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 Glendora Health Care Center during CMS and state inspections, most recent first.
Failure to Deliver Resident Mail Daily: A resident with intact cognition and no behaviors did not receive mail daily. The BOM and Activity Aide stated mail was only passed out when the BOM provided it, and the aide did not distribute it every day. The resident reported having to ask for mail and still not always receiving it, while waiting for bank-related mail. Facility policy required prompt delivery of mail within 24 hours of postal delivery.
A resident with multiple chronic conditions and documented behavioral issues became involved in an altercation with an agency CNA near the nurse’s station after a dispute over hallway noise. The resident and CNA gave conflicting accounts about who initiated contact, but the resident had visible facial scratches and a skin tear, and the CNA stated she recorded the incident on her phone. A nurse witnessed part of the event and reported the resident was trying to kick at the CNA while the CNA continued responding verbally to the resident’s racial slurs.
A resident with Alzheimer's disease and DM, on a regular diet with dysphagia-advanced texture and thin liquids, was served an incorrect portion of ground chicken salad when dietary staff used a #16 scoop (2 oz) instead of the #10 scoop (3.75 oz) specified on the diet ticket and in the recipe. During lunch tray line service, the staff member plated the smaller portion and sent the tray to the cart, and the error was only recognized when the tray was later pulled. The dietary manager later acknowledged that serving utensils had not been checked before tray service, and this error had the potential to affect multiple residents receiving the same menu item.
The facility failed to properly label and store frozen food items, as observed during a kitchen tour. A plastic bag with 10 frozen pork fritters was found undated and loosely wrapped in the freezer. A staff member confirmed the oversight and discarded the fritters. The facility's policy mandates date marking of food when opened, which was not adhered to.
The facility failed to maintain respiratory care equipment for two residents, leading to a deficiency. One resident with a history of respiratory issues had nebulizer equipment improperly stored and unsecured, despite orders for regular cleaning and changing. Another resident receiving hospice care also had unsecured nebulizer equipment, contrary to physician orders. An LPN confirmed the improper storage, resulting in the identified deficiency.
The facility failed to store and monitor medications safely, affecting all residents. Expired bisacodyl suppositories were found, and refrigerator temperature logs were incomplete, with one instance of a temperature at 48°F not reported. The Alixa medication storage room had significant ice buildup, and an LPN used an undated insulin pen against policy.
The facility failed to properly store, label, and monitor food items, affecting all residents. Observations revealed unlabeled and moldy food, improper storage of staff and resident foods, and incomplete temperature logs. Staff interviews highlighted confusion over responsibility for monitoring refrigerator temperatures, contradicting facility policy.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling catheters and surgical wounds, lacked proper infection control in laundry services, and did not disinfect a glucometer after use. Staff did not use PPE during high-contact care, and clean and soiled laundry were improperly handled due to space constraints and broken equipment.
The facility failed to maintain comfortable temperatures on two units, affecting three residents who complained of feeling cold. Temperatures were recorded between 69 and 70 degrees Fahrenheit. Additionally, a resident's bed was missing a headboard, and a nearby heating unit had a broken cover, exposing the heating element. The Director of Maintenance confirmed these issues.
The facility failed to provide individualized activities for residents, leading to deficiencies in meeting their needs. A resident with cognitive and physical impairments reported not being offered activities, and observations confirmed the absence of an updated activity calendar. Another resident expressed interest in activities but was unaware of offerings beyond bingo. Other residents with cognitive impairments were observed without engagement in activities. The absence of the Activity Director and lack of a dedicated activity calendar contributed to the deficiency.
The facility failed to ensure psychotropic medications were administered only when necessary, did not address approvals for gradual dose reductions in a timely manner, and lacked documentation of non-pharmacological interventions and monitoring of target symptoms. This affected several residents, including one who continued receiving trazodone without a reduction attempt and another who received Ativan without prior non-pharmacological interventions. The facility's policy on psychotropic medication use was not followed, as required documentation and interventions were missing.
The facility failed to provide a working call system in three restrooms accessible to residents, potentially affecting seven residents with independent mobility. Observations confirmed that these restrooms, although wheelchair accessible and designated for male or female use, lacked call systems, contrary to the facility's policy requiring call lights in resident areas to ensure assistance can be summoned.
