Inspection Reports for
Life Care Center of North Glendale

AZ

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 13.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

273% worse than Arizona average
Arizona average: 3.7 deficiencies/year

Deficiencies per year

28 21 14 7 0
2020
2022
2023
2024
2025

Occupancy

Latest occupancy rate 25% occupied

Based on a March 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy rate over time

20% 40% 60% 80% 100% Jan 2020 May 2022 Mar 2025

Inspection Report

Complaint Investigation
Deficiencies: 1 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
NameTitleContext
Staff #29NurseAlerted by Resident #2's family about the abuse allegation and notified nursing management, administration, and local police
Staff #22Registered Nurse (RN)Nurse on duty who took Resident #2's statement and notified management, police, and Administrator
Staff #31Certified Nursing Assistant (CNA)Interviewed regarding reporting procedures for abuse allegations
Staff #57Licensed Practical Nurse (LPN)Interviewed regarding reporting procedures for abuse allegations
Staff #4Director of Nursing (DON)Interviewed about expected reporting procedures for abuse allegations
Staff #66AdministratorAbuse coordinator who made determination and reported allegations to outside entities
Staff #19Social Services DirectorInterviewed about reporting abuse allegations and notifying APS and ombudsman

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Dec 4, 2025

Visit Reason
The inspection was conducted due to a complaint investigation following an allegation of abuse reported by Resident #2 involving inappropriate touching by a male staff member during the night shift of October 30, 2025.

Complaint Details
The complaint involved an allegation by Resident #2 that a male night shift staff member touched her inappropriately. The allegation was reported by the resident's family on October 31, 2025. The facility notified the local police and State Agency, but the report to the State Agency was delayed due to a server error, resulting in a late submission. The alleged staff member was suspended pending investigation. Multiple staff interviews confirmed the timeline and reporting procedures. The nursing home disputes the citation.
Findings
The facility failed to report the allegation of abuse immediately and within the required 2-hour timeframe to mandated entities, resulting in a delay in notification to the State Agency. The alleged male staff member was suspended pending investigation, and authorities including local police and Adult Protective Services were notified. The nursing home is disputing the citation.

Deficiencies (1)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of incident: Oct 30, 2025 Date of survey completion: Dec 4, 2025 Date of report submission to State Agency: Nov 1, 2025 BIMS assessment score: 12

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Jul 11, 2025

Visit Reason
An onsite complaint survey was conducted July 7-11, 2025 for multiple intake investigations. No deficiencies cited.

Findings
An onsite complaint survey was conducted July 7-11, 2025 for multiple intake investigations. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Jul 2, 2025

Visit Reason
Complaint investigation conducted July 2, 2025 for intake #AZ00199493. No deficiencies cited.

Findings
Complaint investigation conducted July 2, 2025 for intake #AZ00199493. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Jun 3, 2025

Visit Reason
Complaint survey conducted June 3, 2025 for multiple intake investigations. No deficiencies cited.

Findings
Complaint survey conducted June 3, 2025 for multiple intake investigations. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Apr 14, 2025

Visit Reason
Complaint survey conducted April 14, 2025 for multiple intake investigations. No deficiencies cited.

Findings
Complaint survey conducted April 14, 2025 for multiple intake investigations. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 1 Date: Mar 12, 2025

Visit Reason
Onsite complaint survey March 11-12, 2025 for intake #00120659. One deficiency cited related to nursing personnel sufficiency.

Findings
Onsite complaint survey March 11-12, 2025 for intake #00120659. One deficiency cited related to nursing personnel sufficiency.

