Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glendora Canyon Transitional Care Unit during CMS and state inspections, most recent first.
A resident with sepsis and DM, intact cognition, and functional limitations requiring assistance with ADLs did not have all meal intakes documented by CNAs as required. Review of documentation showed that while most meals had recorded intake amounts, several meals over two months lacked any meal intake entries. A CNA and the DON confirmed that CNAs were expected to chart meal intake, including refusals, after each meal and before the end of the shift, and that this was required by the CNA job description and the facility’s charting and documentation policy.
A resident with a lower leg fracture, hypertension, and dependence on staff for most ADLs lost health insurance coverage for skilled services after Medicare ended because the SSD did not follow through on assisting with a Medi-Cal application. During an IDT meeting, a family member requested help with Medi-Cal, and the SSD said the Business Office Manager would assist, but no effective follow-up occurred. This failure did not comply with the SSD job description and facility policy requiring social services staff to inform and educate about Medicare/Medi-Cal and financial assistance programs and to assist with related financial matters, resulting in the resident personally paying for skilled nursing services after Medicare coverage stopped.
A resident with severe cognitive impairment and legal blindness was physically pushed to the floor by another resident following a verbal altercation, resulting in a comminuted fracture of the hand. Staff and documentation confirmed the incident, and the facility's abuse prevention policy was not effectively implemented to prevent this event.
A resident with severe cognitive impairment and legal blindness alleged being pushed to the floor by another resident, an event witnessed and reported by an LVN. Despite facility policy and mandated reporting requirements, the incident was not reported to the state agency within the required timeframe, as the DON confirmed the delay in notification.
Surveyors observed that two resident shower rooms had temperatures above the facility's policy range, with one room at 82°F and another at 85°F. Both a CNA and an LVN reported the rooms felt hot and stuffy, and the Maintenance Supervisor confirmed ongoing AC issues affecting these areas.
A resident with diabetes and severe cognitive impairment experienced a critically high blood sugar level and required an additional dose of insulin. Facility staff failed to notify the resident's responsible party, did not document the event in the medical record, and did not complete the required SBAR Communication Form, contrary to facility policy.
During an outbreak of COVID-19 and influenza, multiple staff members, a medical provider, and a visitor failed to wear masks properly or at all, and a staff member did not perform hand hygiene before entering a room under enhanced barrier precautions. Despite clear facility policies and public health recommendations requiring mask use and hand hygiene, these protocols were not consistently followed or enforced, even in areas with residents who had active infections.
A resident with Parkinson's disease requested their medication, Pramipexole Dihydrochloride, be administered at 7:30 a.m. to manage tremors. Despite the request being acknowledged by the ADON during an IDT meeting, the facility continued to administer the medication at 9 a.m. until the time was changed days later. This failure to adhere to the resident's care plan potentially increased the resident's tremors.
A resident's medications were found unattended at their bedside, posing a risk due to the resident's severe cognitive impairment. An LVN confirmed the oversight, and the DON noted a similar past incident, highlighting a lapse in medication administration procedures.
Three residents in the facility were found with call lights that were not within reach, contrary to the facility's policy. One resident with hemiplegia had a call light stuck behind bed rails, another with a recent femur fracture could not find their call light, and a third with Alzheimer's had to go around the bed to access it. Staff interviews confirmed that call lights should be easily reachable to ensure timely assistance.
The facility failed to implement its Advance Directives Policy for four residents, resulting in missing or incomplete documentation in their medical records. This included missing Advance Directives and Acknowledgement Forms, which are crucial for ensuring residents' treatment preferences are respected. Interviews with staff confirmed these deficiencies and highlighted the importance of having these documents readily available.
Two residents in an LTC facility faced communication barriers due to ineffective implementation of the facility's language assistance policy. One resident, with heart failure and hypotension, preferred Turkish but was documented as preferring English, leading to communication issues with staff. Another resident, with dementia and hypertension, faced similar issues as the assigned CNA only spoke Spanish and relied on Google Translate without a communication board, contrary to policy.
The facility failed to implement a care plan for a resident with arterial ulcers by not offloading their heels, risking delayed wound healing. Additionally, the facility did not arrange transportation for another resident's medical appointment, resulting in a missed fistulagram. Both deficiencies were due to non-compliance with facility policies on repositioning and transportation.
A resident with Parkinson's disease and multiple pressure ulcers did not receive prescribed wound care for an unstageable pressure ulcer on the right midback for eight days. The treatment, which included cleansing with Normal Saline and applying a hydrocolloid dressing, was not administered due to a registry RN mistakenly discontinuing the order. The DON was unaware of the ulcer until it was inspected, revealing eschar and slough. The facility's policy required MD-ordered treatments, which were not followed, potentially delaying healing.
The facility failed to follow its Policy and Procedure for siderail use for two residents, leading to a deficiency. One resident had siderails installed without a doctor's order or consent, and no alternative interventions were attempted. Another resident had siderails as a mobility aid without a proper assessment or consideration of alternatives. Both residents were at risk for entrapment and injury due to these oversights.
The facility failed to follow its policies on psychotropic medication use for two residents. A resident received Lorazepam without a 14-day stop date, risking unnecessary use. Another resident was given Haloperidol without monitoring for target behavior or side effects, and the medication lacked a specific diagnosis. These actions did not comply with the facility's P&P, which requires stop dates and monitoring for psychotropic medications.
