26 Reports
Inspection Report — Apr 27, 2026
Complaint Investigation
Date: Apr 27, 2026
Visit Reason
On-site complaint investigation of intake #00167249 and intake #2993734 at a Nursing Care Institution, conducted 27 April 2026.
Complaint Details
An onsite complaint survey was conducted on April 27, 2026 for the investigation of the intake #00167249. An onsite complaint survey was conducted on April 27, 2026 for the investigation of the intake #2993734. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 27, 2026
Complaint Investigation
Date: Mar 27, 2026
Visit Reason
On-site complaint investigation of complaint 00161223 at a Nursing Care Institution, conducted 27 March 2026.
Complaint Details
This complaint survey was conducted on March 27, 2026, with the investigation of complaints: 00161223. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Dec 4, 2025
Complaint Investigation
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to an allegation of abuse reported by Resident #2, who claimed that a male night shift staff member touched her inappropriately.
Complaint Details
The complaint involved an allegation by Resident #2 that a male night shift staff member sexually abused her on October 30, 2025. The facility delayed reporting the allegation to the State Agency beyond the mandated 2-hour window. The alleged staff member was suspended, and investigations were conducted by the facility and local police. The nursing home is disputing the citation.
Findings
The facility failed to report the allegation of abuse immediately and within the required 2-hour timeframe to mandated entities. The alleged male staff member was suspended pending investigation, and all authorities including local police, State Agency, and Adult Protective Services were notified, though some notifications were delayed.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of alleged incident: Oct 30, 2025
Date survey completed: Dec 4, 2025
Date report emailed to State Agency: Nov 1, 2025
BIMS assessment score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #29 | Nurse | Alerted by Resident #2's family about the abuse allegation and notified nursing management, administration, and local police |
| Staff #22 | Registered Nurse (RN) | Nurse on duty who took Resident #2's statement and notified management, police, and Administrator |
| Staff #31 | Certified Nursing Assistant (CNA) | Interviewed regarding reporting procedures for abuse allegations |
| Staff #57 | Licensed Practical Nurse (LPN) | Interviewed regarding reporting procedures for abuse allegations |
| Staff #4 | Director of Nursing (DON) | Interviewed about expected reporting procedures for abuse allegations |
| Staff #66 | Administrator | Abuse coordinator who made determination and reported allegations to outside entities |
| Staff #19 | Social Services Director | Interviewed about reporting abuse allegations and notifying APS and ombudsman |
Inspection Report — Nov 26, 2025
Complaint Investigation
Date: Nov 26, 2025
Visit Reason
On-site complaint investigation of intakes AZ00156498/2232291, AZ00157762/2232347, AZ00167267/2232305, AZ00169501/2232260, AZ00172995/2232385, AZ00174410/2232388, AZ00181593/2232397, AZ00182048/2232398 and AZ00182576/2232400 at a Nursing Care Institution, conducted 26 November 2025.
Complaint Details
The Risk-Based complaint survey was conducted on October 28, 2025 for the investigation of intakes: AZ00156498/2232291, AZ00157762/2232347, AZ00167267/2232305, AZ00169501/2232260, AZ00172995/2232385, AZ00174410/2232388, AZ00181593/2232397, AZ00182048/2232398 & AZ00182576/2232400. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Nov 21, 2025
Date: Nov 21, 2025
Visit Reason
On-site inspection of a Nursing Care Institution at Life Care Center of North Glendale conducted 21 November 2025, classified as Other inspection type.
Findings
The inspection found one deficiency related to the maintenance of patient sleeping room doors that could allow heat or smoke transfer, posing harm to patients and staff.
Deficiencies (1)
Patient Sleeping Room Doors Locks — The facility failed to maintain several doors, which could allow heat and/or smoke to transfer and cause harm to patients and staff.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 11, 2025
Complaint Investigation
Date: Jul 11, 2025
Visit Reason
On-site complaint investigation of multiple complaints including intake #AZ00217372 and others at a Nursing Care Institution, conducted 7 through 11 July 2025.