A facility failed to maintain consistent documentation of a resident's code status. The resident, with conditions such as vascular dementia and chronic kidney disease, had a signed DNR form indicating DNRCC status. However, the electronic health record, facility report sheet, and physician orders listed the status as DNRCC-A. This discrepancy was confirmed by the Administrator, indicating a lack of consistency in the resident's code status documentation.
A facility failed to provide a summary of the baseline care plan to a resident and their representative. The resident, with conditions such as epilepsy and dementia, was admitted without a baseline care plan initially located. The Administrator later confirmed the absence of evidence that a summary was provided, despite eventually locating the care plan.
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked necessary details about nectar thickened liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. Another resident's care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user. These errors were confirmed by facility staff.
A facility failed to update a resident's care plan to reflect changes in their functional abilities and weight-bearing status. The resident, with multiple fractures, had physician orders allowing weight bearing as tolerated for certain extremities and requiring a hoyer lift for transfers. Despite these updates, the care plan remained unchanged. Observations showed the resident independently propelling in a wheelchair and grooming, while an STNA confirmed the resident's ability to feed and wash independently. The administrator admitted the care plan was not revised accordingly.
A facility failed to address pharmacy recommendations for a resident receiving antipsychotic medications, olanzapine and risperidone. The pharmacist suggested discontinuing one medication to avoid duplicative therapy and highlighted the need for compliance with regulations on antipsychotic use. The physician's response did not address these recommendations, and AIMS testing was not conducted as advised. The DON confirmed that the pharmacy reviews were not fully responded to, contrary to the facility's policy.
Two residents in a LTC facility experienced medication administration errors, resulting in a 6.6% error rate. A nurse administered colace without a physician's order, failing to give the prescribed sennosides-docusate sodium. Another nurse used an undated insulin lispro pen without priming it, contrary to facility policy and manufacturer instructions.
A facility failed to address the use of a prophylactic antibiotic for a resident with a history of multiple antibiotic use. The resident, with several medical conditions, was prescribed cephalexin for infection prevention after a fall, despite not meeting infection criteria. The DON did not question the physician's order, and the facility's policy did not cover prophylactic antibiotic use, leading to a deficiency in antibiotic stewardship.
The facility failed to implement fall interventions for a resident at risk of falls and did not provide thickened liquids as ordered for another resident at risk of aspiration. Observations showed the absence of a fall mat for one resident, and multiple staff confirmed the lack of awareness of the order. Another resident received regular liquids despite a physician's order for nectar-thick liquids, with staff unaware of the requirement.
A resident with dementia fell into a pond due to inadequate supervision while outside watering plants. The facility failed to provide comprehensive elopement assessments and care plans for several residents, leading to inconsistencies in managing elopement risks. This deficiency affected multiple residents, highlighting the facility's inability to ensure proper supervision and safety measures.
A facility failed to maintain adequate staffing on its memory care unit, leading to incidents involving two residents. One resident fell into a pond while unsupervised, requiring emergency medical attention, while another resident exited the building. The facility's staffing schedules showed a pattern of understaffing, with only one RN and one STNA assigned to the unit. Interviews revealed the facility lacked a specific staffing policy for the memory care unit, and the LNHA confirmed staffing was based on census and resident needs.
Failure to Deliver Resident Mail Daily
Penalty
Summary
The facility failed to ensure that mail was delivered daily to a resident with intact cognition and no behaviors. The resident was admitted with diagnoses including borderline personality disorder, schizoaffective disorder bipolar type, asthma, obstructive sleep apnea, hypertension, obsessive compulsive disorder, insomnia, and anxiety disorder. Review of the quarterly MDS assessment showed the resident had intact cognition and no behaviors. An interview with the Administrator confirmed that mail was passed out to residents by the activity department. The BOM stated the resident had been in her office daily looking for her mail and that the resident was waiting on items from the bank, but none had been received. An Activity Aide stated she only passed out mail when the BOM gave it to her and that the BOM only worked at that building on Tuesdays and Thursdays; she did not pass out mail every day and only did so when there was a pile on her desk. The resident stated the facility did not pass out mail every day, that she had to ask for it, and that she still did not always get it when she asked. Review of facility policy stated mail was to be promptly delivered to the resident within 24 hours of postal delivery.
