Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Home-schdy Cnty Dept Social Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, MS, CHF, a history of falls, and anticoagulant use fell out of bed during care while a CNA was providing a one-person assist. After the first fall, the record did not show a nursing reassessment, therapy evaluation for safe bed mobility, or other new interventions beyond staff education. The resident later fell again during bed care, sustained abrasions, and was ultimately hospitalized with pelvic fractures, active hemorrhage, and pseudoaneurysms requiring embolization.
Pressure ulcer care was not consistently provided for multiple residents. One resident with MS, DM, and severe cognitive impairment had a left heel wound with inconsistent staging and also had a right heel wound and a lower left leg wound without weekly wound assessments. Another resident with a coccyx pressure injury had treatment documented but no weekly wound assessments, and an air mattress was noted in a provider note without a documented order. A third resident with osteomyelitis, MS, and DM missed wound treatment and weekly wound assessment when out for an appointment on the day wound rounds occurred.
Failure to Assess and Document Pain Before PRN Tramadol Administration: A resident with MS, DM, pressure ulcer history, and severe cognitive impairment had a care plan and facility protocol requiring pain assessment and documentation before and after pain meds. The resident received scheduled acetaminophen and later PRN tramadol for unspecified pain, but the record lacked a documented pain assessment, pain location/description, and evidence of provider notification before the tramadol order was obtained; nursing notes only documented that the medication was given, with limited follow-up documentation of effect.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Two residents who were cognitively intact but dependent for ADLs did not receive care as planned. One resident with post-stroke hemiplegia and other medical conditions had no documented baths or showers on two scheduled evening shifts within the initial admission period, despite being care planned for substantial/maximal assist with bathing. Another resident with a hip fracture, heart failure, and paroxysmal atrial fibrillation, care planned for extensive one-person assist with transfers and toileting and bowel documentation every shift, had multiple shifts in which toileting assistance was not documented. Staff reported that showers and care should occur as scheduled and be rescheduled and communicated if missed, but the records did not reflect that this occurred for these residents.
A resident with CAD, PVD, and COPD, who was cognitively intact, reported severe (10/10) pain and trouble breathing after family alerted staff that the resident felt very sick. An RN documented stable VS and no acute distress, and later an NP was contacted and adjusted pain medications. That evening, nursing notes described a significant two-day decline with minimal intake, continuous sleeping, and persistent 10/10 foot pain despite the new regimen, but there was no documented provider notification of this ongoing uncontrolled pain and change in condition. By early the next morning, the resident was very lethargic, non-responsive, hypotensive, and was then sent to the ER, where they were diagnosed with toxic metabolic encephalopathy likely due to severe sepsis from gram-negative pneumonia. The NP stated nurses were expected to call back with reassessment if pain remained uncontrolled, the DON was unaware of the change in condition, and an RN acknowledged documentation should have been better, demonstrating a failure to follow change-of-condition and quality-of-care policies.
Failure to Reassess and Supervise Bed Mobility After Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who was at high risk for falls and bleeding. The resident had diagnoses including congestive heart failure, multiple sclerosis, and a history of falling, and the Minimum Data Set documented severe cognitive impairment and total dependence on staff for bed mobility. The resident’s care plan identified fall risk, anticoagulation therapy with Eliquis, and the need for staff to avoid bumping and to handle the resident gently during hands-on care. Nursing instructions also directed one-person physical assist for bed mobility. After an observed fall out of bed during care, the resident was found on the floor with no injury. The incident documentation stated the resident rolled out of bed while a CNA turned around to get more linen, but there was no documented evidence that nursing reassessed fall risk, assessed whether the resident could safely receive bed mobility care with one staff member, or implemented new interventions to reduce the risk of another accident. The fall risk assessment completed later showed a higher fall risk score than before, but the record did not show a therapy evaluation for safe bed mobility or other new interventions after the fall. The resident later fell out of bed again while care was being provided by one CNA and sustained abrasions. The care plan was updated to add two-person assist for bed mobility and hygiene, but the resident subsequently had a change in condition and was sent to the hospital, where imaging showed pelvic fractures, active hemorrhage, and multiple pseudoaneurysms requiring embolization of the right internal pudendal artery. Survey interviews with nursing leadership confirmed they could not explain why no additional interventions were implemented after the first fall and acknowledged that therapy evaluation or a two-person assist could have been considered, while the medical director stated it was the responsibility of nursing staff to implement interventions to prevent accidents.
Pressure ulcer care and wound assessment failures
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The deficiency involved three residents and included inconsistent wound staging, missing weekly wound assessments, and incomplete wound treatment oversight. The report states that the facility did not ensure proper documentation and follow-through for pressure injuries affecting the heel, coccyx, and lower leg, despite physician orders and care plan interventions calling for daily treatment and weekly assessment. For one resident with multiple sclerosis, diabetes, and severe cognitive impairment, the left heel wound was documented inconsistently over time. The wound was first identified as a deep tissue injury, later described as having opened and as having two blisters, then later documented again as a deep tissue injury or unable to determine. The record also showed that the anatomical drawing initially conflicted with the assessment data. In addition, the resident had a right heel pressure injury and a pressure ulcer on the back of the lower left leg, but the record did not contain weekly wound assessments for either wound while treatment orders were in place. For another resident with fractures, diabetes, and a coccyx pressure ulcer, the wound was identified as stage 2 and treated from the time it was first documented through the end of the review period, but the record did not show weekly wound assessments while the wound was being treated. The medical note also documented an air mattress for the coccyx wound, but there was no documented order for the air mattress in the record. For a third resident with osteomyelitis of the spine, multiple sclerosis, and diabetes, wound care orders were in place for a stage 4 coccyx wound and an unstageable left heel wound, but when the resident was out of the facility for an appointment on the day the in-house wound care provider completed rounds, the treatment record did not show wound treatment that day and there was no documented weekly wound assessment for that week.