Complaint Details
An onsite complaint survey was conducted on July 7 through July 11, 2025 for the investigation of intake #AZ00217372, 2232490, AZ00217374, 2232410, 2232438, AZ00209700, 2232496, AZ00209776, 2232442, AZ00209702, 2232497, AZ00209777, 2232526, AZ00208160, 2232498, AZ00208162, 2232435, AZ00204791, 2232489, AZ00218384, 2232524, AZ00218381, 2232433, AZ00216462, 2232434, AZ00216464, 2232409, AZ00214931, 2232408, AZ00214908, 2232479, AZ00201310, 2232480, AZ00201311, 2232481, AZ00200919, 2232431, AZ00200950, 2232463, AZ00213993, 2232511, AZ00199067, 2232510, AZ00199092, 2232512, AZ00199091, 2232527, AZ00198855, 2232522, AZ00196806, 2232523, AZ00196804, 2232494, AZ00209877, 2232495, AZ00209876, 2232406, 2232488, AZ00219870, AZ00219867, 2232525, AZ00209706, 2232521, AZ00209707, 2232407, AZ00207844, 2232405, AZ00207843, 2232393, AZ00207395, 2232392, AZ00207394, 2232505, AZ00207004, 2232506, AZ00207006, 2232422, AZ00206557, 2232423, AZ00206558, 2232467, AZ00205482, 2232468, AZ00205484, 2232426, AZ00204331, 2232428, AZ00204330, 2232535, AZ00189655, 2232534, AZ00189657, 2232329, AZ00202259, 2232323, AZ00202257, 2232507, AZ00201374, 2232508, AZ00201371, 2232509, AZ00201099, 2232432, AZ00200951, 2232430, AZ00200562, 2232429, AZ00200561, 2232528, AZ00198313, 2232513, AZ00198317, 2232529, AZ00196679, 2232530, AZ00195664, 2232531, AZ00195663, 2232533, AZ00192594, 2232464, AZ00192593, 2232491, AZ00190486, 2232493, AZ00190487, 2232553, AZ00189409, 2232552, AZ00189410, 2232550, AZ00189357, 2232551, AZ00189358, 2232544, AZ00188430, 2232543, AZ00188431, 2232536, AZ00189110, 2232549, AZ00189117, 2232548, AZ00189118, 2232478, AZ00189085, 2232477, AZ00189083, 2232537, AZ00189036, 2232538, AZ00189037, 2232539, AZ00188999, 2232545, AZ00188175, 2232547, AZ00188058, 2232546, AZ00188061, 2232421, AZ00188677, 2232420, AZ00188676, 2232540, AZ00188624, 2232541, AZ00188625, 2232542, AZ00188594, 2232471, AZ00187261, 2232473, AZ00187262, 2232520, AZ00185895, 2232518, AZ00185893, 2232516, AZ00185556, 2232519, AZ00185528, 2232517, AZ00185557, 2232515, AZ00185007, 2232487, AZ00185008, 2232486, AZ00179395, 2232514, AZ00179393.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jul 2, 2025
Complaint Investigation
Date: Jul 2, 2025
Visit Reason
On-site complaint investigation of intake numbers AZ00199493 and AZ00199492 at a Nursing Care Institution, conducted 2 July 2025.
Complaint Details
A complaint investigation was conducted on July 2, 2025 of intake # AZ00199493 and intake # AZ00199492. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jun 3, 2025
Complaint Investigation
Date: Jun 3, 2025
Visit Reason
On-site complaint investigation of intakes 00131686, 00128562, AZ00221748, AZ00221424, AZ00224658, AZ00224372, AZ00221750, and AZ00221421 at a Nursing Care Institution, conducted 3 June 2025.
