Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Glendale Gardens Nursing & Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple chronic conditions, who required assistance with ADLs, requested basic items such as water, oral care supplies, and pain medication. A CNA, who reported feeling overwhelmed while covering two halls, told the resident that some items would have to wait and then, after the resident questioned why the CNA was talking in the hallway, responded with profane and disrespectful language, including telling the resident to "leave me the f*** alone" and to go back to their room and shut up. Multiple staff, including a CMT, RNs, LPNs, CNAs, and the DON, stated that cursing at or around a resident is disrespectful and violates resident rights, and the resident reported that the interaction was hurtful and not respectful of their home and dignity.
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency within the required two-hour timeframe after staff became aware of it. A resident with dementia, Parkinson’s disease, COPD, and atrial fibrillation, who used a wheelchair and was frequently incontinent, allegedly told a family member that a male CNA working nights had tossed the resident roughly into bed and cursed at them. The family reported this to an LPN, who documented the concern and immediately notified the DON. Although facility policy and staff interviews confirmed that abuse allegations, including rough care and cursing, must be reported to the State within two hours, the DON delayed notifying the Administrator until the next night, and the Administrator did not report the allegation to DHSS until two days after the initial report, resulting in noncompliance with required abuse reporting timelines.
The facility did not analyze or document causes of falls, nor did it update care plans or implement new interventions after multiple residents with complex medical conditions experienced repeated falls. Staff interviews revealed inconsistent knowledge about care plan updates, and the facility lacked a specific falls policy.
The facility did not consistently notify physicians and families after resident falls, as required. Two residents experienced multiple falls, with staff sometimes failing to document or communicate these incidents to the appropriate parties. Staff interviews revealed inconsistent understanding and application of notification procedures, and the facility lacked a clear policy on fall and physician notification.
Staff failed to follow physician orders and care plan requirements for two residents with edema, including not documenting follow-up on swelling, not obtaining or documenting orders for Tubi grips, not updating care plans to reflect current treatments, and not consistently completing or recording daily weights as ordered. Multiple staff confirmed that Tubi grips and edema management should be included in care plans and require physician orders, but these steps were not taken or documented.
Failure to Honor Resident Shower Preferences: The facility did not consistently provide showers according to resident preferences and care plans for several residents. Residents reported going weeks without showers, feeling dirty or itchy, and having greasy hair, while records showed missed or limited showers and staff acknowledged staffing shortages, incomplete shower assignments, and residents sometimes going longer than a week without bathing. One resident wanted three showers per week, another wanted two showers per week in the summer, and staff said the facility’s shower coverage was not enough to complete all scheduled showers.
The facility failed to provide written transfer notices to two residents or their representatives when the residents were sent to the hospital. Records showed one resident became unresponsive and was transferred after EMS was called, and another resident was sent to the ER after an RN assessment and NP order. Staff interviews confirmed that families were verbally notified and transfer paperwork was sent with the residents, but no written notice was issued to the resident or family.
A facility failed to keep resident code status information accurate and readily available to staff. Surveyors found that multiple residents had mismatches between the face sheet, physician orders, care plans, and the Resident Face Sheet or CNA quick reference books, with some residents listed as DNR in the record but shown as full code or missing from the books, and one resident’s care plan conflicting with the face sheet and physician orders. Staff interviews showed inconsistent understanding of where code status should be located and who was responsible for keeping the reference books updated.
A facility failed to provide respiratory care per standards of practice when staff did not follow an oxygen order for one resident with COPD, anxiety, and dementia, and did not have complete oxygen orders for three other residents. Observations showed one resident’s nasal cannula off and the concentrator set above the ordered flow, while staff also turned the oxygen off during lunch. For other residents, the chart lacked clear oxygen orders even though staff documented or observed oxygen use for SOB, anxiety, or comfort, and staff interviews showed confusion about the ordered liter flow and whether oxygen orders were present.
Staff failed to consistently sign controlled medication count sheets at shift change for two medication carts. The A/B and C/D narcotic count records showed repeated missing signatures from the oncoming and off going RN, LPN, or CMT, and observations found blank spaces in the controlled medication books. Interviews confirmed that staff were expected to count controlled meds at each shift change and both sign the count record, but some nurses were not signing and one LPN said he/she sometimes forgot to sign even though the count was completed.
Medication Cart Left Unlocked Out of Staff View: A CMT was observed preparing meds at the B hall med cart, leaving it out of sight while the lock was only partially engaged and could be opened by pulling it with fingers instead of a key. The CMT said the cart lock stuck and other CMTs had told him/her not to fully lock it. The DON, LTC Case Manager, and Administrator stated med carts should be locked when not in direct view.