Resident Assault and Unauthorized Video Recording
Penalty
Summary
The facility failed to protect Resident #27 from abuse and video recording by an agency CNA. Resident #27 was admitted with diagnoses including diabetes, hypertension, depression, heart failure, mild dementia, neuropathy, major depressive disorder, anxiety disorder, and hyperlipidemia. His care plan identified behavioral concerns, including racial slurs toward staff, physical aggression, sexual comments, verbal aggression, and disruption of the care environment. The resident’s quarterly MDS assessment documented intact cognition and physical and verbal behaviors toward others. According to the resident’s statement and the facility’s incident review, an altercation occurred between Resident #27 and Agency CNA #100 near the nurse’s station after the resident became upset about noise in the hallway. The resident reported that the CNA made a comment about his mother, and he became angry, stood up, and knocked a basket off the nurse’s station. He stated the CNA then swung at him, hit him in the face, and knocked his glasses off. The resident was noted to have scratches on his forehead and bridge of his nose, and a skin assessment documented two four-centimeter scratches to the face and one one-centimeter skin tear to the nose. The CNA stated that the resident was verbally aggressive, used racial slurs, and advanced toward her, and she said she recorded the altercation on her phone for her safety. The nurse who witnessed part of the event stated the resident was trying to kick at the CNA and that the CNA continued verbally responding to the resident’s racial slurs. The police report reflected conflicting accounts from the resident and the CNA regarding who initiated physical contact, whether the CNA used her foot to create distance, and whether the resident struck the CNA. The report also states that the CNA captured video of the altercation, and the officer viewed the video and noted no injuries on the resident’s face during the recording, with scratches appearing afterward.
Improper Portioning of Ground Chicken Salad on Diet Tickets
Penalty
Summary
The facility failed to ensure residents received proper portion sizes as specified on diet tickets during meal service. A resident with Alzheimer's disease and diabetes mellitus, admitted on 5/28/25, had an annual MDS assessment indicating moderate cognitive impairment and a need for setup assistance with eating. Physician orders for March 2026 specified a regular diet with dysphagia advanced texture and thin liquids. During observation of the lunch tray line on 03/19/26 at 12:15 P.M., the resident’s meal ticket indicated they were to receive ground chicken salad using a #10 scoop (3.75 oz). However, staff member #107 plated the ground chicken salad using a #16 scoop (2 oz), then completed the tray and placed it in the food cart. At 12:17 P.M., when Dietary Aide #109 pulled the tray from the cart, staff member #107 verified that the scoop used was a #16 (2 oz) instead of the required #10 (3.75 oz). In an interview at that time, staff member #107 acknowledged the serving size should have been three ounces and consulted the scoop chart, which confirmed the #16 scoop was only two ounces. The undated chicken salad recipe also specified that a #10 scoop of chicken salad should be placed between two slices of bread. In a later interview at 1:30 P.M., the Dietary Manager stated she believed staff member #107 was nervous and acknowledged she should have checked the serving utensils prior to tray service. This failure affected the identified resident and had the potential to affect eight other residents scheduled to receive ground chicken salad.
Improper Labeling and Storage of Frozen Food
Penalty
Summary
The facility failed to properly label and store frozen food items in the kitchen, which had the potential to affect all residents. During an initial kitchen tour, a plastic bag containing 10 frozen pork fritters was found sitting on top of a cardboard box on the second shelf of the freezer. The bag was neither dated nor sealed properly, as it was loosely wrapped. An interview with a staff member confirmed that the bag was not dated when opened or placed in the freezer, and the staff member subsequently discarded the fritters. The facility's policy requires that food be date-marked at the time it is opened or prepared, which was not followed in this instance.