Complaint Details
A complaint survey was conducted on June 3, 2025 for the investigation of intakes #'s: 00131686, 00128562, AZ00221748, AZ00221424, AZ00224658, AZ00224372, AZ00221750, AZ00221421. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Apr 14, 2025
Complaint Investigation
Date: Apr 14, 2025
Visit Reason
On-site complaint investigation of intakes 00126205, AZ00224070, 00125136, AZ00179030, AZ00176809, AZ00176654, AZ00224119, AZ00224019, AZ00179026, AZ00176808, and AZ00176653 at a Nursing Care Institution, conducted 14 April 2025.
Complaint Details
A complaint survey was conducted on April 14, 2025 for the investigation of intake # 00126205, AZ00224070, 00125136, AZ00179030, AZ00176809, AZ00176654. Federal comments noted investigation of intake # AZ00224119, AZ00224070, AZ00224019, AZ00179026, AZ00176808, AZ00176653. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding insufficient nursing staff to meet resident needs, including delayed call-light responses and inadequate assistance with activities of daily living.
Complaint Details
The investigation was complaint-driven based on multiple resident interviews reporting excessive wait times for call-light responses (up to four hours), delayed continence care, cold food trays, and insufficient staff coverage. Staffing schedules and interviews with staff confirmed chronic understaffing and inability to cover shifts adequately.
Findings
The facility was found to be short staffed, resulting in residents experiencing long wait times for call-light responses, continence care, and assistance with ADLs. Multiple residents reported waiting hours for care, and staff schedules confirmed consistent understaffing, particularly on Hall 200.
Deficiencies (1)
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Number of CNAs scheduled: 4
Number of CNAs scheduled: 2
Wait times: 4
Wait times: 3
Wait times: 1.75
Wait times: 0.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Staffing Coordinator | Provided detailed staffing schedules and confirmed chronic understaffing on Hall 200 |
| Staff #1 | Director of Nursing (DON) | Interviewed regarding staffing issues and resident complaints; supervises staffing with Executive Director |
| Staff #3 | Certified Nursing Assistant (CNA) | Reported on call-light response times and staffing shortages on Hall 200 |
| Staff #79 | Certified Nursing Assistant (CNA) | Reported on call-light response times and staffing shortages on Hall 200 |
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding insufficient nursing staff to meet resident needs, including delayed call-light responses, inadequate continence care, and cold food service.
Complaint Details
The complaint investigation revealed substantiated issues with staffing shortages leading to delayed care, including call-light response times up to four hours, delayed continence care causing rashes, and cold food service. Resident interviews and staff schedules confirmed these findings.
Findings
The facility was found to be short staffed, particularly on Hall 200, resulting in residents experiencing long wait times for call-light responses and assistance with activities of daily living. Multiple residents reported waits of up to several hours for care, and staff interviews confirmed staffing shortages and scheduling difficulties.
Deficiencies (1)
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Number of CNAs needed per shift on Hall 200: 5
Number of CNAs needed per shift on Hall 200: 3
Number of CNAs actually scheduled: 4
Number of CNAs actually scheduled: 2
Call-light wait times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Staffing Coordinator | Provided detailed staffing schedules and confirmed staffing shortages on Hall 200 |
| Staff #1 | Director of Nursing (DON) | Responsible for monitoring staffing ratios and acknowledged ongoing staffing shortages |
| Staff #3 | Certified Nursing Assistant (CNA) | Reported on call-light response times and staffing challenges on Hall 200 |
| Staff #79 | Certified Nursing Assistant (CNA) | Reported on call-light response times and staffing levels on Hall 200 |
Inspection Report — Feb 25, 2025
Complaint Investigation
Date: Feb 25, 2025
Visit Reason
On-site complaint investigation of intake numbers 00115580 and AZ00223526 at a Nursing Care Institution, conducted 25 February 2025.