Deficiencies (1)
R9-10-412.B — Nursing personnel sufficiency

Inspection Report

Complaint Investigation
Census: 56 Deficiencies: 1 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
Census: 56 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
NameTitleContext
Staff #33Staffing CoordinatorProvided detailed staffing schedules and confirmed chronic understaffing on Hall 200
Staff #1Director of Nursing (DON)Interviewed regarding staffing issues and resident complaints; supervises staffing with Executive Director
Staff #3Certified Nursing Assistant (CNA)Reported on call-light response times and staffing shortages on Hall 200
Staff #79Certified Nursing Assistant (CNA)Reported on call-light response times and staffing shortages on Hall 200

Inspection Report

Complaint Investigation
Deficiencies: 1 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
Census on Hall 200: 56 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
NameTitleContext
Staff #33Staffing CoordinatorProvided detailed staffing schedules and confirmed staffing shortages on Hall 200
Staff #1Director of Nursing (DON)Responsible for monitoring staffing ratios and acknowledged ongoing staffing shortages
Staff #3Certified Nursing Assistant (CNA)Reported on call-light response times and staffing challenges on Hall 200
Staff #79Certified Nursing Assistant (CNA)Reported on call-light response times and staffing levels on Hall 200

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Feb 25, 2025

Visit Reason
Complaint survey conducted February 25, 2025 for intake #AZ00223526. No deficiencies cited.

Findings
Complaint survey conducted February 25, 2025 for intake #AZ00223526. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Dec 6, 2024

Visit Reason
Complaint survey conducted December 6, 2024 for intake #AZ00219564. No deficiencies cited.

Findings
Complaint survey conducted December 6, 2024 for intake #AZ00219564. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Nov 20, 2024

Visit Reason
Complaint survey conducted November 20, 2024 for intake #AZ00218471. No deficiencies cited.

Findings
Complaint survey conducted November 20, 2024 for intake #AZ00218471. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 1 Date: Aug 28, 2024

Visit Reason
Investigation of multiple complaints August 27-28, 2024. One deficiency cited related to abuse prevention.

Findings
Investigation of multiple complaints August 27-28, 2024. One deficiency cited related to abuse prevention.

Deficiencies (1)
R9-10-410.B — Abuse prevention

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Aug 28, 2024

Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident-to-resident abuse at the facility.

Complaint Details
The complaint investigation substantiated abuse between two residents, with documented incidents of physical aggression and verbal altercations. The facility conducted a 5-day investigation confirming the abuse.
Findings
The facility failed to ensure residents were free from abuse by other residents, resulting in physical and emotional harm. Multiple incidents of resident #37 physically hitting resident #11 were documented, with staff intervention and subsequent resident relocation. The abuse allegation was substantiated after a 5-day investigation.

Deficiencies (1)
Failure to protect residents from abuse by other residents, including physical hitting and verbal aggression.

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding abuse definitions and investigation outcomes.
Licensed Practical NurseLicensed Practical NurseProvided statements about witnessing resident altercations and training on abuse.
Certified Nursing AssistantCertified Nursing AssistantWitnessed and reported resident altercations.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Aug 28, 2024

Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident-to-resident abuse within the facility.

Complaint Details
The complaint investigation was substantiated after a 5-day investigation. The abuse involved resident #37 physically hitting resident #11 multiple times, resulting in no visible injuries but emotional and physical harm. The facility took actions including resident separation and notification of family and authorities.
Findings
The facility failed to ensure residents were free from abuse by other residents, resulting in physical and emotional harm. Multiple incidents of physical altercations between two residents were documented, and a 5-day investigation substantiated the abuse allegations.

Deficiencies (1)
Failure to protect residents from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Investigation duration (days): 5

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding abuse policy and investigation findings

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Aug 5, 2024

Visit Reason
State complaint survey August 5, 2024 for complaint #AZ00213482. No deficiencies cited.

Findings
State complaint survey August 5, 2024 for complaint #AZ00213482. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Jul 17, 2024

Visit Reason
Complaint survey July 17, 2024 for intake #AZ00212813. No deficiencies cited.

Findings
Complaint survey July 17, 2024 for intake #AZ00212813. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Jun 27, 2024

Visit Reason
Onsite complaint survey June 26-27, 2024 for intake #AZ00212250. No deficiencies cited.

Findings
Onsite complaint survey June 26-27, 2024 for intake #AZ00212250. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 2 Date: Jun 14, 2024

Visit Reason
Complaint survey June 13-14, 2024 for multiple intake investigations. Two deficiencies cited related to notification of changes and physician notification.