Food items were found improperly stored and expired items remained in multiple refrigerators. Surveyors observed uncovered or unlabeled foods, open beverages, dairy items, raw chicken, and other items without open or discard dates in the kitchen and activities area refrigerators. Staff gave conflicting statements about how long opened items could be kept and who was responsible for checking, labeling, and discarding expired food.
The facility failed to maintain its IPCP manual on an annual basis and did not ensure annual TB screening was documented for four residents. The DON, RN QA consultant, and Administrator stated they did not perform or were not aware of annual review of the infection control manual, and RNs reported that the TAR was supposed to alert them when TB screening was due. Several residents had physician orders for annual TB screening, but documentation was missing for one or more years.
Lack of periodic bed rail safety checks and measurements: The facility did not have a regular process to inspect and measure bed rails and bedframes for safety or entrapment risk for several residents with ordered half side rails. Observations found multiple rails loose, wiggling, or gapping from the mattress, and staff interviews showed uncertainty about who was responsible for routine checks; Maintenance said rails were tightened as needed but not documented and there was no regular assessment schedule.
Incomplete and Inaccurate Weekly Skin Assessments: The facility failed to complete and document weekly skin assessments for two residents with active skin concerns and wound treatments. One resident had bilateral lower extremity weeping, open areas, and multiple treatment orders, yet weekly assessments repeatedly stated skin was intact and did not address the drainage or treatments. Another resident had a right shoulder wound with purulent drainage, redness, and antibiotic/topical treatment orders, but routine skin assessments were not documented. Staff and leadership stated nurses were responsible for weekly skin assessments and documentation, but assessments were sometimes missed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment was slapped by an RN after biting the RN's finger during an attempt to remove a plastic straw from the resident's mouth. The incident, witnessed by two NAs, was reported to the DON and Administrator. The RN's action violated the facility's abuse prohibition policy, which protects residents from physical abuse.
The facility failed to report an allegation of abuse involving a CNA and a resident within the required two-hour timeframe. The incident was reported by the resident to a CNA, who informed an RN. However, the RN delayed reporting to the DON, who then delayed informing the Administrator. The incident was reported to the State Survey Agency five hours after the initial report, exceeding the required two-hour window.
The facility failed to follow their abuse policy and protect all residents during an investigation of alleged abuse. A resident alleged that a CNA physically abused them, and the CNA continued to work independently with other residents. Despite the facility's policies requiring immediate suspension of accused staff, the CNA was allowed to continue working their shift without supervision or suspension.
Failure to Treat a Resident With Dignity and Respect Due to Profane Language by CNA
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with dignity and respect when a CNA used profane and disrespectful language toward a resident. Facility resident rights documents state that residents should be treated with consideration and respect, with full recognition of their dignity and individuality. Resident #1 had multiple diagnoses, including metabolic encephalopathy, chronic kidney disease, Type 2 diabetes with neuropathy, unspecified dementia without behavioral disturbances, and major depressive disorder, and required supervision or assistance with activities of daily living such as toileting, dressing, personal hygiene, and showers. On the morning in question, the resident activated the call light and requested items including a new water pitcher because the current one was leaking, a toothbrush, toothpaste, and a pain pill. CNA A reported being overwhelmed and busy covering two halls and told the resident that only some items could be addressed immediately and the rest would have to wait. Multiple written and verbal statements from staff and the resident consistently describe that, after the resident questioned why the CNA could stand in the hallway talking if too busy to obtain the requested items, CNA A responded with profanity. Witnesses and the resident reported that CNA A told the resident it was none of their “f***ing business” what the CNA was doing, that the resident would “f***ing wait,” and to go back to their room and “shut up.” CNA A admitted in a text to the DON and in an interview that they told the resident to “leave me the f*** alone,” acknowledging it was not appropriate. Interviews with multiple staff members, including a CMT, RNs, LPNs, CNAs, and the DON, confirmed that cursing at or around a resident is considered disrespectful and against resident rights. The resident reported feeling that the CNA was being hateful, stated that this was their home and they expected to be treated with respect, and indicated that the CNA’s comments hurt their feelings. The consistent accounts from the resident, witnesses, and CNA A’s own admission demonstrate that the resident was spoken to in a rude and profane manner, in violation of the facility’s stated resident rights and the requirement to treat residents with dignity and respect.