Improper Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to properly maintain respiratory care equipment for two residents, leading to a deficiency in respiratory care. Resident #22, who had a history of opioid abuse, acute respiratory infection, anxiety, and shortness of breath, required staff assistance with activities of daily living, including medication administration. Despite having physician orders to clean and change nebulizer tubing and mask every Sunday night shift, observations revealed that the nebulizer and medication delivery device were not secured in a bag and were improperly stored on top of clothing and papers in the resident's room. The equipment was dated 02/03/25, indicating it had not been changed or secured as required. Similarly, Resident #23, who had diagnoses of congestive heart failure, high blood pressure, and shortness of breath, was receiving hospice services and required staff assistance with medication administration. Physician orders specified cleaning and changing the nebulizer tubing every three days and as needed. However, observations showed that the nebulizer and medication delivery device were left unsecured on a dresser in the resident's room, with tubing dated 02/10/25. Interviews with an LPN confirmed the improper storage and lack of securement for both residents' respiratory equipment, leading to the identified deficiency.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to store and monitor medications safely, which had the potential to affect all residents. During an observation, it was found that two boxes of bisacodyl suppositories were expired, and the Director of Nursing (DON) confirmed they were stock medications for residents. Additionally, the refrigerator in the medication room had multiple boxes of influenza vaccines, tuberculin vials, haldol injection vials, and insulin pens, but the temperature logs were incomplete. The refrigerator temperature was not monitored on several occasions, and on one instance, it was recorded at 48 degrees Fahrenheit, which was not reported to the DON or maintenance personnel. Another observation revealed that the freezer in the Alixa medication storage room was over 50% solid ice, with ice buildup affecting the storage of medications. The temperature logs for this refrigerator were also incomplete, with no documentation since a specific date. Furthermore, an LPN was observed administering insulin to a resident using an undated insulin pen, which was against the facility's policy that required insulin pens to be disposed of after 28 days. The facility's policies on medication storage and insulin pen usage were not adhered to, leading to these deficiencies.
Deficiencies in Food Storage and Monitoring
Penalty
Summary
The facility failed to ensure proper storage, labeling, and monitoring of food items, which could potentially affect all 36 residents. During an initial tour of the kitchen, several deficiencies were observed, including an opened bag of raspberry gelatin mix and dry pasta without labels indicating the open date, and a bag of rolls with visible green mold. These observations were confirmed by a staff member at the time. Additionally, in the nurse's station refrigerator, both staff and resident foods were stored together, with significant ice crystallization and a brown substance spilled in the freezer. Further observations in the South unit's servery refrigerator revealed similar issues, including unlabeled food containers and an open popsicle covered in ice crystals. The temperature log for the freezer was incomplete, with no records for the first half of the month. Interviews with various staff members revealed confusion about responsibility for monitoring and recording refrigerator temperatures, with some staff unaware of the refrigerator's existence. The facility's policy indicated that dietary staff were responsible for monitoring temperatures, but this was contradicted by the Registered Dietitian, who stated it was actually the housekeeping staff's responsibility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, particularly regarding Enhanced Barrier Precautions (EBP) for six residents. These residents had various medical conditions requiring EBP, such as indwelling catheters, surgical wounds, and colostomies. However, observations revealed that there were no isolation bins, PPE, or signage indicating EBP in the rooms of these residents. Staff interviews confirmed a lack of understanding and implementation of EBP, as staff did not use PPE during high-contact care activities, contrary to the facility's policy. Additionally, the facility's laundry services were found to be inadequate, with soiled and clean laundry coming into contact due to space constraints and a broken washing machine. This situation posed a risk of cross-contamination, as observed when a laundry aid moved clean laundry carts against soiled laundry and trash cans. The facility's housekeeping supervisor acknowledged the challenge of maintaining separation between clean and soiled laundry due to the limited space and non-functional equipment. The facility also failed to properly disinfect a glucometer used for blood sugar monitoring. An LPN was observed using a glucometer for a resident without cleaning it before or after use, despite the facility's policy requiring disinfection after each use. The LPN admitted to cleaning the glucometer only once per shift, and the DON confirmed that bleach wipes should have been used for disinfection. The facility's policy outlined specific disinfection procedures, which were not followed, increasing the risk of infection transmission.