The facility failed to follow proper sanitation practices by allowing a staff member's personal lunch bag in the residents' refrigerator, risking cross-contamination. Additionally, a dome drying rack was found rusty and dirty, with no cleaning schedule in place, violating the facility's policies on equipment maintenance.
A resident's MDS was inaccurately coded, listing English as their preferred language instead of Turkish. This error was discovered when the resident, who has heart failure and hypotension, was observed speaking Turkish and unable to communicate in English. A CNA also struggled to communicate with the resident due to this language barrier. The MDS Coordinator admitted the mistake, acknowledging the need for accurate coding to ensure quality care.
A facility failed to create a baseline care plan for a resident with Parkinson's disease and other medical conditions within 48 hours of admission, as required by policy. The resident had severely impaired cognitive abilities and was dependent on staff for care. The Director of Nursing confirmed the oversight, acknowledging the risk of interrupted care due to the absence of a guiding care plan.
A facility failed to create an individualized care plan for a resident on Haloperidol, despite the resident's severe cognitive impairment and need for assistance with daily activities. Interviews with the IPN and DON confirmed the lack of a comprehensive care plan, contrary to the facility's policy requiring such plans within seven days of assessment.
A facility failed to monitor a resident's indwelling catheter for white sediments, a potential sign of UTI, as required by their care plan and facility policy. The resident, with spinal stenosis and hypertension, had a catheter with visible sediments, which were not reported or documented. The Infection Prevention Nurse and DON acknowledged the oversight, highlighting a lapse in monitoring and documentation.
The facility did not follow its policy to update the Daily Nursing Staff Posting (DNSP) within two hours of each shift's start. During a tour, it was found that the DNSP displayed was for the previous day. The Director of Staff Development acknowledged the oversight, stating that the night shift staff should have updated the DNSP. The facility's policy requires the DNSP to be updated and posted in a prominent location accessible to residents and visitors.
A resident with severe cognitive impairment and End Stage Renal Disease was allowed to sign a binding arbitration agreement without verifying their capacity to understand and make decisions. The Admission Coordinator did not check the resident's assessments, leading to a potential denial of the resident's rights.
A resident with MRSA was placed on Contact and Droplet Precautions, but an LVN failed to wear the required PPE while administering medication. The facility's policy required staff to wear a disposable gown and gloves to prevent infection spread, but this protocol was not followed, risking transmission of infectious microorganisms.
A resident's call light system was found to be non-functional, potentially delaying needed care. Despite the resident's capacity to understand and make decisions, and requiring assistance for personal hygiene and transfers, the call light had been non-functional for months. Staff confirmed the issue, and the Maintenance Supervisor acknowledged a communication failure and lack of documentation regarding the problem.
A facility's lack of specific guidelines in its Abuse Prevention Policy led to staff receiving and cashing checks from a resident, resulting in potential financial abuse. The resident, who was cognitively intact and had chronic health issues, signed checks to a CNA and an Activity Aide. Interviews confirmed that accepting money from residents was against policy, but the facility's policy lacked specific instructions on handling residents' money.
A facility failed to follow its policy for nail care by not ensuring a resident was referred to a podiatrist for toenail trimming. The resident, with conditions including gout and peripheral vascular disease, had long, overgrown toenails, raising concerns about infection risk. Despite the care plan's directive for daily foot inspections and podiatrist referrals, the necessary actions were not taken, as confirmed by staff observations and interviews.
A resident at high risk for falls, with conditions like muscle weakness and cognitive impairment, experienced an unwitnessed fall. Despite being confused and needing a sitter, the necessary supervision was not arranged by the LVNs. The MD was informed of the fall but not the resident's confusion, leading to inadequate supervision. The facility's policy on safety and supervision was not followed.
A resident with a history of gout and amputation-related pain was not reassessed for pain relief after receiving acetaminophen, contrary to facility policy. The resident later reported severe pain, and the LVN admitted to not following the protocol for reassessment. The DON confirmed the requirement for reassessment within one hour, highlighting a lapse in pain management procedures.
A CNA worked with an expired certification at a facility, as the DON failed to verify the certification status before scheduling. The facility's policy requires verification of licenses or certifications prior to employment and annually, which was not followed, potentially leading to inadequate resident care.
A resident with end-stage renal disease was transferred multiple times between rooms without documented notification to the resident or responsible party, as required by the facility's policy. Interviews with staff confirmed the lack of documentation and notification.
The facility failed to provide appropriate pressure ulcer care for a resident by not setting the LAL mattress correctly, not turning and repositioning the resident every two hours, and not providing timely incontinent care. These deficiencies were confirmed through observations, interviews, and record reviews.