Failure to Timely Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two-hour timeframe after staff became aware of the allegation. Facility policy, dated March 2016, required that any and all cases of alleged resident neglect, abuse, or misappropriation of resident property be reported immediately, but not later than two hours after forming the suspicion, to the hotline and/or DHSS. Multiple staff, including LPNs, CNAs, the ADON, and the Administrator, acknowledged in interviews that the facility had two hours to report abuse allegations to the State and that rough care and cursing constituted abuse that should be reported immediately. The resident involved had been admitted with diagnoses including Parkinson’s disease, COPD, atrial fibrillation, and dementia, with moderate cognitive impairment, wheelchair use for mobility, and frequent bowel and bladder incontinence. The resident’s care plan noted cognitive impairments related to psychotropic medications and risk for falls due to weakness, medications, and gait disturbance. On a late afternoon, the resident’s family member reported to an LPN, in the presence of another LPN, that the resident said a male CNA working the night shift had tossed the resident roughly into bed and cursed at the resident, and demanded that this CNA no longer provide care. The LPN documented this allegation in a handwritten statement and immediately notified the DON. Despite this immediate internal reporting, the DON did not promptly notify the Administrator or DHSS. The DON stated that the family “was complaining to complain” and did not contact the Administrator until the following night, more than 24 hours after the allegation was reported to facility staff. The Administrator then became aware of the allegation and, on a later morning, notified DHSS, the Ombudsman, and the police, and initiated interviews. DHSS records confirmed that the facility self-reported the allegation two days after staff first became aware of it. Both the DON and the Administrator acknowledged that the allegation of rough care and cursing constituted physical and verbal abuse and that it should have been reported to DHSS immediately, within the two-hour requirement, which did not occur.
Failure to Update Care Plans and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure an environment as free from accident hazards as possible by not analyzing or identifying risks for falls, not implementing new interventions to prevent future falls, and not updating care plans after residents experienced falls. Multiple residents with significant medical histories, including cancer, osteoarthritis, COPD, and heart failure, experienced repeated falls. Despite these incidents, staff did not document investigations into the causes of the falls or update care plans with new interventions tailored to prevent recurrence. For one resident, several falls occurred over a period of months, including unwitnessed falls in the restroom, sliding from a recliner and bed due to weakness, and falling while using a walker. Each incident was documented in nursing progress notes, but the care plan was not revised to reflect these events or to add new preventive measures. There was also no documentation of investigations into the causes of these falls or any analysis to identify contributing factors. Similar patterns were observed with other residents who had falls related to reaching for objects, attempting to get a soda, or experiencing lightheadedness. In each case, the care plans were not updated to include the new falls or interventions, and there was no documentation of investigations into the causes. Interviews with staff revealed inconsistent understanding of when and how to update care plans after falls, with some staff unsure if updates were necessary. The facility also lacked a specific policy regarding falls, further contributing to the deficiency.
Failure to Notify Physician and Family After Resident Falls
Penalty
Summary
The facility failed to notify residents' families and physicians of changes in condition and incidents, specifically regarding falls, in a timely manner for two residents. Documentation revealed that after multiple falls, staff did not consistently notify the physician or family, nor did they always document these notifications. In several instances, falls were either not documented at all or lacked clear records of physician and family notification, despite facility policy requiring such actions. One resident, with diagnoses including non-Hodgkin lymphoma and osteoarthritis, experienced multiple falls over a short period. Progress notes showed that after these incidents, staff sometimes notified the family but failed to notify the physician, and in some cases, neither party was notified. Staff interviews revealed confusion about what constitutes a fall and when notifications should occur, with some staff believing that sliding from a bed or chair did not require physician notification if there were no injuries. Another resident, with high blood pressure and lung cancer, also experienced a fall that was not followed by documented notification of the physician or family. Interviews with nursing staff, the MDS Coordinator, the DON, and the Administrator confirmed inconsistent practices regarding post-fall notifications. Some staff stated that physician notification was not always performed, especially during night shifts or if there were no injuries, despite the expectation that both family and physician should be notified after any fall. The facility did not provide a specific policy regarding falls or physician notification, and the existing documentation policy did not substitute for required event reporting and notifications.
