Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leisure Glen Post Acute Care Center during CMS and state inspections, most recent first.
The facility failed to develop comprehensive care plans for three residents with complex needs. One resident receiving IDPN during dialysis had no documented care plan for monitoring or interventions, and the RN supervisor was unaware of the therapy. A second resident using CPAP had no care plan addressing required precautions such as NPO status before use, oxygen saturation monitoring, or related assessments. A third resident who cried and stated he wanted everything to end and wanted to die had no care plan to address the change in condition, despite staff acknowledging that such statements required care planning.
A resident with MASD, loose stool, impaired mobility, and severely impaired cognition had a care plan for turning, repositioning, and skin protection, but the TXN did not create an individualized repositioning schedule, did not contact the wound consultant, and did not involve the IDT or RP to address noncompliance with repositioning and incontinent care. The resident’s sacrococcyx MASD worsened and the resident was transferred to an acute care hospital. Another resident with DM, dementia, and daily Lantus had an order for weekly finger-stick blood sugar checks, but RN and DON stated daily monitoring was needed to appropriately track response to insulin therapy.
A resident with DM, HF, and epilepsy was observed crying and told staff he wanted everything to end and wanted to die. The CNA reported it to an LVN, who informed the RN supervisor, but the resident’s MD was not notified despite care plan directions to monitor for depression and report significant behavior changes.
Inaccurate MDS Coding of Rejection of Care: A resident with dementia, encephalopathy, and no decision-making capacity had a documented pattern of refusing prescribed meds and lab draws, but the MDS did not code rejection of care in Section E0800. The clinical record showed repeated refusals of BP meds, TSH and lipid panel labs, and other medications, while the MDS coordinator and SSD acknowledged the behavior was coded incorrectly.
Failure to Document Change in Condition and Respiratory Assessment: A resident with acute respiratory failure, encephalopathy, dementia, and a care plan for respiratory distress had inconsistent O2 sat documentation and incomplete nursing assessment records. An SBAR showed stable vital signs earlier in the shift, then later slow, shallow breathing with BP 88/60, RR 10, and O2 sat 63% on room air, but the record did not show what prompted the later vital sign check or document the resident’s level of consciousness or response details. The resident was transferred to the hospital after the desaturation and hypotension were identified.
A resident with an indwelling catheter and impaired cognition had repeated sediment noted in the urine and catheter tubing. The physician ordered the catheter flushed with NS every shift as needed for sediment, but staff did not carry out the order on multiple shifts. During interviews, an LPN said sediment was present and the catheter should have been flushed, while a TXN said he did not flush it and believed the cloudy particles were not sediment.
A resident with MS, CHF, morbid obesity, pulmonary edema, and OSA received CPAP at bedtime, but staff did not document the required pre-procedure assessment or monitoring required by the facility's CPAP/BiPAP policy. The record showed only that the resident was placed on CPAP and tolerated it well, while the DON identified expected complications and the need to assess for nausea, vomiting, abnormal VS, facial trauma, altered mental status, and aspiration risk before use of a full-face mask.
A CNA was rough and loud with a resident who had Parkinson’s disease, dementia, severe cognitive impairment, and a language barrier while changing wet and soiled clothing. The resident stated the CNA yelled, pushed her to turn, and continued care while she cried; the roommate witnessed the yelling and said the resident could not turn on her own. The resident called her family member crying, and afterward frequently asked the family member to contact staff for help with turning and repositioning.
A resident with Parkinson’s disease, dementia, and total care needs reported that a CNA yelled at her and pushed her during incontinence care, and the roommate and family member described the same event. Staff treated the complaint as a miscommunication issue rather than abuse, did not complete a grievance or investigation, did not notify leadership, and the CNA continued working several shifts after the allegation was reported.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive safe and appropriate respiratory care when it was needed, as required by their condition. The facility did not ensure that necessary respiratory support was provided.
A visitor was observed taking cups, juice, water, and spoons from a medication cart without staff intervention, despite facility policy prohibiting such actions to prevent contamination. An LVN did not instruct the visitor to stop, and the incident involved a resident with acute respiratory failure and diabetes. The infection prevention nurse confirmed that this practice is not allowed under the facility's infection control policy.
A resident with dementia and other health conditions was not provided with a functional wall clock in their room, resulting in frustration and disorientation. Staff acknowledged the importance of accurate timekeeping for resident orientation and comfort, and the facility's policy supported this requirement.
A resident's representative reported missing clothing items to the Social Service Assistant, but no grievance report was initiated and no follow-up occurred, despite facility policy requiring prompt action. The resident, who had dementia and required significant assistance, was discharged home without resolution or communication regarding the missing items, resulting in a violation of the resident's right to have grievances addressed.
Two residents with dementia were not properly evaluated for elopement risk, as their MDS and Quarterly Risk Assessments contained inaccuracies regarding their mobility and omitted required elopement risk evaluations. Staff interviews revealed misinterpretation of assessment questions and failure to follow facility policy, resulting in incomplete and inconsistent documentation.
Two residents with dementia did not have their care plans updated to reflect specific behaviors or interventions, despite changes in their condition and observed behaviors such as increased mobility and entering other residents' rooms. Staff interviews and record reviews confirmed that the care plans were not individualized as required by facility policy.