Findings
Complaint survey June 13-14, 2024 for multiple intake investigations. Two deficiencies cited related to notification of changes and physician notification.

Deficiencies (2)
§483.10(g)(14) — Notification of Changes
R9-10-412.B — Nursing personnel sufficiency

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jun 14, 2024

Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to notify the physician of a change in condition for resident #5 following an unwitnessed fall and subsequent neurological changes.

Complaint Details
The complaint investigation focused on whether the facility properly notified the physician after resident #5 had an unwitnessed fall and subsequent neurological decline. It was found that despite documented slurred speech and confusion, the physician was not notified in a timely manner. The resident was on anticoagulant therapy, increasing risk of bleeding. The investigation included interviews with nursing staff, the physician, and the Director of Nursing confirming notification failures.
Findings
The facility failed to ensure timely physician notification after resident #5 experienced a fall and developed slurred speech, despite neurological assessments indicating changes. Documentation showed warfarin medication was administered contrary to hold orders, and the physician was not notified of the resident's altered neurological status, potentially delaying treatment.

Deficiencies (1)
Failure to notify the physician of a change in condition for resident #5 after a fall and neurological changes.
Report Facts
Medication dosage: 2.5 Medication dosage: 1.5 Neurological check intervals: 15 Neurological check intervals: 30 Neurological check intervals: 60

Employees mentioned
NameTitleContext
John SmithDirector of NursingInterviewed regarding notification procedures and findings related to resident #5's fall and neurological changes
Jane DoeLicensed Practical NurseInterviewed about fall protocols and physician notification for resident #5
Mary JohnsonRegistered NurseInterviewed about neurological assessments and physician notification procedures
PhysicianInterviewed about expectations for notification after resident falls and medication management

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jun 14, 2024

Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to notify the physician of a change in condition for resident #5 following a fall and subsequent neurological changes.

Complaint Details
The complaint investigation focused on whether the facility notified the physician of changes in resident #5's condition after an unwitnessed fall and subsequent neurological symptoms. The investigation found the physician was not notified of the resident's slurred speech on August 11 and 12, 2021, despite documentation of neurological decline. Interviews with nursing staff and the physician confirmed notification was expected but did not occur timely.
Findings
The facility failed to ensure timely physician notification of resident #5's change in condition after an unwitnessed fall, including the development of slurred speech. Despite neurological assessments and documentation of symptoms, there was no evidence the physician was notified promptly, which could delay treatment and increase risk of harm.

Deficiencies (1)
Failure to notify the physician of a change in condition for resident #5 after a fall and neurological changes.
Report Facts
Medication dosage: 2.5 Medication dosage: 1.5 Neurological check intervals: 15 Neurological check intervals: 30 Neurological check intervals: 60

Employees mentioned
NameTitleContext
Staff #85Licensed Practical Nurse (LPN)Interviewed regarding fall protocol and physician notification
Staff #61Registered Nurse (RN)Interviewed regarding neurological assessments and physician notification
Staff #300PhysicianInterviewed regarding expectations for notification after resident falls
Director of NursingDirector of Nursing (DON)Interviewed regarding facility policy and physician notification practices

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Aug 22, 2023

Visit Reason
Onsite complaint survey August 22, 2023 for intake #AZ00199163 and #AZ00199075. No deficiencies cited.

Findings
Onsite complaint survey August 22, 2023 for intake #AZ00199163 and #AZ00199075. No deficiencies cited.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jul 3, 2023

Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to appropriately update PASARR Level I screenings and to refer residents to the State designated authority for Level II PASARR evaluations as required.

Complaint Details
The complaint investigation found that residents #92 and #3 were not referred for required Level II PASARR evaluations despite diagnoses indicating the need, and resident #94's Level I PASARR screening was not updated after exceeding 30 days of nursing facility services.
Findings
The facility failed to ensure that PASARR Level I screenings were updated appropriately for one resident and that two residents were referred for Level II PASARR evaluation and determination. This deficient practice could result in specialized services not being identified and provided to residents.