Failure to Follow Physician Orders and Care Plan for Edema Management
Penalty
Summary
Staff failed to provide care according to physician orders, resident preferences, and established standards of practice for two residents with edema. For one resident with a history of non-Hodgkin lymphoma, varicose veins, hypertension, and cardiovascular disease, staff did not document follow-up regarding observed swelling in the feet, ankles, and legs. Although the resident was observed wearing Tubi grips on both lower extremities, there was no physician order for their use, and the care plan did not address the use of Tubi grips or the management of edema. Multiple staff interviews confirmed the absence of an order and lack of care plan documentation for Tubi grips, despite their regular application by CNAs. For another resident with diagnoses including edema, hypertension, and chronic respiratory failure, staff failed to consistently complete and document daily weights as ordered by the physician. The resident's care plan was not updated to reflect new orders for fluid restriction, Tubi grips, and Lasix. Review of the Medication Administration Record (MAR) revealed multiple days where weights were neither documented nor refusals recorded, and there was no documentation of physician notification when significant weight changes occurred. The resident reported ongoing swelling, difficulty walking, and issues with shoe fit due to edema, and expressed that daily weights were not being performed as expected. Interviews with various staff members, including CNAs, LPNs, the MDS Coordinator, the DON, and the Administrator, confirmed that Tubi grips require a physician order and should be included in the care plan, as should edema management and daily weights. Staff acknowledged that daily weights were the responsibility of CNAs, with the charge nurse providing a list of residents requiring weights. Despite these expectations, documentation and care planning were not completed as required, resulting in deficiencies in the provision of care for residents with edema.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring resident preferences for shower frequency for four residents. The deficiency was identified through observation, interview, and record review, and the facility census was 91. The facility procedure for Bath/Shower stated that the purpose of a shower is to maintain skin integrity, comfort, and cleanliness, and each of the affected residents had care plans stating they were to be offered two baths per week and had the right to refuse or request additional baths. Resident #6 had diagnoses including cerebral palsy, spastic hemiplegia, anxiety, major recurrent depression, open wounds, and reduced mobility. The resident’s MDS showed moderate cognitive impairment, dependence on staff for toileting hygiene, transfers, and showering, and risk for pressure ulcer development. Records showed showers were not consistently provided, with no showers documented from 09/01/25 to 09/09/25. During interview and observation, the resident stated a desire for three showers per week, said he/she was lucky to get one shower per week, reported feeling yucky without showers, and said his/her head became itchy when hair was not shampooed. The resident’s hair appeared greasy, and the resident said no shower had been received so far that week. Resident #11 had diagnoses including CHF, diabetes, anxiety, and major recurrent depression. The resident’s MDS showed intact cognition, partial/moderate assistance needed for toileting hygiene and showering, and risk for pressure ulcer development with MASD. The resident’s shower schedule showed limited showers and one refusal in July, one shower in August, and no refusals documented in August. During interview, the resident said staff had not assisted with a shower for a few weeks, that staff had told him/her a shower would be provided the next day, and that his/her head was itching and hair was greasy because of no shower or shampoo. The EMR later showed a shower was received on 09/04/25. Resident #23 had diagnoses including stroke, diabetes, generalized anxiety disorder, and depression. The resident’s MDS showed moderate cognitive impairment, supervision or touching assistance for showering, occasional bladder incontinence, and risk for pressure ulcer development. Records showed only one shower in July and one shower in August, with two refusals documented in August, and no showers documented from 09/01/25 to 09/09/25. The resident stated he/she had not had assistance with a shower for 2 weeks, and observation showed the resident’s hair was visibly oily and stringy. Resident #33 had diagnoses including chronic respiratory failure and generalized anxiety disorder. The resident’s MDS showed intact cognition, substantial/maximal assistance needed for showering and other ADLs, occasional bladder incontinence, and risk for pressure ulcer development. Although this resident received showers more frequently than the others, the resident stated the facility sometimes did not provide enough showers, that he/she felt dirty when showers were missed, and that during the summer he/she wanted two showers per week but sometimes only received one because shower aides were pulled to work the floor. Staff interviews confirmed staffing shortages and inconsistent completion of showers, with shower aides and nursing staff stating residents could go longer than a week without showers and that the facility did not have enough shower aides to complete all showers as scheduled.
Missing Written Transfer Notices
Penalty
Summary
The facility failed to ensure that staff provided written transfer notification to the resident and/or the resident's representative at the time of transfer for two residents. Review of the facility policy titled Discharge/Transfer of Resident stated that staff should explain the transfer and reason to the resident and/or representative and give a copy of the signed transfer or discharge notice to the resident and/or representative or person responsible for care, and that if the transfer is an emergency, the notice may be completed later but as soon as possible. For one resident, progress notes documented that the resident became unresponsive, staff initiated emergency response measures, called 911, and EMS transported the resident after staff notified the DON, physician, and NOK. For the second resident, progress notes documented that the resident was not responding, had diminished breath sounds, the NP ordered transfer to the ER, and staff contacted EMS and sent paperwork with the resident. Review of both residents' records showed no documentation that a written transfer notice was given or mailed to the resident and/or representative for the hospital transfers. Interviews with LPN, SS, BM, LTC CM, DON, and the Administrator confirmed that staff verbally notified families and documented the transfers in the chart, but no written notification was provided to the resident or family.