Complaint Details
The complaint survey was conducted on September 11, 2024, with the investigation of intake #:00115580. The complaint survey was conducted on February 25, 2025, with the investigation of intake #:AZ00223526. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Dec 6, 2024
Complaint Investigation
Date: Dec 6, 2024
Visit Reason
On-site complaint investigation of intake AZ00219564 at a Nursing Care Institution, conducted 6 December 2024.
Complaint Details
A complaint survey was conducted on December 06, 2024 for the investigation of intake # AZ00219564. Federal comments also note a complaint survey for intake # AZ00219563 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Nov 20, 2024
Complaint Investigation
Date: Nov 20, 2024
Visit Reason
On-site complaint investigation of complaints AZ00218471 and AZ00218470 at a Nursing Care Institution, conducted 20 November 2024.
Complaint Details
The Complaint survey was conducted on November 20, 2024, with the investigation of the following complaints AZ00218471 and AZ00218470. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
On-site complaint investigation of complaints AZ00214781, AZ00214776, AZ00214673, AZ00214985, and AZ00214586 at a Nursing Care Institution, conducted 27 to 28 August 2024.
Complaint Details
An investigation of complaints AZ00214781, AZ00214776, AZ00214673, AZ00214985, and AZ00214586 was conducted August 27, 2024 to August 28, 2024. Federal Comments also referenced complaints AZ00214779, AZ00214775, AZ00214670, AZ00214984, and AZ00214586 with the same deficiency cited.
Findings
The investigation substantiated one deficiency related to failure to ensure residents were free from abuse by other residents. The facility implemented safety measures and transferred the aggressive resident to another unit.
Deficiencies (1)
R9-10-410 — The facility failed to ensure that residents are free from abuse by other residents, as evidenced by resident #37 hitting resident #11 multiple times and staff intervening to separate them. The facility notified appropriate parties, conducted a 5-day investigation, and implemented safety and care plan interventions.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | Certified Nursing Assistant | Witnessed resident #37 hit resident #11 and provided a written statement. |
| Staff #41 | Licensed Practical Nurse | Reported hearing residents raising voices and described the incident in a written statement. |
| Staff #54 | Certified Nursing Assistant | Observed interaction between residents #37 and #11 and provided a written statement. |
| Staff #23 | Licensed Practical Nurse | Interviewed and described training on abuse and supervision needs of resident #11. |
| Staff #1 | Director of Nursing | Interviewed and confirmed substantiation of abuse allegation after investigation. |
Inspection Report — Aug 5, 2024
Complaint Investigation
Date: Aug 5, 2024
Visit Reason
On-site complaint investigation of complaint AZ00213482 at a Nursing Care Institution, conducted 5 August 2024.
Complaint Details
The state complaint survey was conducted on August 5, 2024 for the investigation of complaint #AZ00213482. The complaint survey was also conducted on August 5, 2024 for the investigation of complaint #AZ00213481. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 17, 2024
Complaint Investigation
Date: Jul 17, 2024
Visit Reason
On-site complaint investigation of intake AZ00212813 and AZ00212812 at a Nursing Care Institution, conducted 17 July 2024.
Complaint Details
A complaint survey was conducted on July 17, 2024 for the investigation of intake # AZ00212813. A complaint survey was conducted on July 17, 2024 for the investigation of intake # AZ00212812. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jun 27, 2024
Complaint Investigation
Date: Jun 27, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00212250 and AZ00212249 at a Nursing Care Institution, conducted 26 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 26, 2024 for the investigation of intake # AZ00212250 and intake # AZ00212249. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Jun 14, 2024
Complaint Investigation
Date: Jun 14, 2024
Visit Reason
On-site complaint investigation of intakes AZ00207049, AZ00199213, AZ00175679, AZ00211650, and AZ00211749 at a Nursing Care Institution, conducted 13-14 June 2024.
Complaint Details
A complaint survey was conducted on June 13-14, 2024 for the investigation of intake numbers AZ00207049, AZ00199213, AZ00175679, AZ00211650, and AZ00211749. Federal comments referenced investigation of intake numbers AZ00207043, AZ00199213, AZ00175677, AZ00211648, and AZ00211748.