Failure to Consistently Document Resident Meal Intake in Medical Record
Penalty
Summary
Facility staff failed to consistently document a resident’s meal intake in the medical record as required by facility policy and CNA job expectations. The resident was admitted with sepsis and diabetes mellitus and had intact cognition and decision-making capacity. According to the MDS, the resident required setup assistance with eating, supervision with oral hygiene, moderate assistance with toileting hygiene, showering/bathing, and personal hygiene, and maximal assistance with bed-to-chair transfers. Review of the Documentation Survey Report (DSR) for January 2025 showed CNAs documented the resident’s meal intake for 90 of 93 meals, and for February 1–15, 2025, CNAs documented meal intake for 40 of 45 meals, leaving multiple meals without recorded intake amounts. During interview, a CNA stated that CNAs were expected to document after each meal, including when a resident refused to eat, and that documentation should be completed before the end of the shift as a standard of practice. The CNA further stated that if there was no documentation on the DSR, staff would not know how much residents ate and that incomplete documentation would affect continuity of care. The DON similarly stated that without documentation, nursing staff would not know if the resident ate or refused the meal. The CNA job description required recording residents’ food and fluid intake, and the facility’s Charting and Documentation policy required that all services provided to residents be documented completely in the medical record, including date, time, and the signature and title of the person documenting. Despite these requirements, staff did not document the amount of meal intake for all meals during the review period for this resident.
Failure to Provide Social Services Assistance for Continuity of Health Insurance Coverage
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to assist a resident in maintaining mental and psychosocial well-being by ensuring continuity of health insurance coverage. The resident was admitted with a displaced bimalleolar fracture of the left lower leg and hypertension, and was dependent on staff for most ADLs. The resident had decision-making capacity. During an IDT meeting, the resident’s family member expressed interest in applying for Medi-Cal once Medicare coverage for skilled nursing services was ending, and the Social Services Director (SSD) stated they would refer the family member to the Business Office Manager (BOM) for assistance with the Medi-Cal application. The facility issued a Notice of Medicare Non-Coverage indicating the last day of Medicare coverage for skilled services. The SSD reported that they referred the family member to the BOM but did not follow up on the Medi-Cal application or otherwise assist the resident in applying for health insurance. The Assistant DON/Case Manager confirmed that the SSD told the family member during the IDT meeting that the BOM would assist with the Medi-Cal application. The DON reviewed the SSD’s job description, which required the SSD to provide information to residents and families about Medicare/Medi-Cal and other financial assistance programs and to refer them to appropriate social service agencies when needed, and stated the SSD did not follow this job description. The facility’s social services policy required provision of medically related social services, including informing and educating residents and families about health care options and assisting with financial matters. As a result of these failures, the resident had no health insurance after Medicare coverage ended and personally bore the cost of skilled nursing services received thereafter.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its abuse prevention policy. One resident, who had a history of schizoaffective disorder, legal blindness, and severely impaired cognition, was involved in a verbal exchange with another resident. During this interaction, the second resident pushed the first, causing the resident to fall to the floor. The incident was unwitnessed, but the injured resident reported being pushed, and this was corroborated by the other resident's admission and staff observations immediately following the event. Following the fall, the injured resident complained of pain and was assessed by staff, who noted significant discomfort and inability to get up. The resident was transferred to a general acute care hospital for evaluation, where imaging confirmed an acute comminuted fracture of the right 5th metacarpal. Staff interviews and documentation indicated that the resident who pushed the other had a disagreement and admitted to the physical act, with staff witnessing the aftermath and hearing the resident verbally acknowledge the push. The facility's policy and procedure on abuse prevention explicitly states that residents must be protected from abuse, including by other residents. Despite this, the incident occurred, resulting in physical harm to a resident with significant cognitive and physical vulnerabilities. The documentation and interviews confirm that the facility did not prevent the abusive act, leading to the resident's injury.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident with schizoaffective disorder and legal blindness. The resident, who had severely impaired cognition and required assistance with activities of daily living, reported being pushed to the floor by another resident. This allegation was corroborated by a Licensed Vocational Nurse (LVN), who witnessed the accused resident admitting to the act and observed the victim on the floor requesting help. The LVN notified the Administrator and Director of Nursing (DON) of the incident, and was instructed not to complete the abuse reporting form, as the Administrator and DON would handle the reporting. Despite facility policy requiring the reporting of abuse allegations within specified time frames, the incident was not reported to the California Department of Public Health (CDPH) within the required two-hour window. The DON confirmed that the facility failed to meet the mandated reporting timeline for this incident, as outlined in their Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy.
Failure to Maintain Safe and Comfortable Temperatures in Shower Rooms
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures in two resident shower rooms, as observed during a survey. On the third floor, the shower room thermostat read 82°F, and a CNA described the room as hot and stuffy. Similarly, the second-floor shower room was observed at 85°F, with an LVN also noting the room felt hot and stuffy. The Maintenance Supervisor confirmed that the air conditioning was malfunctioning and that high temperatures in the shower rooms had been noted, with repairs scheduled. Facility policy requires that resident areas, including bathing and shower rooms, maintain temperatures between 71°F and 81°F to ensure a safe, clean, and comfortable environment.
Failure to Notify Responsible Party and Document Change in Condition for Resident with Critically High Blood Sugar
Penalty
Summary
The facility failed to follow its policy and procedure regarding changes in a resident's condition or status by not informing a resident's responsible party when the resident experienced a critically high blood sugar level of 480 and required an additional dose of insulin. The responsible party was not notified of this significant change, despite the resident lacking the mental capacity to make medical decisions and being dependent on staff for most activities of daily living. The facility's policy required notification of the resident's representative in such circumstances. Additionally, the facility did not document the resident's blood sugar level of 480 in the medical record, nor did staff complete an SBAR Communication Form or a Change of Condition note as required by facility policy. The Director of Nursing confirmed that there was no documentation of the event, no SBAR form, and no notification to the responsible party in the resident's record. These omissions were identified during a review of the resident's records and interviews with facility staff.