Code Status Information Not Kept Accurate or Accessible
Penalty
Summary
The facility failed to maintain an effective system to make each resident’s code status available to staff at all times. Surveyors found that the facility did not keep accurate, current, and accessible code status information for nine residents, including residents with DNR orders and residents with full code status. The deficiency was identified through interview and record review in a facility with a census of 91 residents. For Resident #2, the face sheet, physician order sheet, and care plan all showed DNR status, but the Resident Face Sheet book showed the resident as full code and the CNA quick reference book did not contain the resident’s information. For Resident #10, the face sheet, physician order sheet, and care plan showed DNR status, but the Resident Face Sheet book and CNA quick reference book did not contain the resident’s information. Similar omissions were found for Residents #27, #30, #7, and #42, whose records showed DNR status but whose information was absent from the Resident Face Sheet book and CNA quick reference book. For Resident #8, the face sheet, physician order sheet, and care plan showed full code status, but the Resident Face Sheet book and CNA quick reference book did not contain the resident’s information. For Resident #33, the face sheet and physician order sheet showed DNR status, but the D hall binder titled Resident Face Sheet did not contain the resident’s face sheet or code status information. For Resident #68, the face sheet and physician order sheet showed full code status, but the care plan showed DNR status, and the D hall binder did not contain the resident’s face sheet or code status information. Staff interviews showed that code status information was expected to be available in the face sheet books, electronic record, or offline eMAR, but staff gave inconsistent descriptions of who maintained the books and when they were updated, and one medical records staff member stated they were unaware that nurses needed hard copies of each resident’s code status.
Incomplete and Incorrect Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care per standards of practice when staff did not administer oxygen according to physician orders for one resident and did not obtain complete oxygen administration orders for three residents. The report states that the facility policy required staff to check the physician’s order for liter flow and method of administration and to administer oxygen as ordered. Surveyors identified that the facility census was 91. For one resident with COPD, anxiety, and dementia, the chart showed an order for oxygen at 2 liters per minute via nasal cannula continuously, every shift. However, observation showed the resident lying in bed with the oxygen tubing lying on the stomach and not in the nose, and the oxygen concentrator was set at 3 liters per minute. During later observation, the resident was in the dining room with a portable oxygen tank, and the concentrator was again set at 3 liters per minute. The resident stated he or she was supposed to be on 2 liters of oxygen all the time and did not adjust the concentrator. CNA interviews confirmed the resident’s oxygen was set at 3 liters per minute, and one CNA turned the oxygen off while the resident ate lunch. For another resident with COPD and CHF, staff documented episodes of shortness of breath, lethargy, and oxygen use for comfort, but the record did not contain an oxygen order. Multiple staff members stated they could not find an oxygen order in the chart, although they reported placing the resident on oxygen at times for breathing difficulty or anxiety. The DON also stated the resident had an oxygen tank from hospice and was not sure whether there was an oxygen order. For a third resident with anxiety and dyspnea, the POS only showed an order to check oxygen saturation every shift to keep levels above 90% for shortness of breath, but no liter flow order was documented. Observations showed the resident on oxygen at 3 liters and later 3.5 liters, while staff and the LTC CM stated there was no oxygen order in the chart. For a fourth resident, the POS showed only an order for oxygen saturation checks every shift, and the record did not reflect a liter amount of oxygen, yet observations showed the resident on oxygen at 3 liters and later wearing oxygen continuously. Staff interviews showed confusion about whether oxygen orders were present and what information they should include.