Facility Fails to Maintain Comfortable Temperatures and Equipment
Penalty
Summary
The facility failed to maintain comfortable temperatures on two units, affecting three residents. Observations and interviews revealed that residents in the common area of the [NAME] unit complained of feeling cold and requested blankets. The temperature in the common area was recorded at 70 degrees Fahrenheit, while the South unit's hallway and resident rooms had temperatures ranging from 69 to 70 degrees Fahrenheit. The facility administrator acknowledged that the air conditioner had been adjusted in anticipation of hot weather, which contributed to the cold environment. Additionally, the facility failed to maintain resident equipment in good repair, specifically concerning a resident's bed and heating unit. The resident's bed was missing a headboard, which was found leaning against the wall with securing brackets on the floor. The baseboard heating unit near the bed had a broken front cover, exposing the heating element to the privacy curtain and bed linens. The Director of Maintenance confirmed these observations, indicating a lack of proper maintenance and repair of resident equipment.
Deficiency in Providing Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities in accordance with assessments for several residents, leading to deficiencies in meeting their social, emotional, and physical needs. Resident #9, who was cognitively intact but had significant physical impairments due to a stroke, reported not being offered activities and rarely leaving his room. Observations confirmed the absence of an updated activity calendar in his room, and there were no documented one-on-one visits for August and September, despite the care plan's interventions. Resident #12, who was also cognitively intact and had a range of interests, expressed unawareness of activities beyond bingo and showed interest in participating if activities aligned with his preferences. However, the activity participation records indicated limited engagement, with refusals and lack of offerings for various activities. Observations showed Resident #12 spending most of his time in his room or briefly visiting a neighboring room, with no active participation in scheduled activities. Other residents, such as Resident #27 and Resident #32, also experienced a lack of engagement in activities. Resident #27, with dementia and behavioral disturbances, was observed lying in bed without interaction or activity offerings. Similarly, Resident #32, with severe cognitive impairment, was mostly observed sitting by the nursing station or in bed, with no evidence of activities being provided. The absence of the Activity Director due to medical leave and the lack of a dedicated activity calendar for the secure unit contributed to the deficiency in providing appropriate and individualized activities for the residents.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that psychotropic medications were administered only when necessary, and did not address approvals for gradual dose reductions (GDR) in a timely manner. Additionally, the facility did not document the monitoring of target symptoms for residents receiving these medications. This affected three residents whose records were reviewed for medication use. For Resident #10, there was a lack of documentation and follow-up on a GDR for trazodone, despite a certified nurse practitioner (CNP) approving a reduction. The resident continued to receive the medication without a reduction attempt, and there was inconsistent documentation of non-pharmacological interventions prior to administering Ativan as needed. Resident #27's care plan required monitoring and recording of target behavior symptoms, but there was no documentation of non-pharmacological interventions being attempted before administering Ativan as needed. The Director of Nursing (DON) confirmed the lack of documentation regarding monitoring for antipsychotic use and target symptoms. The facility's policy on psychotropic medication use was not followed, as non-pharmacological interventions and target symptoms were not documented as required. For Resident #24, there was no documentation of behaviors or non-pharmacological interventions implemented, despite the resident receiving multiple psychotropic medications. The DON confirmed the absence of documentation for non-pharmacological interventions or daily behavior monitoring. Similarly, Resident #21's records lacked documentation of behaviors or non-pharmacological interventions before administering Ativan as needed. The facility's policy stated that psychotropic drugs should only be given when necessary and beneficial, with monitoring and documentation of the resident's response, which was not adhered to in these cases.