Failure to Enforce Mask Use and Hand Hygiene During Infectious Disease Outbreak
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies and procedures, specifically regarding hand hygiene, standard precautions, enhanced barrier precautions, and transmission-based precautions. Multiple staff members, including the receptionist, certified nurse assistants, social services director, maintenance assistant, and a medical doctor, were observed not wearing masks properly, with masks pulled down below the nose and mouth while inside the facility. Additionally, a family member visiting a resident was not wearing a mask, and staff failed to educate or enforce mask-wearing for visitors, despite clear signage and policy requirements during an outbreak of COVID-19 and influenza. Direct observations revealed that staff and visitors were not consistently following mask protocols, even in areas housing residents with active COVID-19 and flu infections. For example, a family member was seen assisting a resident with severe cognitive impairment and multiple comorbidities without a mask, after being told by staff that mask-wearing was optional. Several staff members, including those with direct resident contact and those in administrative or support roles, admitted awareness of the outbreak and the need for proper mask use but did not comply. In one instance, a certified nurse assistant entered an enhanced barrier precautions room without performing hand hygiene, despite posted instructions and facility policy. The facility's own infection control policies, as well as recommendations from the Department of Public Health, required all staff and visitors to wear appropriate masks and perform hand hygiene, especially during an outbreak. Interviews with staff, including the infection prevention nurse and director of nursing, confirmed knowledge of these requirements and the importance of compliance. However, repeated failures to follow these protocols were observed and acknowledged by staff, contributing to the potential for transmission of infectious diseases within the facility.
Failure to Administer Medication at Resident's Requested Time
Penalty
Summary
The facility failed to protect the right of a resident to participate in their treatment plan by not administering Pramipexole Dihydrochloride at the resident's requested time. The resident, who was admitted with diagnoses including Parkinson's disease, had the capacity to understand and make decisions. Despite the resident's request to have the medication administered at 7:30 a.m. to help manage tremors associated with Parkinson's disease, the facility continued to administer the medication at 9 a.m. until the time was finally changed on January 27, 2025. The Assistant Director of Nursing (ADON) confirmed awareness of the resident's request during an interdisciplinary team meeting on January 21, 2025, but the change was not implemented until January 24, 2025. The facility's policy on resident rights, which includes the right to participate in care planning and treatment, was not adhered to in this instance. This oversight had the potential to increase the resident's tremors due to the delayed administration of the medication.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications for one of the sampled residents were kept locked in secure storage. During an observation, a medication cup containing three unidentified pills was found unattended at the bedside of a resident who was severely impaired in cognitive skills and required assistance for daily activities. The resident was unable to recall how long the medication had been there, indicating a lapse in proper medication administration and storage procedures. Licensed Vocational Nurse (LVN) 1 confirmed the unattended medications and identified LVN 2 as the responsible nurse, who was on a lunch break at the time. LVN 2 later acknowledged the oversight, admitting that they should have stayed with the resident to ensure the medications were taken. The Director of Nursing (DON) noted that this was not the first instance of such an oversight by LVN 2, emphasizing that staff are required to remain with residents during medication administration to ensure medications are swallowed and not left unattended.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, which is a violation of the facility's policy and procedure regarding the resident call system. Resident 14, who was admitted with hemiplegia and hemiparesis affecting the left side, was observed with a call light that was not accessible, as it was stuck at the back of the padded bed side rails. This resident was assessed as high risk for falls due to intermittent confusion and being chair-bound, and the care plan required the call light to be within reach to prevent falls and injuries. Resident 251, who had a recent fall resulting in a femur fracture and was at risk for falls, was also found with an inaccessible call light. The call light was placed at the upper right side of the bed, making it difficult for the resident to find and use it. The care plan for this resident specified that the call light should be within easy reach to ensure timely assistance from staff. Similarly, Resident 211, diagnosed with Alzheimer's disease and dementia, had a call light that was not within reach. The call light was rolled on the wall on the opposite side of the bed, requiring the resident to go around the bed to access it. The care plan for this resident indicated that the call light should be attached within reach to assist with activities of daily living and prevent falls. Interviews with staff confirmed the expectation that call lights should be placed within reach and on the strong side of the resident.
Failure to Implement Advance Directives Policy
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for four residents, leading to deficiencies in maintaining and documenting these critical legal documents. For Resident 47, the facility did not ensure that a copy of the Advance Directive was included in the resident's medical record or uploaded into the PointClickCare system. This oversight was confirmed during interviews with the Medical Records staff, the Social Services Director, and the Assistant Director of Nursing, all of whom acknowledged the necessity of having the Advance Directive readily available to guide care, especially in emergencies. Similarly, Resident 89's Advance Directive Acknowledgement Form was missing from the medical record. Interviews with the Infection Prevention Nurse, the Social Services Director, and the Director of Nursing revealed that the form was not initiated or included in the resident's chart, which is essential for understanding and respecting the resident's treatment preferences. The absence of this documentation could lead to care that does not align with the resident's wishes. For Resident 82, the facility did not complete the Advance Directive Acknowledgement Form upon admission, and the resident's family member reported that the purpose of an Advance Directive was not discussed. The Social Services Director confirmed that the form was blank, indicating a lack of education provided to the resident or responsible party. Additionally, Resident 92's Advance Directive was not found in the medical or electronic chart, despite the form indicating its existence. The Social Services Director and Director of Nursing both emphasized the importance of having this documentation to ensure the resident's wishes are known and respected.