A resident with a history of pressure injury and multiple risk factors was found with their Low Air Loss mattress set at 350 lbs, despite the correct setting being 120-180 lbs as indicated by both physician orders and manufacturer guidelines. Staff interviews revealed a lack of awareness and responsibility for ensuring the correct mattress setting, resulting in noncompliance with prescribed pressure ulcer prevention measures.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards.
The facility did not post required daily nurse staffing information, including the number of RNs, LPNs/LVNs, and CNAs per shift, in a visible location as required by policy. Instead, the information was placed behind other postings, making it inaccessible to residents and visitors. Staff interviews confirmed this practice, and the DON acknowledged the failure to provide clear staffing data as outlined in facility procedures.
The facility failed to conduct annual competency evaluations for CNAs, as required by their policy. Interviews and record reviews revealed that three CNAs had not been evaluated annually, and there was no system to track performance evaluations. The DSD, new to the position, lacked a system to log and track the ACCC, and an in-person lesson conducted by the IPN did not cover all required skills.
The facility failed to properly label and store food items, with multiple open items in the refrigerator lacking use-by dates. Additionally, improper hygiene practices were observed, as a staff member did not change soiled gloves before handling clean plates and utensils. These actions violate the facility's policies on food safety and handling.
A resident with cognitive impairments was assisted during a meal by a CNA who stood over them, contrary to the facility's policy requiring staff to be seated to promote dignity. The DON confirmed the policy and the CNA acknowledged the inappropriateness of standing.
A resident with a history of falls and impaired cognitive skills was found without a call light within reach while sitting in a wheelchair with a meal tray. The facility's policy requires call lights to be accessible, but this was not followed, as confirmed by a CNA.
A resident was not informed about the location of the meal menu, impacting their ability to make food choices. Despite having a care plan for nutritional risk, the resident was unaware of alternative meal options and experienced delays in receiving requested meals. Staff provided inconsistent information about menu locations, and the resident's limited mobility and poor vision further hindered access.
A facility failed to ensure a copy of an Advance Health Care Directive (AHCD) was available in a resident's medical record. The resident, with fluctuating decision-making capacity and moderate cognitive impairment, had a POLST indicating an AHCD, but it was not filed in their chart. Interviews with staff revealed that the resident's family held the original AHCD, and there was no follow-up to obtain a copy, contrary to facility policy.
A resident with moderate cognitive impairment and language barriers did not have a care plan addressing communication needs, leading to potential miscommunication with staff. Despite the resident's inability to understand or speak the facility's formal language, no measures were documented to facilitate communication, as confirmed by staff interviews and record reviews.
A resident with moderate cognitive impairment and limited English proficiency was not provided with a communication board, as required by the facility's policy. Despite the resident's ability to verbalize needs in a foreign language, staff confirmed the absence of a communication board, which was necessary for effective communication and care delivery.
A resident with severe cognitive impairment and incontinence was left in a wet brief for nearly an hour, despite calling for help. Staff failed to respond promptly, leading to a delay in care. The facility's policy requires immediate assistance to prevent skin damage, which was not followed.
A resident with severe cognitive impairment and respiratory issues was found with an empty oxygen tank, indicating a failure in providing continuous oxygen therapy. The LVN was unsure of the last check or setup of the tank, and there was no documentation of the assessment or setup as required by the facility's policy. The DON confirmed the lack of adherence to the policy, which mandates documentation and periodic checks by licensed staff.
A resident with a Permacath for hemodialysis was found with a dressing that was peeling off, contrary to the facility's infection control policy. The dressing should have been changed by staff when its integrity was compromised, as confirmed by the DON and a nurse. This failure put the resident at risk for infection and dislodgement of the Permacath.
A resident with hemiplegia and moderately impaired cognition reported feeling sexually and verbally abused by the Administrator due to inappropriate comments made in a common area. Despite law enforcement involvement, the Social Services Director did not document follow-up attempts, and the Director of Nursing confirmed no investigation was conducted, violating the facility's policy on abuse reporting and investigation.
Failure to Develop Comprehensive Care Plans for IDPN, CPAP, and Suicidal Statements
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents with significant medical and behavioral needs. Resident 32 had diagnoses including dementia and end stage renal disease with dialysis dependence, and the record showed he was receiving intradialytic parenteral nutrition (IDPN) at the dialysis center on dialysis days. The dialysis communication record documented multiple IDPN administrations, but the registered nurse supervisor stated she was not aware the resident was receiving IDPN, did not know what it was for, and did not know why it was being given. The nurse also stated she would contact the dialysis center to determine what interventions were needed while the resident received IDPN. The facility’s renal disease policy stated nursing staff would communicate changes of condition specific to the resident with each treatment. Resident 71 had diagnoses including multiple sclerosis, pulmonary edema, morbid obesity, and congestive heart failure, and the MDS indicated the resident used CPAP since admission. The physician ordered CPAP at bedtime, and during observation the resident had the CPAP machine at bedside and stated he used it nightly. Snacks were observed at bedside. The DON stated the resident should not eat or drink for 2 hours before CPAP use, that this intervention should be in the care plan, and that a general assessment including vital signs, oxygen saturation, and respiratory status should be included. However, there was no care plan or interventions identified for CPAP use, including complications or contraindications, despite the facility policy requiring the resident to be NPO for at least 2 hours before using a full-face mask and to monitor oxygen saturation and general assessment findings. Resident 91 had diagnoses including diabetes mellitus, heart failure, and epilepsy, and the MDS indicated intact cognition and did not identify thoughts of wishing for death or self-harm. During observation, the resident was crying and told a CNA that he wanted everything to end and wanted to die. The RN supervisor stated that this change in condition required a care plan because it communicates to staff what the resident needs and how interventions are to be met. The facility’s care plan policy stated that ongoing assessments should result in revisions to the comprehensive person-centered care plan when the resident’s condition changes and that care planning should include the resident and/or representative. No care plan was developed to address the resident’s verbalization of wanting to die.
