeding assistance. The facility's policy on meal assistance, dated April 2018, specifies that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents during meals.
Failure to Maintain Accessible Advance Directive and POLST in Resident's Chart
Penalty
Summary
The facility failed to ensure that an advance directive and a Physician Orders for Life Sustaining Treatment (POLST) were accessible in the medical records of a resident. This deficiency was identified during a review of the resident's paper chart, which did not contain a copy of the advance directive and the original POLST. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that it was the facility's practice and protocol to have these documents in the physical paper chart to guide care during emergencies. The absence of these documents in the chart was acknowledged by the staff, who emphasized the importance of having them readily available to prevent delays in care. The resident involved had a history of dementia, seizures, and urinary tract infections, and was assessed as having severely impaired cognitive skills, requiring significant assistance with daily activities. The facility's policy and procedure documents indicated that the advance directive and POLST should be filed in the resident's clinical record and be easily accessible. The Director of Nursing (DON) also confirmed the expectation that these documents be present in the resident's chart, highlighting the potential for delayed or negatively affected care if they were missing.
Inadequate Supervision for High Fall Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision for two residents who were at high risk for falls. Resident 4, who had a history of falls and was assessed as a high fall risk, was observed reaching for drinks on a bedside table without a floor mat next to the bed, contrary to the care plan. The Licensed Vocational Nurse (LVN) was unaware of the need for a floor mat, and the Director of Nursing (DON) confirmed that the care plan was not implemented, which could lead to major injury from a fall. Resident 23, also a high fall risk, experienced a fall in a room that was not his own, resulting in skin tears. The care plan for Resident 23 included frequent visual monitoring, but there was no documentation of such monitoring. Staff members, including the Treatment Nurse (TN), Registered Nurse (RN), and Certified Nurse Assistant (CNA), were unaware of who was responsible for monitoring Resident 23 or why he was in another room. The DON acknowledged the lack of documentation and monitoring, which was highlighted by the fact that a visitor, not staff, witnessed the fall. The facility's policies on comprehensive care planning and fall prevention were not followed, as interventions to manage risk factors and ensure increased supervision for high-risk residents were not implemented. The DON admitted that there was no policy for supervision, but stated that high fall risk residents should be supervised at least every hour. The lack of supervision and failure to implement care plan interventions for both residents had the potential to cause major injury from falls.
Failure to Implement Alternative Interventions Before Siderail Installation
Penalty
Summary
The facility failed to implement appropriate alternative interventions before installing bilateral 1/4 siderails for a resident, which could lead to the risk of entrapment and physical injury. The resident, who was admitted and readmitted with conditions such as hypertensive heart disease, chronic kidney disease, heart failure, and muscle weakness, was found to have moderately impaired cognition and was dependent on assistance for mobility. Despite these conditions, the facility did not attempt alternative interventions before resorting to siderails. The resident's medical records indicated that the siderails were installed for bed mobility and to assist with getting in and out of bed. However, the facility's assessment and care plan did not reflect the use of alternative methods before the installation of siderails. The assessment noted the use of frequent monitoring, reminders to use call lights, and restorative care, but no additional alternative interventions were implemented. Furthermore, the resident's head, neck, and chest were not measured to assess the risk of entrapment. Interviews with the Director of Nursing (DON) revealed that the facility did not follow its policies and procedures for bedside rail assessment and management. The DON acknowledged that the immediate use of siderails without implementing appropriate interventions could cause entrapment. The facility's policy required the use of alternate methods and the least restrictive measures before installing siderails, which was not adhered to in this case.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, the Infection Preventionist (IP) did not document wound care treatment provided on a specific date, as she was covering for the treatment nurse and forgot to record it in the Treatment Administration Record (TAR) and Progress Notes. This resident had a stage four pressure ulcer requiring specific treatment, and the lack of documentation could lead to inconsistencies in care. The Director of Nursing emphasized the importance of documenting wound care to ensure continuity and accuracy in treatment. For another resident, there was an error in documenting the discharge disposition. The discharge summary indicated the resident was discharged to an assisted living facility, while the Minimum Data Set (MDS) inaccurately recorded the discharge to a hospital. The MDS Nurse acknowledged the mistake and stated that the resident's discharge disposition should have been documented correctly. The facility's policy and procedure on documentation guidelines require accurate recording of resident events, which was not adhered to in this case.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, 12 out of 16 rooms were found to be below this standard during a review of the Client Accommodation Analysis form. The rooms in question included Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, and 15, which were all measured to be less than the required square footage per resident. Despite this deficiency, interviews with residents and staff indicated that there were no reported issues with the space available for care, movement, or privacy. During the re-certification survey, it was observed that the rooms provided sufficient space for residents' freedom of movement and the necessary nursing care. Each resident had access to individual bedside tables and over-the-bed tables, and the rooms were equipped to handle necessary medical equipment without impacting care delivery. The facility had submitted a Room Waiver Request, indicating that the Administrator and Director of Nursing would monitor room capacity and ensure that the rooms did not exceed their allowed capacity.