Communication Barriers for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide an effective communication method for two non-English speaking residents, which had the potential to affect their quality of life and care. Resident 17, who was readmitted with heart failure and hypotension, was documented as having English as their preferred language in the Minimum Data Set (MDS), despite actually preferring Turkish. This discrepancy led to communication issues, as observed when a Certified Nursing Assistant (CNA) was unable to effectively communicate with Resident 17, relying solely on a communication board. The facility's policy indicated the use of bilingual staff, interpreters, and translation apps, but these were not effectively utilized in Resident 17's case. Similarly, Resident 92, who was admitted with dementia and hypertension, was also affected by communication barriers. Although Resident 92's MDS indicated English as the preferred language, a CNA assigned to provide one-on-one monitoring only spoke Spanish and used Google Translate to communicate. There was no communication board available at Resident 92's bedside, contrary to the facility's policy. This lack of effective communication tools posed a risk of unmet needs and potential emergencies, as noted by the Director of Nursing.
Failure to Implement Care Plans and Arrange Transportation
Penalty
Summary
The facility failed to implement the care plan for a resident with arterial ulcers on both feet. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed with their heels lying directly on the mattress, contrary to the care plan's directive to offload the heels to prevent worsening of the wounds. Certified Nursing Assistant 2 acknowledged the need for offloading to prevent further complications, and the Director of Nursing confirmed that not following the care plan could delay wound healing. Another deficiency involved the facility's failure to provide transportation for a resident to a scheduled medical appointment. The resident, who had severe cognitive impairments and was dependent on staff, missed a fistulagram appointment due to the facility's oversight in arranging transportation. The resident's family member reported swelling around the fistula site, which was the reason for the appointment. The Director of Nursing and Licensed Vocational Nurse 2 confirmed that the transportation was not arranged, and there was no documentation of the appointment in the facility's records. The facility's policies and procedures for repositioning and transportation were not followed, contributing to these deficiencies. The repositioning policy required staff to adhere to the care plan for specific positioning needs, while the transportation policy mandated assistance in arranging transportation for appointments. Both policies were not implemented, leading to potential risks for the residents involved.
Failure to Provide Ordered Wound Care for Unstageable Pressure Ulcer
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the Medical Doctor for an unstageable pressure ulcer on the right midback of a resident, identified as Resident 82. This resident was readmitted to the facility with multiple diagnoses, including Parkinson's disease and various pressure ulcers. The care plan for potential skin breakdown required treatment initiation as ordered by the MD. However, from 10/30/2024 to 11/7/2024, the resident did not receive the prescribed treatment for the unstageable pressure ulcer, which involved cleansing with Normal Saline and applying a hydrocolloid dressing every three days. Treatment Nurse 1 confirmed the absence of treatment during this period and noted that the wound could worsen without proper care. The Director of Nursing (DON) revealed that the treatment order was mistakenly discontinued by a registry RN on 10/31/2024, and all admission orders were reentered, leading to the oversight. The DON was unaware of the unstageable pressure ulcer until the issue was raised. Upon inspection, the ulcer was found to have eschar and slough, with measurements indicating a lack of depth. The facility's policy required MD-ordered wound treatments, which were not followed, potentially delaying wound healing. The DON acknowledged that missing treatments could worsen the wound.
Failure to Follow Siderail Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of siderails for two residents, leading to a deficiency. For Resident 26, the facility did not obtain a doctor's order or consent for the use of siderails, nor did it attempt appropriate alternative interventions before installing the siderails. Resident 26, who had diagnoses including osteomyelitis, peripheral vascular disease, and dementia, was observed with 1/4 siderails up on both sides of the bed without documented evidence of necessary assessments or consent. The Assistant Director of Nursing confirmed the lack of documentation and stated that siderails should not have been used without a physician's order and consent. Similarly, for Resident 28, the facility did not conduct a siderail use assessment or attempt alternative interventions before installing siderails. Resident 28, who had multiple rib fractures, hemiplegia, and hemiparesis, was also observed with 1/4 siderails up on both sides of the bed. Despite having an order for siderails as a mobility aid, there was no documented evidence of an assessment or consideration of less restrictive alternatives. The Assistant Director of Nursing acknowledged the absence of documentation for the necessary assessments and interventions, which placed both residents at risk for entrapment and injury.
Failure to Implement Psychotropic Medication Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the use of psychotropic and antipsychotic medications for two residents. For Resident 82, the facility did not ensure that the PRN order for Lorazepam, prescribed for restlessness and agitation, included a stop date of 14 days. This oversight was acknowledged by both a Registered Nurse and the Director of Nursing, who confirmed that the absence of a stop date could lead to unnecessary medication use. For Resident 96, the facility did not monitor the target behavior and adverse side effects associated with the use of Haloperidol, an antipsychotic medication. The medication order lacked a specific diagnosis, and there was no documentation of monitoring for agitation or side effects since the resident's admission. Both the Infection Prevention Nurse and the Director of Nursing confirmed the lack of monitoring and documentation, emphasizing the need for specific diagnoses and regular monitoring to assess the medication's effectiveness. The facility's P&P requires that PRN psychotropic medications have a stop date and that any continuation beyond 14 days must be justified by the practitioner. Additionally, the P&P mandates that staff observe, document, and report the effectiveness and side effects of antipsychotic medications to the attending physician. These requirements were not met for Residents 82 and 96, leading to the potential for unnecessary medication use and adverse consequences.