Failure to provide ordered skin care and appropriate blood glucose monitoring
Penalty
Summary
Resident 8 had MASD involving the sacrococcyx area extending to both buttocks and was also receiving lactulose with frequent loose stool. The resident’s care plan identified risk for skin breakdown related to impaired mobility, incontinence, non-compliance with treatment and positioning, frequent loose stool, and refusal of perineal care, and it directed staff to assist and encourage turning and repositioning every 2 hours and as needed. The resident’s records also showed severely impaired cognition, dependence for toileting hygiene, and high risk for pressure sore on Braden Scale assessments. Despite these findings, the treatment nurse stated he assessed the resident’s skin but did not notify the physician or RP of the high risk for pressure sore. The treatment nurse also stated he developed the care plan for noncompliance with turning and repositioning but did not assess the resident or contact the RP to determine the cause of the noncompliance or identify specific interventions to protect the irritated skin. He stated he did not create an individualized repositioning schedule and that the resident did not receive a wound consultation when the MASD appeared on the sacrococcyx. The DON stated the treatment nurse should have developed an individualized repositioning schedule in accordance with the care plan, and that the IDT should have assessed the resident and contacted the RP sooner to determine the cause and create individualized interventions for the resident’s noncompliance with repositioning and incontinent care. Resident 8’s transfer form showed the resident was sent to an acute care hospital for worsening MASD in the sacrococcyx area extending to bilateral buttocks and nonpitting edema. The facility policy on prevention of pressure injuries required review of the care plan, identification of risk factors and interventions, prompt skin care after incontinence, and repositioning on an individualized schedule determined by the interdisciplinary care team. Resident 58 had type 2 DM, dementia, severely impaired cognition, and was receiving daily Lantus insulin and linagliptin, but the physician order summary listed finger-stick blood sugar testing only every Saturday before breakfast. RN 1 and the DON stated that blood glucose should have been monitored daily rather than weekly because the resident was receiving daily insulin therapy, and the facility diabetes protocol stated residents receiving insulin should have blood glucose monitored twice a day if well controlled.
Failure to Notify Physician After Resident Expressed Suicidal Thoughts
Penalty
Summary
The facility failed to notify the resident’s physician after a significant change in condition when the resident was found crying and told staff that he wanted everything to end and wanted to die. The resident had diagnoses including DM, heart failure, and epilepsy. His MDS dated 4/2/2026 indicated cognition was intact and did not show thoughts of wishing to die or self-harm. His care plan dated 3/26/2026 identified risks related to polypharmacy, including depression, and directed staff to monitor for adverse reactions such as agitation, lethargy, confusion, and depression. Another care plan for antianxiety medication use directed staff to notify the MD for significant decline in behavior if behavior interfered with daily care or functioning. On 6/29/2026, a CNA observed the resident crying and heard him verbalize that he wanted everything to end and wanted to die. The CNA reported this to an LVN, who went to the resident’s room and was told by the resident that he was okay. The LVN then informed the RN supervisor, who also spoke with the resident and documented that he said he was okay. During interview, the RN supervisor stated the resident’s primary physician was not informed of the resident’s statement that he wanted to die.
Inaccurate MDS Coding of Rejection of Care
Penalty
Summary
The facility failed to update Resident 50’s MDS to accurately reflect documented behaviors of refusing prescribed medications and laboratory blood draws. Resident 50 was readmitted with diagnoses including dementia and encephalopathy, and the H&P stated that the resident did not have capacity to understand and make decisions and had a history of refusing treatment. The clinical record showed multiple change-of-condition entries documenting refusals. On 5/25/2026, Resident 50 refused blood pressure medications unless the systolic BP was greater than 140. On 6/19/2026, the resident refused labs for TSH and a lipid panel. On 6/23/2026, the resident refused medications. However, the MDS dated [DATE] indicated moderately impaired cognition and stated that the resident did not exhibit behaviors associated with rejection of evaluation or care, including refusing bloodwork and medications. During interviews and record review, the MDS coordinator stated that Resident 50 had a documented pattern of refusing treatment, including prescribed medications and laboratory blood draws, and acknowledged that the behavior was not coded accurately in Section E0800. The Social Services Director stated that she was responsible for coding the behavioral section of the MDS and coded it incorrectly. The RN stated that the resident had a documented pattern of refusing treatment and that the MDS should be updated to accurately reflect the resident’s condition.