Findings
The inspection found two deficiencies related to failure to notify the physician of a resident's significant change in condition and change of condition. Both deficiencies involved Resident #5 and the failure to promptly inform the physician about changes in the resident's status following a fall and altered mental condition.
Deficiencies (2)
§483.10(g)(14) — The facility failed to ensure the physician was notified of a change of condition for Resident #5, which could result in delayed treatment after the resident experienced a fall and altered mental status.
R9-10-412.B — The director of nursing failed to ensure the physician was notified within 24 hours of a significant change in condition for Resident #5, despite documented changes including slurred speech and confusion after a fall.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #85 | Licensed Practical Nurse | Interviewed regarding notification procedures following a resident fall and change in condition. |
Inspection Report — Aug 22, 2023
Complaint Investigation
Date: Aug 22, 2023
Visit Reason
On-site complaint investigation of intakes AZ00199163, AZ00199075, and AZ00199162 at a Nursing Care Institution, conducted 22 August 2023.
Complaint Details
An onsite survey was conducted on August 22, 2023 for the investigation of intake #s: AZ00199163 and AZ00199075. The complaint survey was conducted on August 22, 2023 for the investigation of intake #s: AZ00199162 and AZ00199075. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 3, 2023
Date: Jul 3, 2023
Visit Reason
On-site inspection of a Nursing Care Institution at Life Care Center of North Glendale conducted 3 July 2023 as an Other type inspection with worksheet type Nursing Care Institution.
Findings
The inspection found four deficiencies related to fire safety and building maintenance, including issues with exit door locking force, kitchen cooking area hazards, door latching failures, and exposed electrical wiring. Plans of correction were provided for all deficiencies.
Deficiencies (4)
Egress door locking force — The facility failed to maintain two special locking exit doors that required more than the allowed force to release, potentially endangering patients and staff in an emergency.
Cooking facilities hazard — Rags were found on the gas line and floor behind the kitchen cook top, indicating failure to properly clean and inspect the kitchen hood baffles, which could fuel a fire.
Corridor doors maintenance — Several doors throughout the building failed to latch securely or had excessive gaps, risking the passage of smoke and heat that could harm patients and staff.
R9-10-403.E — The facility failed to ensure exposed electrical wiring under the kitchen disposal was properly protected, posing a hazard to patients and staff.
Report Facts
Deficiencies cited: 4
Inspection Report — Jul 3, 2023
Annual Inspection
Date: Jul 3, 2023
Visit Reason
Annual compliance inspection of Life Care Center of North Glendale conducted 28 June to 3 July 2023, using the Nursing Care Institution worksheet.
Findings
Two deficiencies were cited related to inadequate PASRR Level II evaluation referrals for a resident with bipolar disorder and antipsychotic medication orders.
Deficiencies (2)
R9-10-403.C — The facility failed to ensure policies and procedures were implemented to protect the health and safety of a resident with bipolar disorder by not referring the resident for a PASRR Level II evaluation despite escalated behaviors and prescribed antipsychotic medication.
§483.20(k) — The facility did not refer a resident with bipolar disorder and prescribed antipsychotic medication to the State authority for PASRR Level II evaluation and determination, risking unmet resident needs and services.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #99 | Social Service Director | Interview regarding resident #92's Level I PASRR and need for Level II evaluation |
Inspection Report — Jul 3, 2023
Complaint Investigation
Date: Jul 3, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to properly update PASRR Level I screenings and to refer residents with serious mental illness or intellectual disabilities for Level II evaluations as required by state regulations.
Complaint Details
The complaint investigation focused on the facility's compliance with PASRR screening and referral requirements for residents with mental disorders or intellectual disabilities. The investigation found that required Level II referrals were not made for residents with diagnoses and behaviors indicating the need, and that PASRR Level I screenings were not updated as required.