Improper Food Handling and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a survey. A staff member's personal lunch bag was found inside the walk-in refrigerator designated for storing residents' food. This action was acknowledged by the Dietary Aide (DA 3) who admitted that personal belongings should not be placed in the residents' refrigerator due to the risk of cross-contamination, which could lead to food-borne illnesses among residents. Additionally, the facility did not maintain cleanliness standards for kitchen equipment. The dome drying rack was found to be rusty and dirty, which was confirmed by both DA 3 and the Dietary Supervisor (DS). The DS admitted that there was no cleaning schedule for the dome drying rack, and it should be free from rust and debris to ensure health and safety. The facility's policies indicated that personal items should be stored separately from food and that effective maintenance management is essential for sanitation, but these were not followed.
Inaccurate MDS Coding for Language Preference
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident's language preference, which is a federally mandated resident assessment tool. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including heart failure and hypotension. The resident's quarterly MDS inaccurately indicated that their preferred language was English, despite the resident's actual preference being Turkish. This discrepancy was discovered during an observation and interview where the resident was found speaking Turkish over the phone and was unable to communicate effectively in English. Further observations revealed that a Certified Nursing Assistant (CNA) was unable to communicate with the resident due to the language barrier, confirming the resident's limited English proficiency. The MDS Coordinator acknowledged the error in coding the resident's preferred language and admitted that the MDS should have been accurately coded to reflect the resident's current assessment and preference. The facility's policy and procedure for resident assessment, revised in 2019, mandates that the resident assessment coordinator ensures timely and appropriate assessments, which was not adhered to in this case.
Failure to Create Baseline Care Plan for Resident
Penalty
Summary
The facility failed to create a baseline care plan for a resident upon their admission, which was necessary to address the resident's immediate care needs within 48 hours. The resident, who was admitted and readmitted with conditions including Parkinson's disease, communication deficits, chronic non-pressure ulcers, and a stage three pressure ulcer, had severely impaired cognitive abilities and was dependent on staff for various activities. Despite these needs, the baseline care plan was not completed, as confirmed by the Director of Nursing during a review and interview. The absence of a baseline care plan was acknowledged by the Director of Nursing, who stated that it should have been completed to guide staff in providing appropriate care based on the resident's immediate needs. The facility's policy, revised in December 2016, mandates the development of a baseline care plan within 48 hours of admission to ensure the resident's immediate care needs are met. The failure to adhere to this policy placed the resident at risk of an interruption in care.
Failure to Develop Individualized Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident who was prescribed Haloperidol, an antipsychotic medication. The resident, who was admitted with diagnoses of depression and dementia, had severely impaired cognition and required significant assistance with daily activities. Despite these needs, there was no clinical documentation indicating that a care plan was initiated and implemented to manage the use of Haloperidol, as required by the facility's policy and procedure. Interviews with the facility's Infection Prevention Nurse and Director of Nursing confirmed the absence of a comprehensive care plan tailored to the resident's specific needs for the use of Haloperidol. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of completing the required comprehensive assessment, but this was not done, potentially affecting the resident's treatment and care related to the medication.
Failure to Monitor Catheter for Signs of Infection
Penalty
Summary
The facility failed to properly assess and monitor a resident's indwelling catheter for the presence of white sediments, which could indicate a urinary tract infection (UTI). The resident, who was admitted with spinal stenosis and essential hypertension, had an indwelling catheter as part of their care plan. The care plan required staff to monitor and report any signs of UTI, such as changes in urine color, clarity, and odor, to the physician. However, during an observation, it was noted that the resident's catheter tubing and drainage bag contained white sediments, which were not reported or documented as required by the facility's policy. The Infection Prevention Nurse acknowledged the presence of white sediments and stated that it could be a sign of infection, requiring the tubing to be flushed and the physician to be notified. The Director of Nursing confirmed that the resident's catheter should have been monitored every eight hours for signs of infection, but there was no documentation of such monitoring. The facility's policy on catheter care emphasized the need to observe and report signs of urinary tract infection immediately, but this was not adhered to in the case of the resident.
Failure to Update Daily Nursing Staff Posting
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the posting of actual nursing hours within two hours of the start of each shift. On a tour conducted on 11/7/24, it was observed that the nursing hours posted in the facility's entrance lobby were for the previous day, 11/6/24, instead of the current date. During an interview, the Director of Staff Development (DSD) acknowledged that the Daily Nursing Staff Posting (DNSP) should have been updated to reflect 11/7/24 and admitted that the facility's policy was not followed. The DSD explained that the night shift staff were responsible for updating the DNSP, but this was not done. A review of the facility's P&P, revised in July 2016, confirmed that the DNSP should be updated within two hours of the beginning of each shift and posted in a prominent location accessible to residents and visitors.