Failure to Document Change in Condition and Respiratory Assessment
Penalty
Summary
The facility failed to provide necessary treatment and care in accordance with professional standards of practice for one sampled resident who had acute respiratory failure, encephalopathy, dementia, and a care plan for respiratory distress. The care plan directed staff to monitor for signs and symptoms of respiratory distress, including increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, and confusion. The resident’s MDS later indicated severely impaired cognition and continuous oxygen therapy. The resident’s weights and vitals summary showed no documentation of oxygen saturation during the 7 AM to 3 PM shift from 4/4/2026 through 4/16/2026, and oxygen saturation was inconsistently documented on only a few overnight shifts. A nursing progress note at 3:42 PM on 4/16/2026 documented the resident as asleep with even and unlabored respirations, but did not assess level of consciousness. An SBAR documented that at 3 PM the resident was awake in bed with BP 102/58, HR 88, RR 15, temperature 97.7 F, and O2 sat 96% on room air, and at 4 PM the resident was asleep and responsive to verbal and tactile stimuli, but there was no documented evidence that vital signs were taken at 4 PM or what type of response the resident gave. The same SBAR documented that at 4:56 PM the charge nurse noted slow, shallow breathing and the resident remained responsive to verbal and tactile stimuli, with BP 88/60, HR 93, RR 10, and O2 sat 63% on room air. The resident’s RP and physician were notified and the resident was transferred to GACH due to desaturation and hypotension. The record did not document what prompted the staff to check the resident’s vital signs at 4:56 PM after the resident had been observed in stable condition at 3 PM and 4 PM. During interview, the DON stated the documentation did not determine whether a change of condition had already occurred and acknowledged that routine vitals were supposed to be assessed as part of the licensed nurse’s assessment.
Failure to Flush Indwelling Catheter When Sediment Was Present
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter by not following the physician’s order to flush the catheter when sediment was present in the urine. The resident was admitted with diagnoses including neuromuscular dysfunction of the bladder and heart failure, and the MDS indicated severely impaired cognitive skills and the presence of an indwelling catheter. The record also showed the resident needed assistance with several activities of daily living, including toileting hygiene and transfers. Progress notes documented sediment in the resident’s urine on multiple occasions, and survey observations found a moderate amount of white, cloudy sediment in the catheter tubing. On one observation, the catheter tubing was hanging on the bed frame and cloudy sediment was visible in the urine. The physician had ordered the indwelling catheter to be flushed every shift with 50 mL of normal saline as needed if sediment was present, starting on 6/28/2026. During interviews and record review, the LVN stated sediment was present and that licensed nurses should flush the catheter per the physician’s order to prevent clogging and reduce the risk of UTI. The TXN stated he did not flush the catheter on multiple shifts and that there was no record of other nurses flushing it during the reviewed period. The TXN also stated he believed the white cloudy particles were not sediment, while the DON stated nurses should accurately assess urine appearance, recognize sediment, and follow the physician’s order to flush the catheter to maintain patency and prevent UTI.
CPAP Assessment and Monitoring Not Completed
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident who used CPAP. Resident 71 was admitted with diagnoses including multiple sclerosis, pulmonary edema, morbid obesity, congestive heart failure, and obstructive sleep apnea, and the MDS indicated the resident had intact cognition and had used CPAP since admission. The physician order directed CPAP at bedtime with pressure of 8 CMH2O and oxygen at 30% (2.5 liters per minute). The respiratory administration record showed CPAP was administered at bedtime, and the care plan identified CPAP use for OSA with a goal of maintaining normal breathing pattern, normal skin color, and regular respiratory rate/pattern. During interview and record review, staff were unable to show that the resident was assessed in accordance with the facility's CPAP/BiPAP Support policy. The policy required that the resident not eat for two hours before using a full-face mask and that a general assessment be completed, including vital signs and oxygen saturation, prior to the procedure. The DON stated complications of CPAP included nausea, vomiting, abnormal vital signs, facial trauma, altered mental status, and that aspiration could occur if the resident was not assessed for these conditions. However, the progress note for the CPAP use documented only that the resident was placed on CPAP with the ordered settings and tolerated the procedure well, and the RNS stated the note did not include an assessment for complications related to CPAP. An LVN stated she was not aware of complications of CPAP and that none were listed in the physician orders or MAR.