Absence of Call Systems in Resident Restrooms
Penalty
Summary
The facility failed to ensure that a working call system was available in three restrooms accessible to residents, which could potentially affect seven residents identified as independent with mobility and transfers. Observations conducted from September 15 to September 19, 2024, revealed that these restrooms, located near the middle of the extended hall and on the [NAME] residential hall, were unlocked at all times except when in use. Despite being wheelchair accessible and designated for male or female use, none of these restrooms had a call system installed. During an interview on September 19, 2024, the Maintenance Director confirmed that the restrooms were kept unlocked and could be locked from the inside. However, it was verified that no call system was in place in any of the three restrooms, allowing residents easy access to use them without the ability to call for assistance if needed. The facility's policy, titled 'Call Lights: Accessibility and Timely Response,' mandates that call lights be available at each resident's bedside, toilet, and bathing facility to ensure residents can call for assistance, which was not adhered to in this instance.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status documentation, affecting a resident with multiple diagnoses including vascular dementia and chronic kidney disease. The resident had a signed Do Not Resuscitate (DNR) form indicating Do Not Resuscitate Comfort Care (DNRCC) status, effective immediately. However, the electronic health record and facility report sheet listed the resident's code status as Do Not Resuscitate Comfort Care Arrest (DNRCC-A), which allows for life-saving measures before cardiac or respiratory arrest but only comfort care afterward. Additionally, the physician orders dated January 18, 2024, also indicated a DNRCC-A code status. The discrepancy was confirmed by the Administrator, highlighting a failure to maintain consistent documentation of the resident's code status across different records.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with a summary of the baseline care plan, affecting one of the four residents reviewed for baseline care plans. The medical record review and interview revealed that a resident with diagnoses including epilepsy, depression, delirium, dementia, and mood disorder was admitted to the facility on 05/10/24. However, no baseline care plan was initially located. On 09/18/24, the Administrator confirmed the absence of a baseline care plan or evidence that a summary was provided to the resident or their representative. Later, the Administrator provided the baseline care plan but still lacked evidence that a summary was given to the resident and their representative.
Deficiencies in Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. For one resident, who was moderately cognitively impaired and at nutritional risk, the care plan did not include necessary details about nectar thickened liquids or instructions regarding thin liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. The resident had a diagnosis of pneumonitis due to inhalation of food and vomit, requiring specific dietary modifications to prevent aspiration. The omission was confirmed by the Regional Clinical Director during an interview. For another resident with diagnoses including adjustment disorder, dementia, major depressive disorder, type two diabetes mellitus, and hypertension, the care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user according to multiple assessments. This error persisted across several care plan reviews over nearly two years. The facility's Administrator confirmed the inaccuracy, acknowledging that the resident had never been a smoker.
Failure to Revise Care Plan for Resident's Functional Abilities
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident #34, to accurately reflect their current functional abilities and weight-bearing status. Resident #34 was admitted with multiple fractures, including the right femur, tibia, fibula, and a displaced fracture in the left hand. Initially, the care plan indicated non-weight bearing for all extremities due to these fractures. However, subsequent physician orders updated the resident's weight-bearing status, allowing weight bearing as tolerated for certain extremities and requiring a hoyer lift with two assists for transfers. Despite these changes, the care plan was not updated to reflect the new weight-bearing instructions or the assistance needed for care. Observations and interviews conducted during the survey revealed discrepancies between the care plan and the resident's actual abilities. Resident #34 was observed propelling himself in a wheelchair and grooming himself using both upper extremities, indicating a level of independence not reflected in the care plan. An interview with a State Tested Nursing Assistant (STNA) confirmed that the resident was capable of feeding himself with setup, washing his upper body independently, and occasionally self-transferring, despite being advised against it. The facility's administrator acknowledged that the care plan had not been revised to reflect these changes in the resident's functional abilities and weight-bearing status.
Failure to Address Pharmacy Recommendations for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that all pharmacy recommendations were addressed by physicians, affecting a resident who was receiving two antipsychotic medications, olanzapine and risperidone. The pharmacist requested a diagnosis to support the use of these medications and suggested discontinuing one to avoid duplicative therapy. However, the physician's response only included a change in diagnosis to dementia, without addressing the recommendation to discontinue one of the medications. Additionally, the pharmacist highlighted the need for compliance with Centers for Medicare and Medicaid regulations regarding the use of antipsychotic medications, which require a prescriber evaluation for continued use beyond 14 days. This recommendation was acknowledged by the physician but not acted upon. Furthermore, the pharmacist recommended that Abnormal Involuntary Movements (AIMS) testing be conducted due to the use of antipsychotics, but no such test was found in the resident's electronic health record. The Director of Nursing (DON) confirmed that the pharmacy reviews for September and October 2023 were not fully responded to, and there was no additional documentation to indicate that the recommendations were addressed. The facility's Medication Regimen Review policy requires staff to act upon all recommendations, but this was not followed in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and policy, resulting in a medication error rate of 6.6%. This deficiency was observed in two residents. In the first instance, a Registered Nurse administered colace, a stool softener, to a resident without a physician's order for it. Instead, the resident had an order for sennosides-docusate sodium, which was not administered as prescribed. The facility's Medication Administration policy, which instructs staff to ensure the right drug is administered, was not followed. In the second instance, a Licensed Practical Nurse used an insulin lispro pen that was undated and not primed before administration. The nurse incorrectly believed the pen primed itself automatically. The facility's Insulin Pen policy requires insulin pens to be primed before each use and disposed of after 28 days, which was not adhered to. The manufacturer's instructions also specify that insulin lispro pens should be used within 28 days or discarded.