Failure to Verify Resident Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 301, had the capacity to understand and make decisions before signing a Resident-Facility Arbitration Agreement (AA). Resident 301, who was admitted with diagnoses including pneumonia and End Stage Renal Disease, was assessed to have severely impaired cognitive skills for daily decision-making. The Minimum Data Set (MDS) indicated that the resident sometimes understood others and was sometimes self-understood, but was dependent on others for personal hygiene and transfers. Furthermore, the History and Physical (H&P) report confirmed that Resident 301 did not have the capacity to understand and make decisions. Despite these assessments, the Admission Coordinator allowed Resident 301 to sign the AA without verifying the resident's capacity to do so. The Admission Coordinator admitted to not checking the MDS assessment and H&P before allowing the resident to sign the legal document. An observation conducted later showed that Resident 301 was unable to communicate when asked questions, further indicating the resident's lack of capacity to make informed decisions. This oversight had the potential to result in the resident being unable to make an informed decision and having their rights denied.
Failure to Follow Isolation Precautions for MRSA-Infected Resident
Penalty
Summary
The facility failed to adhere to its Policy and Procedures regarding Isolation - Categories of Transmission-Based Precautions for a resident diagnosed with methicillin-resistant staphylococcus aureus (MRSA) infection. The resident, who had moderately impaired cognition and required assistance with daily activities, was placed on Contact and Droplet Precautions. However, during an observation, a Licensed Vocational Nurse (LVN) was seen administering medication to the resident without wearing the required personal protective equipment (PPE), such as gloves and a gown, which was necessary to prevent the spread of infection. Interviews with the LVN, the facility's Infection Preventionist Nurse, and the Director of Nursing confirmed that the staff was aware of the need to wear PPE when entering the resident's room. The facility's policy, dated 10/2018, clearly stated that staff and visitors should wear a disposable gown upon entering the room and remove it before leaving to avoid contamination. Despite this, the LVN did not follow the protocol, which had the potential to transmit infectious microorganisms and increase the risk of infection for other residents in the facility.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure that a functioning call light system was available for a resident, identified as Resident 17, which could potentially delay the provision of needed care and services. Resident 17, who was readmitted to the facility with diagnoses including heart failure and hypotension, had the capacity to understand and make decisions, and required partial assistance for personal hygiene and transfers. During an observation, it was noted that Resident 17's call light was not functioning, and the resident's roommate confirmed that the call light had been non-functional for a couple of months. Both a Certified Nursing Assistant and a Licensed Vocational Nurse verified that the call light was not working, emphasizing the importance of a functioning call light for timely response to the resident's needs. The Maintenance Supervisor indicated that there was a Maintenance Log for reporting equipment issues, but no issue regarding Resident 17's call light was documented. The Maintenance Supervisor also noted a lack of a checklist or system to ensure all equipment was checked, and acknowledged a communication failure between the nursing staff and the maintenance department. The facility's policy stated that residents should have a means to call staff for assistance from their bed and other areas, but this was not adhered to in the case of Resident 17.
Deficiency in Abuse Prevention Policy Regarding Resident's Money Handling
Penalty
Summary
The facility failed to include specific guidelines in its Abuse Prevention Policy and Procedure on how staff should handle residents' property, particularly money, to prevent financial abuse. This deficiency was identified during a review of the facility's policies and procedures, which lacked detailed instructions on managing residents' financial matters. The absence of such guidelines contributed to a situation where staff members received and cashed personal checks from a resident, leading to potential financial abuse. The deficiency involved a resident who was cognitively intact and had a history of chronic obstructive pulmonary disease, chronic pain syndrome, and major depressive disorder. The resident's family member reported that the resident had signed checks to facility staff, which was inappropriate. Photocopies of the checks showed significant amounts of money were given to a Certified Nursing Assistant and an Activity Aide, who were no longer employed at the facility, except for the CNA who was suspended pending investigation. Interviews with various staff members, including Licensed Vocational Nurses and the Social Services Director, confirmed that it was against facility policy for staff to accept money or gifts from residents. The facility's Administrator acknowledged that the CNA involved felt uncomfortable taking the money and recognized the act as financial abuse, despite the resident's alleged consent. The facility's existing Abuse Prevention Policy did not provide specific actions for handling residents' money, which contributed to the deficiency.
Failure to Ensure Timely Podiatry Referral for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the care of fingernails and toenails for one resident, identified as Resident 4. This deficiency was observed when the facility did not ensure that the assigned Licensed Vocational Nurses (LVNs) notified the Social Services Director (SSD) to refer Resident 4 to a podiatrist for the cleaning and trimming of long and overgrown toenails. Resident 4, who was admitted with diagnoses including gout, infection of an amputation stump, and peripheral vascular disease, was dependent on assistance for various activities of daily living, including lower body dressing and putting on/taking off footwear. The resident's care plan, which was untitled, indicated that staff should inspect the resident's feet daily and refer them to a podiatrist for foot care needs, including toenail trimming. During an observation and interview, it was noted that Resident 4's left toenails were long, overgrown, and yellow, and the resident expressed concern about the risk of infection. LVN 7 acknowledged the condition of the toenails and stated the need to inform the SSD to schedule a podiatrist appointment. The Director of Nursing (DON) confirmed the importance of keeping toenails clean and trimmed to prevent infection and injury, and stated that CNAs were responsible for inspecting toenails and informing the LVN and SSD when trimming was needed. The facility's policy, revised in 2018, emphasized the importance of regular nail care to prevent infections and injuries, particularly for diabetic residents or those with circulatory impairments, whose nails should not be trimmed by staff unless permitted otherwise.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for falls. The resident, who had a history of falls and was diagnosed with conditions such as generalized muscle weakness, type II diabetes mellitus, and encephalopathy, experienced an unwitnessed fall. Despite being assessed as confused and needing a sitter, the necessary order for one-to-one supervision was not obtained by the Licensed Vocational Nurses (LVNs) involved. The resident's care plan indicated several risk factors for falls, including cognitive impairment and the use of cardiac and anti-hypertensive medications. After the fall, the resident was found to be confused and experiencing hallucinations, yet the LVNs did not update the care plan or complete the necessary documentation to secure a sitter. The Medical Doctor (MD) was informed of the fall but not of the resident's confusion or the need for a sitter, which could have prevented further incidents. Interviews with the nursing staff revealed a lack of communication and understanding of the process for obtaining a sitter. The Director of Nursing confirmed that the LVNs should have obtained a physician's order for a sitter following the fall. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision, which was not adhered to in this case.