Rough and Loud Personal Care During Language Barrier
Penalty
Summary
The facility failed to treat one resident in a manner that promoted respect and dignity when a CNA was rough and loud during personal care. The resident was admitted with Parkinson’s disease, muscle weakness, arthritis, and dementia, and the MDS indicated severely impaired cognition and dependence on staff for rolling, dressing, bathing, toileting/hygiene, and substantial assistance with personal hygiene and oral hygiene. The resident also had a care plan for a communication problem due to a language barrier, with interventions to use a translator as needed, confirm understanding, use a low tone of voice, speak slowly, and present one thought or command at a time. During care for wet and soiled clothing, the resident stated the CNA raised her voice, yelled at her to turn onto her side, and pushed her while changing her clothes. The resident stated the CNA knew she could not turn on her own but continued yelling at her. The resident said the interaction caused her to feel anxious toward the CNA and that she immediately called her family member while crying to report what happened. The resident’s roommate stated she heard the resident crying and saw the CNA yelling at the resident and questioning why she was not wearing a hospital gown while trying to remove wet clothing. The roommate stated she told the CNA the resident could not turn on her own and needed help, but the CNA continued the care while the resident cried and then left her crying. The roommate also stated the CNA told the resident, "You are going to give me a stroke." The family member reported that after the incident, the resident frequently called her to ask her to contact staff for help with turning and repositioning, and the family member was concerned about the resident’s ongoing apprehension about requesting assistance directly from staff.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse investigation and reporting policy after a family member reported that a CNA was loud and rough with a resident during care. The resident was admitted with Parkinson’s disease, muscle weakness, arthritis, and dementia, and her assessment showed severely impaired cognition and dependence on staff for turning, dressing, bathing, toileting hygiene, personal hygiene, oral hygiene, and partial assistance with eating. Her care plan also directed staff to assist with turning and repositioning using a draw sheet or lifting device and to use communication strategies because of a language barrier. The resident, her family member, and her roommate described that the CNA yelled at the resident, pushed her while turning her to the side, and complained about the resident’s wet and tight clothing during incontinence care. The resident stated she felt anxious toward the CNA afterward and frequently called her family member to ask staff to assist her rather than asking the CNA. The family member reported that she immediately called the facility after the resident cried and described the CNA screaming and pushing her, and the roommate stated she witnessed the CNA yelling at the resident and left the resident crying. The roommate also stated she called the family member right away and did not report the incident to facility staff because of fear of retaliation. Facility staff did not identify the event as abuse at the time it was reported. The LVN who received the family member’s call denied being told that the CNA was yelling and rough with the resident, and the DSD stated he viewed the matter as a miscommunication issue rather than abuse. The DON stated there was no grievance report or investigation for the allegation, and the administrator stated she had not been informed of any abuse allegation. The alleged abuser continued working after the report, and the record showed the CNA worked multiple shifts after the complaint before being suspended when the health department visited. The facility’s abuse policy required prompt reporting of abuse allegations to local, state, and federal agencies, thorough investigation, immediate suspension of the accused employee, and prevention of further potential abuse, but those actions were not carried out when the allegation was first reported.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care in accordance with their needs. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Enforce Infection Control Policy for Visitor Access to Medication Cart
Penalty
Summary
During a medication pass observation, a visitor was seen taking multiple cups from the middle of a cup stack on top of the medication cart and pouring juice and water in the presence of an LVN. The LVN did not intervene or instruct the visitor that obtaining cups, juice, and water from the medication cart was not permitted. Shortly after, the same visitor was observed exiting a resident's room and returning to the medication cart to grab spoons, again without any staff intervention. The resident involved had been admitted with acute respiratory failure with hypoxia and type 2 diabetes mellitus. According to the facility's infection prevention policy, visitors and residents are not allowed to access items from the medication cart to prevent contamination, as their hand hygiene status is unknown. The infection prevention nurse confirmed that this practice is not allowed due to the risk of contamination, and the facility's policy requires education and instruction for residents, visitors, and volunteers on hand hygiene and infection control practices.
Failure to Provide Functional Wall Clock for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not ensuring the presence of a functional wall clock in the resident's room. The resident, who had diagnoses including dementia, osteoarthritis, and muscle wasting, was observed to be frustrated and disoriented due to the incorrect time displayed on the wall clock. The resident expressed frustration at having to ask staff for the correct time, and staff confirmed that the clock was not showing the accurate time. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, confirmed the importance of having a functional clock for resident orientation and comfort. The facility's own policy emphasized the need for a homelike environment, which includes providing accurate and functional clocks in resident rooms. The lack of a working clock directly contributed to the resident's confusion and frustration, as observed and reported by both the resident and staff.
Failure to Promptly Address Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly address a grievance reported by the representative of a resident with dementia, atherosclerotic heart disease, and chronic kidney disease. The resident, who required varying levels of assistance with daily activities and did not have the capacity to make decisions, was discharged home, at which point her representative reported missing clothing items to the Social Service Assistant (SSA). Despite being informed of the missing items, the SSA did not initiate a grievance report or follow up with the representative, and no entry was made in the facility's grievance log. The SSA acknowledged that a grievance report should have been initiated and that failing to do so was a violation of the resident's rights. Further interviews with the Director of Nursing (DON) and the Administrator confirmed that they were not informed of the grievance and that the facility's policy required prompt initiation and resolution of grievances. The facility's policies also stipulated that all grievances should be responded to in writing, with actions and rationale documented. The lack of prompt response and failure to follow established grievance procedures resulted in a delay in investigating the missing clothing and violated the resident's right to have grievances addressed without discrimination or reprisal.