Missing Signatures on Controlled Medication Count Sheets
Penalty
Summary
The facility failed to provide pharmaceutical services with a consistent system of reconciliation for controlled substances when staff did not consistently sign the controlled medication count sheets at shift change for two medication/treatment carts. The facility policy titled, Narcotic Count, required an incoming and outgoing RN, LPN, or CMT to count narcotics at each shift change and record the date and signature after the count was completed. The census was 91. Review of the A/B Nurse Controlled Drugs-Count Record showed repeated missing signatures during August and September 2025. The record documented numerous instances in which the oncoming nurse, the off going nurse, or both failed to sign after the controlled medication count was completed on the A/B hall cart. An observation of the A/B hall-controlled medication book on 09/10/25 showed several blank spaces where nurses had failed to sign at change of shift in September 2025. Review of the C/D Nurse Controlled Drugs-Count Record showed the same pattern of missing signatures during August and September 2025. The record documented multiple shift changes where the off going nurse, the oncoming nurse, or both failed to sign, and one date when no nurses signed the count. An observation of the C/D hall-controlled medication book on 09/10/25 also showed several blank spaces where nurses had failed to sign at change of shift. During interviews, RN C, LPN D, the LTC Case Manager, the DON, the Administrator, and LPN A all acknowledged that the oncoming and off going nurse or CMT should count the controlled medications and both should sign the narcotic count record, and LPN A stated he/she sometimes forgot to sign even though the count was completed.
Medication Cart Left Unlocked Out of Staff View
Penalty
Summary
The facility failed to ensure resident medications were secure when a staff member left a medication cart unlocked while it was out of his/her line of sight. During observation on 09/05/25, Certified Medication Technician (CMT) K was seen preparing medications at the B hall medication cart, pressing the cart lock in only slightly so that it protruded about one inch with a visible red dot, then walking away from the cart and into a resident's room out of sight of the cart. When CMT K returned, he/she was able to pull the lock out with his/her fingers without using a key and open the cart drawers to prepare additional medications. The same sequence was observed again when the CMT left the cart, out of line of sight, to administer medications and provide water to a resident, then returned and opened the cart drawers by pulling the lock with fingers rather than a key. During interview, CMT K stated the B hall medication cart did not lock properly and that he/she did not fully compress the lock because it sometimes stuck; he/she also said other CMTs had told him/her not to lock the cart due to the sticking lock. CMT L stated the B hall cart drawers had to be lined up correctly for the lock to fully engage and said he/she did not leave the unlocked cart unattended. The LTC Case Manager, DON, and Administrator each stated that medication carts should be locked when not in use or when not in the staff member's direct line of sight, and the DON stated the cart needed to be fully locked if staff were going out of sight of it.
Improper Food Storage and Expired Items Left in Refrigerators
Penalty
Summary
Food was not stored in a manner to protect it from contamination and expired items were left in multiple refrigerators throughout the facility. Surveyors observed food items in the kitchen walk-in refrigerator, the kitchen double-door refrigerator, and the activities area refrigerator that were either uncovered, not sealed, or missing required labels and dates. Examples included bread with a best-by date of 08/07/25, thawed icing with no date, orange sauce and chopped tomato and onion with no label or date, raw chicken stored in plastic bags on a bottom shelf with no date, and multiple pitchers, cartons, and open containers of beverages and dairy items without open dates or discard dates. The observations also showed several expired items still present in storage areas. These included sliced cheese dated past its use-by date, half and half creamer with an expiration date of 09/02/25, an open bottle of mustard with an expiration date of 01/01/25, and multiple open cartons of juice marked with dates from 06/17/25 and 08/12/25. In the activities area refrigerator, staff observed open bottles, salad dressing servings, flour, and flavored creamer without labels or open dates, despite signage on the refrigerator stating that all items must be covered and labeled with name and date. During interviews, staff gave inconsistent statements about how long opened items could be kept and who was responsible for checking and dating items. The AD stated activity staff checked the refrigerator periodically and used the manufacturer expiration date rather than the date the item was opened. Dietary staff stated opened items should be labeled with the open date and dispose date, but gave different timeframes of three days or five days. The DM stated items should be covered and dated, open juices should be discarded after three days, and activity staff were responsible for labeling, disposing of expired items, and temping the activity room refrigerator, while the Administrator stated the DM was responsible for overseeing food storage and expired food disposal and that the DM was responsible for checking and temping the activity room refrigerator.
Failure to Maintain Infection Control Policies and Annual TB Screening
Penalty
Summary
The facility failed to implement its infection prevention and control program when it did not ensure that each resident was screened annually for tuberculosis and did not review and update its infection prevention and control policies and procedures manual on an annual basis. The Infection Prevention and Control Policy manual contained policy dates of 04/23/20, 08/11/20, 05/15/23, and 05/18/23, but there was no documentation showing the manual had been reviewed or revised annually. During interviews, the RN/Quality Assurance Consultant, DON, and Administrator each stated they were not aware of, or did not perform, an annual review of the infection control policies and procedures manual. The facility also failed to document annual TB screening for four residents. Resident #22, who had COPD, had an annual TB screening form completed on 02/18/24, but no annual TB screening form was documented for 2025. Resident #30, admitted on 12/05/15, had a physician order for 2-step PPD upon admission and annual TB screening, but no annual TB screening form was documented for 2025. Resident #1 had a physician order for 2-step PPD upon admission and annual TB screening, but staff did not document TB annual screening information for 2023, 2024, or 2025. Resident #42, who had Huntington's disease, protein-calorie malnutrition, and anxiety, had an annual screening completed on 06/18/23, but no TB screening was documented for 2024 or 2025. Staff interviews indicated RNs were responsible for completing annual resident TB screenings and that the TAR was supposed to alert nurses when a screening was due.