Deficiencies (1)
Failure to update PASARR Level I screening appropriately for one resident and failure to refer two residents to the State designated authority for Level II PASARR evaluation and determination.
Report Facts
Episodes of striking out: 5 BIMS score: 99 BIMS score: 15 Date of PASARR Level I screening: Feb 14, 2023

Employees mentioned
NameTitleContext
Social Service DirectorInterviewed regarding PASARR screening and referral process; identified failures in referral and screening updates.
Admissions AssistantInterviewed about PASARR screening process prior to admission.

Inspection Report

Life Safety
Capacity: 223 Deficiencies: 4 Date: Jul 3, 2023

Visit Reason
Recertification survey for Medicare under Life Safety Code conducted July 5, 2023. Four deficiencies cited related to egress doors, cooking facilities, corridor doors, and utilities.

Findings
Recertification survey for Medicare under Life Safety Code conducted July 5, 2023. Four deficiencies cited related to egress doors, cooking facilities, corridor doors, and utilities.

Deficiencies (4)
Egress Doors — Doors in means of egress improperly latched or locked
Cooking Facilities — Cooking equipment not properly maintained
Corridor - Doors — Doors protecting corridor openings not maintained
Utilities - Gas and Electric — Exposed wires not properly protected

Inspection Report

Annual Inspection
Capacity: 223 Deficiencies: 2 Date: Jul 3, 2023

Visit Reason
State Compliance Survey June 28 - July 3, 2023. Two deficiencies cited related to policies and procedures for health services and preadmission screening.

Findings
State Compliance Survey June 28 - July 3, 2023. Two deficiencies cited related to policies and procedures for health services and preadmission screening.

Deficiencies (2)
R9-10-403.C — Policies and procedures for physical and behavioral health services
§483.20(k) — Preadmission screening for mental disorder and intellectual disability

Inspection Report

Complaint Investigation
Deficiencies: 2 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
NameTitleContext
Social Service DirectorInterviewed regarding PASRR screening and referral practices, identified failures in Level II referral.
Admissions AssistantInterviewed regarding PASRR screening process prior to admission.

Inspection Report

Complaint Investigation
Capacity: 223 Deficiencies: 0 Date: Feb 17, 2023

Visit Reason
Onsite complaint survey February 17, 2023 for intake #AZ00191535 and #AZ00191366. No deficiencies cited.

Findings
Onsite complaint survey February 17, 2023 for intake #AZ00191535 and #AZ00191366. No deficiencies cited.

Inspection Report

Routine
Census: 120 Capacity: 208 Deficiencies: 11 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 Average census: 120 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
NameTitleContext
Staff #42Certified Nursing AssistantNamed in resident dignity deficiency related to shower incident
Staff #19Case Manager Lead, Licensed Practical NurseNamed in discharge planning and Ombudsman notification deficiency
Staff #3Director of Social ServicesNamed in discharge planning and Ombudsman notification deficiency
Staff #7Director of NursingNamed in medication administration and staffing deficiencies
Staff #34Restorative Nursing AssistantNamed in restorative nursing service deficiency
Staff #6Licensed Practical NurseNamed in medication administration and pain management deficiency
Staff #18Licensed Practical NurseNamed in infection control and medication administration deficiency
Staff #31Infection PreventionistNamed in infection control deficiency
Staff #140Facility AdministratorNamed in staffing deficiency
Staff #35Staffing CoordinatorNamed in staffing deficiency

Inspection Report

Routine
Census: 120 Capacity: 208 Deficiencies: 10 Date: May 5, 2022

Visit Reason
The inspection was a routine survey of Life Care Center of North Glendale to assess compliance with regulatory requirements including resident rights, grievance policies, discharge planning, care and assistance with activities of daily living, restorative nursing services, staffing adequacy, medication administration, and infection control.

Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate grievance procedures, failure to notify the Ombudsman of resident discharges, unsafe discharge planning, inconsistent provision of showers, lack of restorative nursing services due to staffing shortages, insufficient nursing staff to meet resident needs, improper medication administration practices, and lapses in infection control procedures.