Failure to Transfer Resident Promptly After Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as Resident 1, who experienced a change in condition. On the night in question, Resident 1, who had a history of chronic obstructive pulmonary disease, respiratory failure, and generalized anxiety disorder, began experiencing chest pain and difficulty breathing. Despite the resident's request to be transferred to an acute hospital, the facility delayed the transfer for over four hours. The resident's emergency contact, who was also the medical power of attorney, requested the transfer, but the Licensed Vocational Nurse (LVN) on duty did not take immediate action. The LVN, who was new to the facility and from a nursing registry, was the only licensed nurse on duty during the shift. She was unaware of the facility's protocol for handling such situations and attempted to contact the Director of Nursing (DON) and the Administrator for guidance but received no response. The LVN assessed the resident and initially determined that there was no distress, but later, when the resident reported chest pain, she called 911, and the resident was eventually transferred to the hospital. The LVN did not document the situation using the facility's standard SBAR form, which is a professional standard of practice. The facility's policies and procedures, including those related to resident rights, change of condition, and discharge against medical advice, were not followed. The DON, who is responsible for 24-hour accountability, did not respond to the LVN's messages until after the resident had been transferred. The failure to promptly assess, recognize, and intervene in the resident's change of condition, as well as the lack of documentation and adherence to protocols, contributed to the deficiency in care provided to Resident 1.
Inadequate Competency of LVN Leads to Delayed Emergency Response
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) from a Nursing Registry demonstrated the necessary competency to provide adequate care for a resident. The resident, who was admitted with chronic obstructive pulmonary disease, respiratory failure, and generalized anxiety disorder, experienced chest pain and difficulty breathing. Despite the resident's emergency contact requesting a transfer to the hospital, the LVN did not take immediate action, citing a lack of awareness of the facility's protocol and inability to reach the Director of Nursing (DON) or Administrator for guidance. The LVN, who was the only licensed nurse on duty, assessed the resident and determined there was no distress, despite the resident's complaints. The LVN attempted to have the resident sign an Against Medical Advice (AMA) form, which was refused. It was not until the resident reported chest pain again that the LVN called 911, resulting in a delayed transfer to the hospital. Interviews with the emergency contact and the resident confirmed the resident's distress and the LVN's inaction. Further investigation revealed that the LVN had not completed the facility's nursing competency checklist prior to working at the facility, and there was no documentation of such. The DON confirmed the absence of a policy and procedure for staffing competency and acknowledged that the LVN did not create an SBAR, which is a standard practice at the facility. This lack of competency assessment and documentation contributed to the deficiency in care provided to the resident.
Failure to Prevent Unnecessary Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident with dementia and combative behavior was free from physical restraints, which were used for discipline or convenience. On one occasion, a Licensed Vocational Nurse (LVN) restrained the resident by crossing their arms across the chest and above the head, dragging them from their room to the Nursing Station. This action was taken when the resident exhibited mood swings, anxiety, and agitation, leading to physical injury, including redness and bruising on the resident's hand, and verbalized pain in both hands and shoulders. The facility did not implement the resident's care plan interventions for dementia and communication problems, which included establishing rapport, making eye contact, and using appropriate words and gestures. The Interdisciplinary Team (IDT) failed to develop a comprehensive care plan to address the resident's new behaviors, such as combativeness, punching, scratching, and kicking, which were observed on multiple occasions. The care plan was not updated to address the root cause of the resident's behavior symptoms, nor were specific interventions developed to manage the resident's agitation and combativeness. The facility's policy on Physical Restraint Management was not followed, as the LVN used physical restraints to prevent being hit, kicked, and spit on by the resident. This resulted in the resident's freedom of movement being restricted, causing physical and psychosocial harm. The facility's failure to address the resident's behavioral issues and implement appropriate care plan interventions led to the unnecessary use of physical restraints, placing the resident and others at risk for further harm.
Removal Plan
- The facility interviewed 30 interviewable residents and screened for any incidents of being physically restrained during care by the Social Services Designee and 12 non-interviewable residents received body check to determine any unexplained bruising or redness by licensed nurses and the DON.
- The facility started Training and Education headed by the Nurse Consultant Director of Staff Education and the DON, regarding abuse and physical restraints. The training on Managing Behavior and Care plan will be completed.
- The facility started ln-service training for staff nurses regarding updating comprehensive care plans for residents that exhibit combative behaviors to be completed and to include on the care plan not to use any type of restraints.
- The facility started an In-service training for staff and nurses on managing residents that exhibit combative behaviors. Staff from nursing department (Registered Nurse, LVN, Certified Nurse Assistants, Restorative Nurse Assistants) Dietary Department, Housekeeping, Maintenance and Department Managers (Social Service, Medical Records staff, Rehabilitation Department, Minimum Data Set, DON, DSD, IPN, Business Office Manager), have been trained and will continue training until all staff have attended.
- The facility conducted an In-service training for staff (RN, LVN, CNA, RNA, Housekeeping, Dietary Department, Maintenance and Department Managers) on what constitutes a physical restraint and its definition.
- The nurse consultant conducted an In-service to all RNs, LVNs, CNAs, and RNAs, Housekeeping, Maintenance staff, Dietary staff, and Department Managers regarding Behavior Management, Abuse and Physical Restraints.
- The SSD, DON and Activity Director will conduct interviews of alert residents to determine if they have been physically restrained during care at least daily for the next 3 days and weekly for two weeks and monthly thereafter.
- CNAs will continue to conduct body checks for all residents to identify any unexplained redness or bruising during showers and will be reported to the Charge nurse/Treatment nurse and/or to DON for further intervention and reporting.
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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) |
|---|---|---|---|---|
| Glendale Healthcare Center | 0.1 mi | ★★★★★ | 10 | 0 |
| Chestnut Ridge Post Acute Llc | 0.4 mi | ★★★★★ | 35 | 1 |
| Leisure Glen Post Acute Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Broadway Manor Care Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 1.1 mi | ★★★★★ | 35 | 0 |
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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.