Lack of periodic bed rail safety checks and measurements
Penalty
Summary
The facility failed to have a process in place for periodic bed rail safety checks, including measurements of the bed frame and bed rails for risk of entrapment, for seven residents. The facility policy required regular inspections of all bedframes, mattresses, and bed rails to identify possible entrapment areas, and the bed rail manual stated that ongoing evaluation and frequent reassessment of bed rail need were part of bed safety. However, staff and leadership described no regular assessment or maintenance schedule, and documentation of periodic assessment and measurements was not provided for the affected residents. Resident #22 had COPD, chronic kidney disease, anxiety, and depression, and had bilateral half side rails ordered for repositioning and transfers. Observations showed the right rail was loose, wiggled from top to bottom, and could be pushed in to touch the mattress. Resident #30 had Down Syndrome, chronic kidney disease, anxiety, depression, and epilepsy, and had half side rails ordered for repositioning/transferring. Observations showed the left rail had a gap from the mattress and moved back and forth and up and down. Resident #91 had Alzheimer's disease and anxiety, and had bilateral half side rails ordered for repositioning/transferring. The resident reported the right rail had been loose for months and said the rail fell to the floor the day before one observation; staff observed the rail moving several inches and the resident said he/she did not feel it was safe. Resident #1 had senile degeneration of the brain and anxiety, with bilateral half side rails ordered for transfers and repositioning. Observations showed the rails were loose and one rail leaned over at about 120 degrees while the resident held it. Resident #5 had dementia without behavioral disturbance, major depressive disorder, and anxiety disorder, with bilateral half side rails ordered for bed mobility and transfers, but no periodic assessment or measurements were documented. Resident #8 had a coagulation defect, major depressive disorder, and anxiety, with bilateral half rails ordered for bed mobility per resident request; observations showed both rails were loose to the touch. Resident #21 had a cerebral infarction, amputation, hemiplegia, and seizures, with bilateral half side rails ordered for bed mobility and transfers; records also lacked periodic assessment and measurements, although one observation showed both rails secure to the touch. Staff interviews showed CNA, RN, LTC CM, Maintenance, DON, and the Administrator were unsure of a regular process for checking bed rail safety, while Maintenance stated rails were tightened as needed but not documented and there was no regular assessment or maintenance schedule.
Incomplete and Inaccurate Weekly Skin Assessments
Penalty
Summary
The facility failed to provide accurate and timely skin assessments for two residents who had identified skin concerns and active skin treatments. Facility policy stated that wounds were to be prevented and treated and that ongoing skin assessment with weekly documentation of status was required, but the facility did not have a separate policy regarding skin assessments. Surveyors found that weekly skin assessments were not completed or were documented inaccurately for both residents, including repeated documentation that skin was intact despite ongoing drainage, open areas, and ordered treatments. One resident was admitted with dementia, diabetes, hypertension, heart failure, chronic kidney disease, cellulitis, anxiety, and spondylolisthesis. The resident’s care plan directed staff to keep skin intact, assess for risk factors, and report any signs of skin breakdown. The record showed bilateral lower extremity weeping beginning in early July, with orders for tubi-grips, gauze as needed for weeping edema, and later multiple wound treatment orders for the legs and thigh. Despite these findings and orders, weekly skin assessments in July and August repeatedly documented skin intact with no interventions or treatments, and did not address the bilateral lower extremity weeping, open areas, or ordered dressings. The record also showed the resident continued to have drainage, wrapped the legs independently at times, and had ongoing wound care needs documented in progress notes. The second resident was readmitted with a history of cerebral infarction, amputation, hemiplegia, diabetes, and seizures. The care plan identified the resident as at risk for altered skin integrity due to decreased mobility and incontinence. The record showed a right shoulder wound with purulent drainage, redness, and warmth, followed by antibiotic and topical treatment orders. However, staff did not document routine skin assessments for August 2025, and no routine skin assessments were documented for the week of 09/01/25 to 09/07/25. Interviews with nursing staff and leadership confirmed that nurses were responsible for weekly skin assessments, that the assessments should be documented in the electronic record and on the TAR, and that assessments were sometimes missed when staff were busy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
RN's Inappropriate Response to Resident's Bite