Failure to Address Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to address the use of a prophylactic antibiotic for a resident who had a recent history of multiple antibiotic use. This deficiency was identified during a review of medical records, infection surveillance records, and facility policies, as well as through interviews. The resident in question had several diagnoses, including dementia with behavioral disturbance, benign prostatic hypertrophy (BPH), neuromuscular dysfunction of the bladder, and heart disease. Since admission, the resident had been prescribed multiple antibiotics for various conditions, including urinary tract infections and oral infections. Despite this extensive antibiotic history, the facility did not adequately address the use of a prophylactic antibiotic, cephalexin, which was ordered for infection prevention following a laceration post-fall. The Director of Nursing (DON) acknowledged that the resident did not meet the McGeer Criteria for infection, which is used for infection surveillance. The DON admitted that the facility's policy on Antibiotic Prescribing Practices did not address the use of prophylactic antibiotics, and she had not questioned the physician's order for the antibiotic, despite the risk of multi-drug resistant organisms. The facility's Antibiotic Stewardship Program indicated that the DON should ensure antibiotics are prescribed appropriately, but this was not done in this case. The deficiency was noted because the facility did not follow best practices and professional guidelines in prescribing antibiotics, particularly in the context of prophylactic use without clear justification.
Failure to Implement Fall and Nutrition Interventions
Penalty
Summary
The facility failed to implement fall interventions as per the care plan for Resident #12, who was at risk for falls due to conditions such as mild dementia, visual loss, and generalized muscle weakness. Despite an order for a fall mat to be placed on the exit side of the bed, observations on multiple occasions revealed that no mat was present. Interviews with staff, including a State tested Nursing Assistant (STNA), confirmed the absence of the fall mat and a lack of awareness of the order. The report sheet used by aides did not include instructions for the fall mat, indicating a communication breakdown in implementing the care plan. Additionally, the facility did not ensure that Resident #1 received thickened liquids as ordered, which was crucial due to the resident's risk of aspiration. Despite a physician's order for nectar-thick liquids, observations and interviews revealed that the resident was consistently provided with regular liquids. Multiple STNAs and an LPN confirmed the discrepancy, with some staff unaware of the thickened liquid requirement, and others indicating that the order had not been updated in the task record or diet card. This oversight resulted in the resident receiving inappropriate liquid consistency, contrary to the care plan and physician's orders.
Inadequate Supervision and Elopement Risk Management
Penalty
Summary
The facility failed to provide adequate supervision to a resident with dementia, resulting in the resident falling into a pond outside the facility. The resident, who was residing in the secured memory care unit, was left unattended while outside watering plants. During this time, the resident attempted to retrieve water from the pond, slipped, and fell into it. The resident was found with wet hair and clothing, coughing, and was subsequently transferred to the hospital for evaluation and treatment of aspiration pneumonia. The incident highlighted a lack of comprehensive, accurate, and individualized elopement assessments and care plans for several residents, including those with a history of wandering and exit-seeking behaviors. The facility's failure to ensure proper supervision and safety measures for residents at risk of elopement affected multiple residents, as evidenced by the lack of appropriate interventions and care plans. This deficiency was noted in the medical records and assessments of several residents, who were identified as being at risk for elopement but did not have corresponding care plans in place. The facility's assessment and care planning processes were found to be inconsistent and inaccurate, as demonstrated by the discrepancies in the elopement risk assessments and care plans for multiple residents. These inconsistencies contributed to the facility's inability to adequately supervise and protect residents from potential harm, as evidenced by the incident involving the resident who fell into the pond. The facility's failure to address these issues in a timely manner resulted in a deficiency that posed a risk of more than minimal harm to the residents.