Failure to Accurately Complete MDS and Elopement Risk Assessments for Residents with Dementia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) and Quarterly Risk Assessments were completed accurately for two residents diagnosed with dementia. Both residents were not properly evaluated for elopement risk, despite documentation indicating they were independently mobile within the facility. The assessments either omitted the elopement risk evaluation or incorrectly stated that the residents were not independently mobile, which was inconsistent with other records and staff observations. For one resident, multiple assessments and interviews revealed discrepancies in documentation regarding mobility and elopement risk. The resident was noted to walk frequently without limitation, yet the elopement risk evaluation was not completed, and the assessment incorrectly indicated the resident was not independently mobile. Staff interviews confirmed that the resident was seen walking throughout the facility, but the MDS nurse misinterpreted the assessment questions and did not consider dementia as a risk factor for elopement. The nurse admitted to using personal judgment rather than following assessment protocols, and the oversight was not caught during supervisory review. A second resident with similar diagnoses also had inconsistent documentation regarding mobility and elopement risk. The resident was described as walking occasionally with no limitation, but the risk assessment was not completed, and the evaluation again incorrectly indicated the resident was not independently mobile. Staff interviews confirmed the elopement risk evaluation was not completed due to a misunderstanding of the assessment criteria. Facility policy required accurate and complete risk assessments on admission and quarterly, but these were not followed, resulting in inaccurate documentation for both residents.
Failure to Revise Dementia Care Plans with Resident-Specific Behaviors
Penalty
Summary
The facility failed to ensure that care plans were revised to include resident-specific behaviors for two residents diagnosed with dementia. For one resident, records showed diagnoses of metabolic encephalopathy, unspecified dementia, and Alzheimer's disease, with documentation indicating the resident lacked decision-making capacity. Despite increased mobility and behaviors such as entering other residents' rooms, the dementia care plan did not specify behaviors to monitor or interventions tailored to the resident. Interviews with nursing staff confirmed that the care plan lacked resident-specific details and that updates should have been made to address observed behaviors. Similarly, another resident with unspecified dementia, muscle wasting, and cognitive communication deficits also had a care plan that did not identify specific behaviors to monitor. Staff interviews and record reviews confirmed the absence of individualized behavioral interventions in the care plan. The facility's policy required comprehensive, person-centered care plans to be updated as residents' conditions changed, but this was not followed for these residents, resulting in care plans that were not tailored to their current needs and behaviors.
Failure to Set Pressure Mattress According to Resident Weight
Penalty
Summary
The facility failed to set the Alternating Pressure Mattress (APM) according to the resident's weight as specified in both the manufacturer's guidelines and the physician's orders. A review of the resident's records showed that the physician had ordered a Low Air Loss mattress for skin management, with instructions to monitor its function and settings every shift. During observation, the mattress was found set at 350 lbs, while a sticker on the bed indicated the correct setting should be between 120-180 lbs based on the resident's weight. Staff interviews revealed that the Licensed Vocational Nurse was unaware of the correct setting and deferred responsibility to the Treatment Nurse, who also confirmed the setting was incorrect and could not explain why it had been set improperly. The resident involved had a history of significant medical issues, including a previous unstageable pressure injury to the sacrococcyx, muscle wasting, and type 2 diabetes, and was assessed as being at continued risk for skin breakdown. The resident was also noted to have severely impaired cognition and required assistance with daily activities. Despite these risk factors and clear preventive measures outlined in the care plan, the mattress was not set appropriately, as required by both the physician's order and the manufacturer's instructions.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Prominently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, specifically the number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs)/Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Nursing Assistants (NAs) per shift, in a prominent and visible location as required by facility policy. Observations on two separate days revealed that only the Census and Direct Care Service Hours per Patient Day (DHPPD) were posted near the facility entrance and nursing stations, with no visible information about the actual number of nursing staff on duty for each shift. During one observation, it was discovered that the required staffing information was placed behind the DHPPD posting, making it not visible to residents and visitors. Interviews with the staff member responsible for posting the information confirmed that the staffing data had consistently been placed behind the DHPPD, contrary to the policy that requires clear and visible posting. The Director of Nursing (DON) acknowledged that the facility did not post the complete nursing staffing information for each shift, which could result in residents and visitors not knowing the actual number of nursing staff providing care. Review of the facility's policy confirmed the requirement to post nurse staffing data for each shift in a prominent and accessible location within two hours of the beginning of each shift.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to complete annual performance reviews for Certified Nurse Assistants (CNAs) by not conducting the Annual Core Clinical Competencies (ACCC) assessments. This deficiency was identified through interviews and record reviews, revealing that three out of five CNAs had not been evaluated for their competencies annually. The facility lacked a system to track the CNAs' performance evaluations, which could potentially result in residents not receiving quality care from CNAs with insufficient skills and competencies. The facility's tracking log did not indicate which CNAs required training, and there was no system in place to ensure that the ACCC was completed or up to date. Interviews with the Registered Nurse (RN) and the Director of Staff Development (DSD) confirmed that CNAs were supposed to have yearly clinical skills competency checks. However, the DSD, who had been in the position for eleven weeks, admitted to not having a system to log and track the CNAs' ACCC. Additionally, the Infection Control Nurse (IPN) conducted an in-person lesson in July and August 2023, which was considered an annual ACCC, but not all skills listed in the facility's CNA Core Clinical Competencies were included. The facility's policy and procedure required competency evaluations upon hire, annually, and as deemed necessary, but these were not consistently conducted.