Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Leisure Glen Post Acute Care Center during CMS and state inspections, most recent first.
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.
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 6,747 citations issued within 25 miles in the last 12 months — including the 34 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 | ★★★★★ | 10 | 0 |
| Glenhaven Healthcare | 0.7 mi | ★★★★★ | 14 | 0 |
| Ararat Post Acute | 0.9 mi | ★★★★★ | 20 | 0 |
| Chestnut Ridge Post Acute Llc | 1 mi | ★★★★★ | 35 | 1 |
| Glendale Post Acute Center | 1.6 mi | ★★★★★ | 24 | 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.