Removal Plan
- Licensed Practical Nurse (LPN) #101 completed an assessment on Resident #1.
- The resident was transported to the emergency room.
- The Administrator/Director of Nursing (DON) provided 1:1 education to staff including Registered Nurse (RN) #103, LPN #102, and LPN #101 who were directly involved in the Resident #1's fall/incident. An emphasis was placed on ensuring residents were not left alone outside and had on proper footwear.
- The DON and/or designee educated all staff (three RNs, nine LPNs, 14 State tested Nursing Assistants) on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility fall related policies including proper footwear and not leaving residents unattended outside. All nursing staff were educated except one LPN, LPN #100 who was out on medical leave and would be educated prior to her return to work.
- An audit revealed no other residents were at risk for being left alone outside as this and the root cause analysis determined that the fall would not have occurred had Resident #1 not been left alone outside.
- Immediate education provided to staff.
- Audits of risk management were conducted and would be reviewed by the LNHA twice weekly for four weeks to ensure no other incidents occur related to residents being left alone outside unattended twice weekly times four weeks.
- Resident #1's care plan was reviewed and updated to reflect Resident #1 was not to wear flip flops while outside.
- The LNHA conducted a formal and written Root Cause Analysis (RCA) with members of the AD HOC Quality Assurance and Performance Improvement (QAPI) that included the Medical Director, DON, Maintenance, LNHA and social service designee.
- A QAPI Performance Improvement Plan (PIP) was initiated to report on the above monitoring and auditing procedures. All findings from the PIP would be presented at the monthly Quality Assessment and Assurance (QAA) meeting. Monitoring/auditing and reporting would continue for a minimum of three months.
- Maintenance Director #150 filled in the pond with dirt.
- Assessments were completed by LPN #102 and LPN #108 for all 30 facility residents to identify residents who are at risk for elopement.
- Regional MDS Nurse #151 verified elopement assessments and care plans were completed to ensure accurate and consistent information and assessments.
- Regional MDS Nurse #151 verified fall assessments and care plan audit for all 33 residents were completed to ensure accurate and consistent information.
Inadequate Staffing Leads to Resident Incidents in Memory Care Unit
Penalty
Summary
The facility failed to maintain sufficient staffing levels on the secured memory care unit, affecting the care and supervision of residents. On the day of the survey, there were two licensed nurses and three State Tested Nursing Assistants (STNAs) for 33 residents, with only one Registered Nurse (RN) and one STNA assigned to the memory care unit. This staffing level was inadequate to meet the needs of the residents, as evidenced by the incident involving two residents. The facility's staffing schedules from May and June showed a consistent pattern of understaffing, with only one nurse assigned to the memory care unit without additional dedicated staff. An incident occurred where a resident, while watering plants in the courtyard, fell into a pond and required emergency medical attention for possible aspiration of pond water. The RN on duty, who was new and being oriented, was left alone on the unit when another resident exited the building, requiring the RN to leave the first resident unsupervised. This lack of supervision led to the resident slipping into the pond, highlighting the insufficient staffing and supervision on the memory care unit. Interviews with staff revealed that the facility had only recently started assigning an STNA to the memory care unit, and there was no specific staffing policy for the unit. The Licensed Nursing Home Administrator (LNHA) confirmed that staffing was based on census and resident needs, but the facility assessment did not specifically address the memory care unit. The deficiency was investigated under Complaint Number OH00155248, indicating non-compliance with staffing requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wooster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wayne County Care Center | 2.4 mi | ★★★★★ | 4 | 0 |
| Smithville Western Care Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Wooster Community Hospital Snf | 3 mi | ★★★★★ | 0 | 0 |
| Avenue At Wooster | 3.8 mi | ★★★★★ | 4 | 0 |
| West View Healthy Living | 4.5 mi | ★★★★★ | 0 | 0 |
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