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not labeling, dating, and storing food properly in the refrigerator and freezer. During an observation, multiple open food items in the walk-in refrigerator were found without a use-by date, including chicken broth, lemon juice, sweet sour sauce, yogurt, feta cheese, half watermelon, fruit cocktail, bacon, fish, milk, apple sauce, and Ready Care shakes. The Dietary Service Supervisor acknowledged the absence of use-by date labels and stated that the facility relies on the manufacturer's expiration date. Additionally, frozen food boxes were observed on the floor of the freezer, which is against proper storage practices. Dry items, including canned goods, were also found without use-by dates. The facility also failed to maintain proper hygiene practices during food handling. An observation revealed that a staff member did not change visibly soiled gloves before plating residents' food. The staff member used the same gloves to handle clean plates and other utensils after handling food items like breaded fish filet and lasagna, which resulted in cross-contamination. The facility's policy requires gloves to be changed when soiled, but the staff member admitted to not changing gloves. The Infection Preventionist confirmed that items like apple sauce and juice on the medication cart must be changed daily and labeled with a use-by date to ensure safety.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care that maintained or enhanced a resident's dignity and respect, as observed during a meal assistance for a resident with severely impaired cognitive skills. The resident, who was admitted with diagnoses including hyperlipidemia and type II diabetes mellitus, required partial assistance with daily activities. During a meal observation, a Certified Nursing Assistant (CNA) was seen standing over the resident while assisting with feeding, creating a two-foot height difference between them. This was contrary to the facility's policy, which requires staff to be at eye level and seated to promote resident dignity during meals. Interviews conducted with the CNA and the Director of Nursing (DON) confirmed that the CNA did not sit while assisting the resident, acknowledging that standing was inappropriate. The DON reiterated the facility's policy that staff should be seated to ensure a dignified dining experience for residents. The facility's policy on dignity, revised in February 2024, emphasizes treating residents with respect and providing a dignified dining experience at all times.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident 11. This deficiency was observed during a survey when Resident 11 was found sitting in a wheelchair with a lunch tray in front of her, and no staff present to assist. The call light, which is crucial for requesting assistance, was not within reach of the resident. This oversight was confirmed by CNA 4, who acknowledged the importance of having the call light accessible, especially in emergencies such as choking while eating. Resident 11's medical history includes repeated falls and abnormalities in gait and mobility, and she is considered high risk for falls. Her care plan emphasizes the need to reinforce the use of the call light for assistance. Additionally, the resident's Minimum Data Set (MDS) assessment indicates severely impaired cognitive skills and a requirement for extensive assistance with daily activities. The facility's policy, revised in 2010, mandates that the call light should be within easy reach for residents confined to a bed or chair, which was not adhered to in this instance.
Failure to Inform Resident of Meal Menu Location
Penalty
Summary
The facility failed to ensure that Resident 46 was informed about the location of the facility's monthly and alternative meal menus, which is a violation of the resident's right to self-determination and choice in food preferences. Resident 46, who was admitted with a right femur fracture and mobility issues, was not aware of where to find the menu and expressed that alternative meal requests took one to two hours to fulfill. The resident had a care plan indicating nutritional risk and required dietary services to assess food preferences and offer alternatives, yet was not informed about the availability of an alternative menu. Interviews with staff revealed inconsistencies in the location of the menu, with some stating it was kept in residents' rooms, while others indicated it was posted in the hallway or in front of the kitchen. Observations confirmed the absence of a menu in Resident 46's room, and the resident, who had poor vision and limited mobility, was unable to access the menu independently. The family member of Resident 46 also confirmed a lack of communication regarding the menu's location and the availability of alternative meal options. The facility's policy required accommodating resident preferences and offering food substitutes, but this was not effectively communicated or implemented for Resident 46.
Failure to Maintain Advance Health Care Directive in Resident's Record
Penalty
Summary
The facility failed to ensure that a copy of an Advance Health Care Directives form (AHCD) was readily available in the medical record of one of the sampled residents, Resident 162. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 162, who was admitted with diagnoses including hyperlipidemia and major depression, had fluctuating capacity to understand and make decisions, as noted in their History and Physical Examination. The Minimum Data Set indicated that the resident's cognitive skills were moderately impaired, requiring assistance with daily activities. Despite having a Physician Orders for Life-Sustaining Treatment form indicating the existence of an AHCD, the document was not found in the resident's medical chart. Interviews with facility staff, including an LVN, the Director of Nursing (DON), and the Social Service Director (SSD), revealed that the AHCD was not filed in the resident's medical record. The LVN acknowledged the importance of having the AHCD in the chart to understand the resident's wishes. The DON confirmed that staff should obtain and file a copy of the AHCD if it exists. The SSD stated that the resident's family had the original AHCD and was supposed to provide a copy to the facility, but there was no documentation of follow-up to obtain it. The facility's policy required the SSD or admission staff to place a copy of the AHCD in the resident's medical record upon admission, which was not done in this case.
Failure to Address Communication Needs in Resident Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the communication needs of Resident 35, who was unable to understand and speak the formal language used in the facility. This deficiency was identified through observation, interviews, and record reviews. Resident 35, who has diagnoses including encephalopathy, diabetes mellitus, and muscle weakness, was noted to have moderate cognitive impairment and required supervision for activities such as eating. Despite these needs, the resident's care plan lacked documentation to address communication barriers, as the resident was only able to verbalize needs in a foreign language. During interactions with staff, it was observed that Resident 35 communicated in a non-English language, which staff members, including a CNA and an LVN, could not understand. The LVN confirmed the absence of a care plan for communication needs, acknowledging its importance for facilitating effective communication between staff and the resident. The Director of Nursing also recognized the necessity of a care plan to address these needs, especially during care delivery. The facility's policy on comprehensive, person-centered care plans emphasizes incorporating identified problem areas to prevent or reduce functional decline, yet this was not adhered to in Resident 35's case.