Findings
The facility failed to ensure that PASRR Level I screenings were updated appropriately for one resident and that two residents were referred to the State designated authority for Level II PASRR evaluation and determination. This deficient practice could result in specialized services not being identified and provided to residents.
Deficiencies (2)
Failure to update PASRR Level I screening appropriately for resident #94.
Failure to refer residents #92 and #3 to the State designated authority for Level II PASRR evaluation and determination despite diagnoses and prescribed medications indicating the need.
Report Facts
Episodes of striking out: 5
Episodes of striking out: 2
BIMS score: 99
BIMS score: 15
Date of PASRR Level I screening: Feb 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding PASRR screening and referral practices, identified failures in Level II referral. | |
| Admissions Assistant | Interviewed regarding PASRR screening process prior to admission. |
Inspection Report — May 5, 2022
Routine
Date: May 5, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, staffing, medication administration, discharge planning, grievance handling, and infection control at Life Care Center of North Glendale.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate grievance resolution, failure to notify Ombudsman of discharge, unsafe discharge planning, inconsistent provision of showers, lack of restorative nursing services, insufficient staffing leading to unmet resident needs, improper medication administration, lack of behavioral monitoring for psychotropic medication, and lapses in infection control practices.
Deficiencies (11)
Failure to ensure one resident was treated with respect and dignity by staff.
Failure to ensure residents could voice grievances without fear of retaliation.
Failure to notify the Ombudsman of resident discharge.
Failure to ensure discharge planning included safe environment and caregiver training.
Failure to provide consistent showers per schedule to residents.
Failure to provide restorative nursing services as ordered due to staffing issues.
Failure to maintain adequate nursing staff to meet resident needs, resulting in delayed assistance and unmet care needs.
Administration of opioid pain medication to resident reporting no pain.
Administration of blood pressure medication despite resident's blood pressure below ordered parameter without physician notification.
Failure to monitor behaviors for resident receiving psychotropic medication.
Failure to follow infection control procedures during medication administration and meal service.
Report Facts
Facility licensed beds: 208
Residents assigned per CNA: 35
Residents assigned per CNA: 43
Medication doses administered outside parameters: 1
Missed showers: 19
Residents on RNA program: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #42 | Certified Nursing Assistant | Named in resident dignity deficiency related to shower incident |
| Staff #19 | Case Manager Lead, Licensed Practical Nurse | Named in discharge planning and Ombudsman notification deficiency |
| Staff #3 | Director of Social Services | Named in discharge planning and Ombudsman notification deficiency |
| Staff #7 | Director of Nursing | Named in medication administration and staffing deficiencies |
| Staff #34 | Restorative Nursing Assistant | Named in restorative nursing service deficiency |
| Staff #6 | Licensed Practical Nurse | Named in medication administration and pain management deficiency |
| Staff #18 | Licensed Practical Nurse | Named in infection control and medication administration deficiency |
| Staff #31 | Infection Preventionist | Named in infection control deficiency |
| Staff #140 | Facility Administrator | Named in staffing deficiency |
| Staff #35 | Staffing Coordinator | Named in staffing deficiency |
Inspection Report — Jan 8, 2020
Annual Inspection
Date: Jan 8, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and investigate specific incidents including medication errors, wound care, resident safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete PASARR screening updates, administration of expired medication, inadequate discharge planning and wound care, inconsistent assistance with hearing aids, insufficient nursing staff, lack of oxygen orders, medication errors, and failure to follow infection control procedures.
Deficiencies (13)
Failure to ensure a resident was treated with dignity, including staff using offensive labels.
Failure to update PASARR level I screening for a resident whose stay exceeded 30 days.
Administration of expired medication to a resident.
Failure to ensure discharge information included complete assessment and instructions for burn wounds.
Failure to provide appropriate wound care and documentation for residents with pressure ulcers and skin injuries.