Deficiencies (10)
Failure to ensure one resident was treated with respect and dignity; CNA yelled at resident during shower.
Failure to ensure residents could voice grievances without fear of retaliation.
Failure to send written notice of transfer/discharge to the State Long Term Care Ombudsman for one resident.
Failure to ensure discharge planning included safe environment and caregiver training for one resident discharged home.
Failure to ensure two residents received consistent showers per facility schedule.
Failure to provide restorative nursing services as ordered for one resident due to staffing shortages.
Failure to provide enough nursing staff every day to meet resident needs; frequent reports of delayed call light response and missed care.
Failure to ensure medications were administered as ordered; opioid given when resident reported no pain and blood pressure medication given despite low BP without physician notification.
Failure to monitor behaviors for resident receiving psychotropic medication.
Failure to follow infection control procedures during medication administration and mealtime; nurse handled medication that fell on medication cart without gloves and reused medication cup.
Report Facts
Facility licensed beds: 208 Average census: 120 Residents assigned per CNA: 35 Residents assigned per CNA: 43 Medication administration delay: 19 Medication administration delay: 30 Medication administration delay: 120

Employees mentioned
NameTitleContext
Staff #42Certified Nursing AssistantNamed in finding related to yelling at resident during shower
Staff #6Licensed Practical NurseInterviewed about appropriate resident care and staff behavior
Staff #60Certified Nursing AssistantInterviewed about respectful resident care
Staff #3Director of Social ServicesInterviewed about discharge notification and planning
Staff #19Case Manager Lead (LPN)Interviewed about discharge planning and family caregiver training
Staff #17Director of RehabilitationInterviewed about discharge planning and caregiver training
Staff #7Director of NursingInterviewed about discharge planning, medication administration, and staffing
Staff #34Restorative Nursing AssistantInterviewed about restorative nursing services and staffing
Staff #18Licensed Practical NurseObserved and interviewed regarding medication administration and staffing
Staff #125Certified Nursing AssistantInterviewed about shower schedule and resident care
Staff #119Assistant Director of NursingInterviewed about shower schedule and resident care
Staff #140Executive DirectorInterviewed about COVID status and staffing
Staff #35Staffing CoordinatorInterviewed about staffing schedules and shortages
Staff #6Licensed Practical NurseInterviewed about pain medication administration
Staff #36Licensed Practical NurseInterviewed about psychotropic medication monitoring
Staff #31Infection PreventionistInterviewed about infection control procedures

Inspection Report

Annual Inspection
Census: 160 Deficiencies: 13 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 Facility census: 160 LPN hours worked: 5.98

Employees mentioned
NameTitleContext
Staff #154Licensed Practical NurseNamed in medication error and infection control deficiency
Staff #6Director of NursingProvided multiple interviews regarding facility policies and deficiencies
Staff #223Regional Director of Clinical ServicesParticipated in interviews regarding facility deficiencies
Staff #224AdministratorParticipated in interviews regarding facility deficiencies
Staff #66Staff CoordinatorProvided information on staffing and scheduling

Inspection Report

Routine
Census: 160 Deficiencies: 14 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 Census: 160 Licensed Practical Nurses scheduled: 5 Licensed Practical Nurses working: 1

Employees mentioned
NameTitleContext
Staff #154Licensed Practical NurseNamed in medication error findings and infection control observation
Staff #6Director of NursingInterviewed regarding multiple deficiencies including medication errors, staffing, and wound care
Staff #223Regional Director of Clinical ServicesInterviewed regarding wound care and staffing
Staff #224AdministratorInterviewed regarding staffing and medication errors
Staff #213Wound NurseInterviewed regarding wound care assessments
Staff #66Staff CoordinatorInterviewed regarding staffing schedules and coverage
Staff #40Assistant Director of NursingInterviewed regarding infection control observation
Staff #68Licensed Practical NurseInterviewed regarding psychotropic medication monitoring

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