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a Registered Nurse (RN) slapped the resident in response to being bitten. The incident occurred when the RN, along with two Nurse Aides (NAs), attempted to remove an object from the resident's mouth. The resident, who was severely cognitively impaired and required supervision while eating, was chewing on a plastic straw and refused to spit it out. In an attempt to retrieve the straw, the RN used their fingers to open the resident's mouth, resulting in the resident biting the RN's finger. Following the bite, the RN reacted by slapping the resident on the left cheek, which was witnessed by the two NAs. The RN claimed that the slap was a reflexive response to the pain from the bite and described it as a very light tap. However, both NAs reported the incident to the Director of Nursing (DON), who then informed the Administrator. The facility's policy clearly prohibits any form of abuse, including physical abuse, which is defined as hitting or slapping a resident. The resident involved in the incident had a history of anxiety, unspecified dementia, and major depressive disorder, which contributed to their cognitive impairment. The facility's investigation revealed that the RN's actions were inappropriate and not in line with the facility's abuse prohibition policy. The incident highlights a failure in ensuring the resident's right to be free from abuse, as outlined in the facility's policies and the resident's rights documentation.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a Certified Nursing Assistant (CNA) and a resident within the required two-hour timeframe. The incident occurred when the resident reported that CNA B had grabbed their wrist and forcefully put them back to bed, causing pain and a small bruise. The resident reported the incident to another CNA (CNA K) around 1:50 A.M., who then informed the Registered Nurse (RN A). However, RN A did not report the incident to the Director of Nursing (DON) until approximately 4:30 A.M., and the DON subsequently informed the Administrator at 6:19 A.M. The Administrator then reported the incident to the State Survey Agency at 7:00 A.M., which was five hours after the initial report by the resident, exceeding the required two-hour reporting window for abuse allegations. The facility's policies clearly state that any allegations of abuse must be reported immediately to the Administrator and the State Survey Agency within two hours if the event involves abuse or results in serious bodily injury. Despite these policies, there was a significant delay in reporting the incident. Interviews with various staff members, including CNAs, RNs, and the DON, revealed inconsistencies in their understanding of the reporting procedures and timelines. Some staff members believed that the DON had up to 24 to 48 hours to report such incidents, while others were aware of the two-hour requirement but failed to act accordingly. The resident involved had a history of dementia, depression, hemiplegia, and reduced mobility, requiring substantial assistance for daily activities. The delay in reporting the abuse allegation not only violated the facility's policies but also potentially compromised the resident's safety and well-being. The failure to adhere to the mandated reporting timelines highlights a critical gap in the facility's abuse reporting protocol and staff training, leading to the identified deficiency.
Failure to Follow Abuse Policy and Protect Residents During Investigation
Penalty
Summary
The facility failed to follow their abuse policy and protect all residents during an investigation of alleged abuse. A resident alleged that a CNA physically abused them, and the CNA continued to work independently with other residents. The facility's policies require that any staff member accused of abuse be suspended immediately to prevent further potential abuse, but this was not followed in this case. The resident involved had a history of dementia, depression, hemiplegia, and reduced mobility, requiring substantial assistance for daily activities. The resident reported that the CNA took them by the wrist and slammed them down hard onto the bed, resulting in a small bruise. Despite this allegation, the CNA was allowed to continue working their shift without supervision or suspension. Interviews with staff revealed that there was a lack of clear direction and adherence to the facility's abuse policies. The RN and DON did not ensure the immediate suspension of the CNA, and the CNA continued to care for other residents. The Administrator acknowledged that the other residents were not protected from the CNA during the investigation, highlighting a significant lapse in following established protocols to ensure resident safety.
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 134 citations issued within 25 miles in the last 12 months — including the 1 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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| James River Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 1 | 0 |
| Spring Valley Health & Rehabilitation Center | 2.9 mi | ★★★★★ | 33 | 0 |
| Springfield Villa | 3.5 mi | ★★★★★ | 10 | 1 |
| Cox Medical Centers Meyer Orthopedic And Surgical | 3.5 mi | ★★★★★ | 1 | 0 |
| Birch Pointe Health And Rehabilitation | 4.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Glendale Gardens Nursing & Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.