Failure to Reassess Pain Management
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) reassessed the pain level of a resident after administering acetaminophen for mild pain, as per the facility's policy and procedure. The resident, who had a history of gout, infection of an amputation stump, and peripheral vascular disease, was admitted with acute pain related to amputation. The care plan for the resident included goals for adequate pain relief and interventions such as administering analgesia and monitoring its effectiveness. On the day of the incident, the resident complained of mild pain and was given acetaminophen. However, the LVN did not reassess the resident's pain level within the required 30 minutes to one hour after administration. Later, the resident reported experiencing severe pain, rated 9 out of 10, and stated that no one had checked if the pain medication was effective. The LVN acknowledged the failure to reassess the pain level and recognized that the resident's pain could worsen without proper evaluation. The Director of Nursing confirmed that the facility's process required reassessment of pain medication effectiveness within one hour of administration. The facility's policy indicated that nursing staff should assess pain whenever there is a significant change in condition or worsening of existing pain. The failure to follow this protocol resulted in unrelieved pain for the resident and placed them at risk for psychosocial harm.
Expired CNA Certification Leads to Deficiency
Penalty
Summary
The facility failed to ensure that one of its certified nursing assistants (CNA 1) had an active CNA certification while employed and performing resident care. This deficiency was identified during an interview and record review, where it was revealed that CNA 1 worked on multiple dates with an expired CNA certificate. The Director of Nursing (DON) acknowledged this oversight, admitting that they did not verify the certification status before scheduling CNA 1 for work. The facility's policy and procedure, titled 'Credentialing of Nursing Service Personnel,' requires nursing personnel to present verification of their license or certification prior to employment and annually by February 1st. However, the DON admitted to failing to adhere to this policy, resulting in CNA 1 working without a valid certification. This lapse in following established procedures had the potential to lead to inadequate and unsafe resident care due to a knowledge, training, and certification deficit.
Failure to Notify Resident and Responsible Party of Room Changes
Penalty
Summary
The facility failed to notify a resident and the resident's responsible party prior to room or bed changes, as required by the facility's policy and procedure. The resident, who had diagnoses including difficulty walking and end-stage renal disease, was transferred multiple times between rooms without documented evidence of notification. Interviews with the Infection Preventionist Nurse, Social Services Director, and Director of Nursing confirmed the lack of documentation and notification for these room changes. The resident's medical records indicated that the resident had the capacity to understand and make decisions, although later assessments showed moderately impaired cognition. Despite this, the facility's policy required advance written notice of room changes, which was not provided. The resident expressed that he did not remember being notified about the room changes and did not want to be moved. The facility's policy clearly stated that all parties involved in a room change should receive advance written notice, including the reasons for the change, but this procedure was not followed.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate care and necessary services to prevent pressure ulcers and promote healing. Specifically, the licensed nurses did not set Resident 3's low air loss (LAL) mattress settings accurately based on the resident's weight or comfort. The mattress was observed to be set at 240 lbs, while Resident 3's actual weight was 119 lbs. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an interview and observation. The Director of Nursing (DON) acknowledged that setting the mattress at the correct weight is crucial for wound healing. Additionally, the nursing staff did not turn and reposition Resident 3 every two hours as indicated in the resident's care plan. Resident 3 reported that she had not been turned since the morning, and this was confirmed during an observation and interview. The care plan specifically required turning and repositioning every two hours to prevent further skin breakdown. The facility also failed to provide timely incontinent care to Resident 3 after a bowel movement. Multiple observations showed that Resident 3 had to wait for extended periods before receiving incontinent care, resulting in soiled conditions that could exacerbate her pressure ulcers. The DON and other staff members acknowledged the importance of timely incontinent care and proper communication among staff to ensure that residents' needs are promptly addressed.
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 3,249 citations issued within 25 miles in the last 12 months — including the 9 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 Glendora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesa Glen Care Center | 0.7 mi | — | 21 | 0 |
| Gladstone Sub-acute And Rehab Center | 1.4 mi | — | 4 | 0 |
| Glendora Grand, Inc | 1.9 mi | — | 3 | 0 |
| Arbor Glen Care Center | 2.1 mi | — | 24 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 3.1 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 August 2026) and official state health department websites.