Failure to Provide Communication Tool for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool for a resident who did not understand the formal language used in the facility. This deficiency was identified during an observation and interview with a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who both confirmed that the resident did not have a communication board. The resident, who was admitted with diagnoses including encephalopathy, diabetes mellitus, and muscle weakness, was noted to have moderate cognitive impairment and required supervision for activities such as eating. Despite the resident's ability to verbalize needs in a foreign language, the facility did not provide a communication board, which was necessary for effective communication between the resident and staff. The facility's policy and procedure on communication with persons with limited English proficiency indicated that language assistance should be provided through interpreters and a communication board. However, the communication board was not made available in the resident's room, contrary to the facility's policy. Interviews with the Director of Nursing (DON) and other staff confirmed that the resident only understood and communicated in a foreign language, and a communication board was essential for immediate communication needs, especially during care. The lack of a communication board had the potential to lead to miscommunication and delay in care delivery for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely care and services for a resident with urine and bowel incontinence, as outlined in the resident's care plan and the facility's policy. The resident, who was admitted with conditions including muscle wasting, diabetes, osteoporosis, and urinary tract infection, was observed to have severe cognitive impairment and was dependent on assistance for personal hygiene. The care plan specified that the resident should be kept clean and dry to prevent skin breakdown and urinary tract infections, with incontinence care provided promptly after each episode. On the day of the incident, the resident was observed tapping on the bed siderail and calling for help after urinating in her brief. Despite this, multiple staff members walked past the room without assisting. It was not until nearly an hour later that a Certified Nurse Assistant (CNA) attended to the resident, who stated she was busy with another task. The CNA acknowledged that she should have sought help from other staff members to assist the resident sooner. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), confirmed that the resident should have received immediate assistance to prevent skin damage from prolonged exposure to a wet brief. The facility's policy emphasized the importance of prompt incontinence care to prevent pressure injuries, highlighting a failure in staff communication and response to the resident's needs.
Failure to Ensure Continuous Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who has severe cognitive impairment and a history of respiratory issues, was observed with an empty oxygen tank, indicating a lack of oxygen supply. The Licensed Vocational Nurse (LVN) acknowledged that the oxygen tank was empty and was unsure when it was last checked or who connected it. There was no documented evidence of the oxygen tank being assessed or the resident being set up to use it. The Director of Nursing (DON) confirmed that the facility's policy and procedure for oxygen administration required documentation of the setup and periodic checks of the oxygen tank level by licensed nursing staff. The policy also outlined specific documentation requirements, including the date and time of the procedure, the name and title of the individual performing it, and assessment data. The lack of documentation and assessment led to the resident being connected to an empty oxygen tank, which could have resulted in an episode of shortness of breath.
Failure to Maintain Permacath Dressing Integrity
Penalty
Summary
The facility failed to implement its infection prevention and control policy for a resident with a Permacath used for hemodialysis. The resident, who was admitted with diagnoses including dependence on renal dialysis and type 2 diabetes mellitus, was observed with a transparent gauze dressing on the Permacath that was peeling off at three corners, and the gauze dressing had come loose. This observation was made during a visit, and it was confirmed by a Licensed Vocational Nurse, who acknowledged that the dressing should be changed by dialysis staff during each treatment to minimize infection risk. The Director of Nursing confirmed the importance of maintaining the dressing in a clean, dry, and intact manner to prevent infection. The facility's policy indicated that licensed nurses should change the dressing if its integrity is compromised. However, the dressing was not changed despite being loose, which was against the facility's policy and the physician's orders. This oversight placed the resident at risk for infection and potential dislodgement of the Permacath.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Department and other officials within the mandated timeframe of two hours. This deficiency involved a resident who had been admitted with diagnoses including hemiplegia and hemiparesis following a stroke. The resident, who had moderately impaired cognition, reported feeling sexually and verbally abused by the Administrator due to a lack of privacy and inappropriate comments made in a common area regarding the use of a suppository applicator. The incident was initially brought to the facility's attention when two local law enforcement officers visited to speak with the resident about the concerns raised. Despite the involvement of law enforcement, the Social Services Director (SSD) did not document any follow-up attempts to speak with the resident, and the Director of Nursing (DON) confirmed that there was no documented evidence of an investigation or follow-up. The facility's policy required all reports of abuse to be thoroughly investigated and documented, but this was not adhered to in this case. The failure to report and investigate the allegation in a timely manner could potentially lead to underreporting and inadequate addressing of abuse allegations, compromising the resident's psychosocial well-being.
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 7,890 citations issued within 25 miles in the last 12 months — including the 23 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) |
|---|---|---|---|---|
| Glendale Healthcare Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Glenhaven Healthcare | 0.7 mi | ★★★★★ | 14 | 0 |
| Ararat Post Acute | 0.9 mi | ★★★★★ | 19 | 0 |
| Chestnut Ridge Post Acute Llc | 1 mi | ★★★★★ | 44 | 1 |
| Glendale Post Acute Center | 1.6 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.