Failure to provide consistent assistance with hearing aids to a resident with hearing loss.
Failure to reassess resident for safety with handling hot liquids after developing tremors, resulting in burns.
Failure to have a physician's order for oxygen use for a resident receiving oxygen therapy.
Insufficient nursing staff to meet resident needs, resulting in delayed call light response and unmet care needs.
Failure to post daily nurse staffing information including actual hours worked by licensed and unlicensed staff.
Failure to monitor target behaviors related to antipsychotic medication use for a resident.
Medication errors including administering wrong medication and incorrect dosing of nasal spray.
Failure to follow infection control procedures during medication administration, including handling spilled medication.
Report Facts
Medication error rate: 7.69
LPN hours worked: 5.98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #154 | Licensed Practical Nurse | Named in medication error and infection control deficiency |
| Staff #6 | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| Staff #223 | Regional Director of Clinical Services | Participated in interviews regarding facility deficiencies |
| Staff #224 | Administrator | Participated in interviews regarding facility deficiencies |
| Staff #66 | Staff Coordinator | Provided information on staffing and scheduling |
Inspection Report — Jan 8, 2020
Routine
Date: Jan 8, 2020
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements and investigate resident care and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity, PASARR screening updates, medication administration errors, discharge planning and communication, wound care and pressure ulcer management, hearing aid assistance, medication error rates, infection control practices, staffing adequacy, oxygen use without order, and psychotropic medication monitoring.
Deficiencies (14)
Failure to ensure a resident was treated in a dignified manner, including staff using offensive labels.
Failure to update PASARR level I screening for a resident who remained longer than 30 days.
Failure to ensure expired medication was not administered to a resident.
Failure to ensure discharge information contained complete recapitulation and instructions for burn wound treatment.
Failure to provide appropriate wound care and assessment for residents with pressure ulcers and skin injuries.
Failure to provide consistent assistance with hearing aids to a resident with hearing loss.
Failure to ensure appropriate pressure ulcer care and prevention for residents with pressure ulcers.
Failure to reassess resident for safety with handling hot liquids after developing tremors, resulting in burn injuries.
Failure to have a physician's order for oxygen use for a resident receiving oxygen therapy.
Insufficient nursing staff to meet resident needs, resulting in delayed response to call lights and unmet care needs.
Failure to post daily nurse staffing information including actual hours worked by licensed and unlicensed staff.
Failure to monitor target behaviors related to antipsychotic medication use for a resident.
Medication errors including administering wrong medication and incorrect dosing of nasal spray.
Failure to follow infection control procedures when handling medications, including reusing spilled medication.
Report Facts
Medication error rate: 7.69
Licensed Practical Nurses scheduled: 5
Licensed Practical Nurses working: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #154 | Licensed Practical Nurse | Named in medication error findings and infection control observation |
| Staff #6 | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, staffing, and wound care |
| Staff #223 | Regional Director of Clinical Services | Interviewed regarding wound care and staffing |
| Staff #224 | Administrator | Interviewed regarding staffing and medication errors |
| Staff #213 | Wound Nurse | Interviewed regarding wound care assessments |
| Staff #66 | Staff Coordinator | Interviewed regarding staffing schedules and coverage |
| Staff #40 | Assistant Director of Nursing | Interviewed regarding infection control observation |
| Staff #68 | Licensed Practical Nurse | Interviewed regarding psychotropic medication monitoring |
7 CMS Surveys
CMS Survey — Jun 14, 2024
Jun 14, 2024
CMS Survey — Aug 28, 2024
Aug 28, 2024
CMS Survey — Mar 12, 2025
Mar 12, 2025
CMS Survey — Dec 4, 2025
Dec 4, 2025
CMS Survey — Jan 8, 2020
Jan 8, 2020
CMS Survey — May 5, 2022
May 5, 2022
CMS Survey — Jul 3, 2023
Jul 3, 2023
Viewing
Loading inspection reports...