Failure to Assess and Document Pain Before PRN Tramadol Administration
Penalty
Summary
Pain management was not provided in accordance with professional standards of practice and the resident’s comprehensive care plan for one resident with multiple sclerosis, diabetes, pressure ulcer history, and severe cognitive impairment. The resident’s care plan called for ongoing assessment of pain, including onset, location, description, intensity, and aggravating or alleviating factors, and for medications to be administered as ordered. The facility also had a pain management protocol requiring pain to be monitored and documented before and after pain medication, with follow-up documentation within one hour of administration and a progress note reflecting the medication and effect for each dose. The resident had standing acetaminophen ordered every eight hours and later received a new PRN tramadol order for unspecified pain. Survey review found no documented evidence of a pain assessment or physician notification before the tramadol order was obtained, and the medication record and nursing notes did not document the description or location of the pain. Tramadol was administered multiple times, but the notes only stated that it was given, and in two instances that it had a positive effect, without documenting the pain details required by the care plan and facility protocol. The DON stated the resident should have had a pain assessment before the on-call provider was contacted, and the RN involved stated she did not recall the order and believed the supervisor would have handled the provider call and documentation.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
Failure to Provide and Document Scheduled Bathing and Toileting Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living in accordance with professional standards for two cognitively intact, dependent residents. One resident with hemiplegia following a prior stroke, essential hypertension, and hypo-osmolality/hyponatremia was care planned as requiring substantial/maximal assistance for bathing and extensive assist of two for bed mobility and transfers. The CNA accountability record for bathing showed no documented evidence that this resident received a bath or shower on two scheduled evening shifts in late December, including within the first two weeks after admission. This lack of documented bathing occurred despite the resident’s identified need for extensive assistance with all ADLs. Another resident with a displaced intertrochanteric fracture of the right femur, heart failure, and paroxysmal atrial fibrillation was care planned as requiring extensive one-person assistance for transfers, ambulation, and toileting, with CNAs directed to document bowel elimination every shift. Review of CNA toileting documentation for July showed multiple shifts with no recorded toileting assistance, including several day, evening, and night shifts across the month. During interviews, a CNA and an LPN stated that residents should receive showers on their scheduled days and that any missed showers or care would be reported to nursing and rescheduled, but the records for these two residents did not show that the planned toileting and bathing care was provided or documented as required.
Failure to Notify Provider and Respond to Resident’s Significant Decline and Uncontrolled Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding change in condition. The resident had diagnoses including CAD, PVD, and COPD and was documented as cognitively intact. On one day, the resident’s daughter called reporting that the resident said they were "very, very sick." An RN assessed the resident, noting stable vital signs, clear upper lung sounds, refusal of lower lobe assessment, complaint of trouble breathing, oxygen saturation of 90%, and refusal of oxygen and dressing change. The RN informed the daughter that the resident was not in acute distress and not dying. Later that day, the NP on call was notified of the resident’s uncontrolled pain rated 10/10, and new orders were obtained for scheduled and PRN pain medications. That evening, nursing documentation described a significant decline over the prior two days, including minimal intake, no eating, sleeping throughout the 15:00–23:00 shift, and continued 10/10 left foot pain despite the earlier medication adjustment. The resident was lethargic but could be roused to take medications before returning to sleep. Despite this documented significant decline and persistent severe pain, there is no documentation that the provider was notified at that time of the change in condition or ongoing uncontrolled pain, contrary to the facility’s change of condition and quality of care policies that require timely evaluation and provider notification when changes occur. In the early morning hours of the following day, the resident was documented as very lethargic and non-responsive, with hypotension, bradycardia, low temperature, and an inability to obtain an oxygen saturation reading. At that point, the NP ordered transfer to the ER, where the resident was diagnosed with toxic metabolic encephalopathy likely in the setting of severe sepsis due to gram-negative pneumonia. The NP later stated that if pain was not controlled, nursing staff were expected to call back with reassessment findings, including vital signs, mental status, and history, for further direction. The DON reported not being aware of the resident’s change in condition during this period, and an RN interviewed acknowledged that documentation for this resident should have been better. These actions and omissions demonstrate that the facility did not promptly identify, evaluate, and communicate the resident’s change in condition and persistent severe pain in accordance with its policies and professional standards.
What surveyors are citing around you — mapped
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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 156 citations issued within 25 miles in the last 12 months — including the 5 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Scotia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pathways Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Baptist Health Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Ellis Residential & Rehabilitation Center | 4.9 mi | — | 0 | 0 |
| Schenectady Center For Rehabilitation And Nursing | 5.8 mi | ★★★★★ | 27 | 0 |
| Seton Health At Schuyler Ridge Residential H C | 6.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.