Complete Care at Glendale West

Inspectors wroteBased on interview and record, the facility did not ensure 1(R1) of 1 resident was assessed by the interdisciplinary team to determine it was clinically appropriate to self-administer medication.*On 11/11/25 Surveyor observed a medication cup marked with R1's first name & noon with two white tablets.

Inspectors wroteBased on Interview and record review, the facility did not ensure showers were provided for 3 out of 3 residents (R1, R2, and R3) dependent on staff for Activities of Daily Living (ADLs). Findings Include: The facility policy, entitled Activities of Daily Living (ADLs), dated 12/24, stated: The facility will comma based on the residence comprehensive assessment and consistent with the residents' needs and choices comma ensure a residence abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: - Bathing, dressing, grooming, and oral care. Policy Explanation and compliance Guidelines: - A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition grooming and personal and oral hygiene. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents received assessment, treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for a change in condition.*On 8/26/25 R1 received Oxycodone 5 mg during the night shift & rated his pain level at 8. This was the first time R1 received Oxycodone during the night shift & at this pain level. There was no assessment of what was causing R1's pain and other vitals. R1's physician ordered vital signs taken every day due to hypertension. The last vital sign documented in August is on 8/13/25. Interviews with CNA's revealed on 8/25/25 & 8/26/26 R1 was not feeling good, didn't look good and on the morning of 8/26/25 interviews revealed there was no urine in R1's urinary collection bag. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R1) of 1 Residents.* Appropriate hand hygiene was not observed during incontinence cares for R1, R1's urinary collection bag was observed on the floor and Licensed Practical Nurse (LPN)-I was not wearing a gown while removing the urinary collection bag off the floor and removing R1's pants who is on EBP (enhanced barrier precautions).

Inspectors wroteBased on observation and interviews, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 4 (R65, R68, R173, and R174) of 10 Residents reviewed for dignity. *R65 was observed to be in a gown during 3 days of the survey process and prefers to be dressed. *R68 was observed to be in the hallway by the nurse's station in a gown during the survey process. *R173 was observed to be in the dining room eating lunch in a gown. *R174 was observed walking down the hallway with therapy in a gown. Findings Include: The facility's Accommodation of Needs policy implemented 2/25 documents: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 Residents (R172, R23, R13 and R65) of 18 sampled residents were fully informed of, but not limited to; resident rights, required financial information and options, and consent to treat prior to or upon admission. *R172 was admitted to the facility on [DATE] and did not sign the admission agreement within a reasonable timeframe which includes facility information regarding: consent for treatment, financial agreement, and resident rights and responsibilities. R172 was discharged from the facility on 3/28/25, and did not acknowledge receipt of the admission agreement before discharge from the facility. On 3/22/25 R172 alleged $1800 was missing from the resident. Review of whether R172 was aware of the facility options/restrictions available to safeguard R172's belongings was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 5 (R13, R23, R65, R173, R322) of 18 Residents. *R13, R23, R65, and R173's baseline care plans were not completed within the required 48-hour timeframe. The facility did not provide evidence that the baseline care plan was reviewed with the resident or the resident's representative. *R322 was admitted to the facility on [DATE]. R322's baseline care plan was signed by facility staff as being complete on 12/24/24, which is not within the required 48-hour timeframe. R322's baseline care plan was not signed by R322.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident receiving an antidepressant medication was comprehensively assessed for use. This was observed with 1 (R40) of 5 resident medication reviews. * R40 was admitted to the facility on an antidepressant medication. There is not a comprehensive assessment for use of the medication, including indicators for use and non-pharmacological interventions.

Inspectors wroteBased on record review and interview, the facility did not conduct a comprehensive assessment of depression/mood with the admission Minimum Data Set (MDS), and Significant Change in Status (SCS) MDS, for 1 (R40's) of 18 sampled residents. * R40 was admitted to the facility with orders to receive Prozac (an antidepressant) daily. R40's admission MDS dated [DATE] and SCS MDS dated [DATE] do not fully assess R40's depression/mood symptoms to lead to a Care Area Assessment (CAA) and development of a comprehensive plan of care for R40 that addresses indicators for use, individual symptoms for R40 and intervention to include nonpharmacological interventions (Cross-reference F605).

Inspectors wroteBased on interview and record review, the facility did not ensure residents are accurately screened for a mental disorder prior to admission or prior to the expiration of a 30-day exemption for 2 (R41 and R13) of 4 residents reviewed for the PASARR (Preadmission Screening and Resident Review). *R41 did not have a PASARR level 1 screen resubmitted prior to the expiration of the 30-day exemption documented on the original PASARR level 1. *R13 did not have a serious mental illness documented on the PASARR level 1 which would have triggered the PASARR level 2 to be initiated.

Inspectors wroteBased on record review and interview, the facility did not develop a comprehensive plan of care for residents on antidepressant medication. This was observed with 3 (R40, R6, & R71) of 18 residents reviewed for plans of care. * R40 and R6 were admitted to the facility on antidepressant medication and did not have a plan of care for their depression. * R71 did not have bowel or bladder care that included goals and interventions.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure residents with vision impairment received proper treatment and assistive devices including arrangements for an optometrist (eye doctor) visit for 1 (R21) of 1 resident's reviewed for vision. R21 has not been seen by an optometrist since 8/20/21 and R21's last missed vision appointment on 11/18/22 was never rescheduled to evaluate R21's advancing vision issues with an active request and signed consent to receive vision care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent an accident from occurring for 1 of 1 Resident (R65) reviewed for accidents. *R65's physician orders instructed 1:1 (one on one) supervision with all meals. Surveyor had observations during the survey process of R65 not receiving supervision with meals. Findings Include: The facility's Accidents and Supervision policy implemented 11/24 documents: .Policy: The Resident environment will remain as free of accident hazards as is possible. Each Resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication rate was below 5 percent in 1 (R422) of 3 residents observed receiving medications. The facility medication error rate was 16.67 percent. *R422 had medications that were not administered in the right dose or were omitted from the medications administered. R422 had insulin ordered and the wrong dose was drawn up in the syringe.

Inspectors wroteBased on interview and record review, the facility did not ensure the residents were free of significant medication errors for 1 (R122) of 1 resident reviewed for medication transcriptions. R122 had a hospital discharge order for Apixaban, an anticoagulant, 5 mg once in the morning and once at bedtime. The order was transcribed by the facility as Apixaban 5 mg once daily. R122 was a resident of the facility for 34 days and received the wrong dose of Apixaban on those days.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medical record for 1 (R33) of 18 residents reviewed was complete accurately documented and readily accessible. *During the survey investigation, it was determined R33 was admitted to the facility on [DATE] with multiple pressure injuries that were not comprehensively assessed until 11/25/2024, three days after admission, and treatments were not documented as being completed from 11/22/2024 to 11/25/2024. On 5/28/25, after completion of the survey, the facility submitted hand written documents that were not part of the medical record that indicated details of wound assessments alleged to be completed on 11/22/24. The hand written forms did not include who completed the documentation and were not included as part of the formal medical record until concerns were raised by the surveyor.

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (R45) of 11 residents observed. *R45 was placed in Enhanced Barrier Precautions (EBP) and facility staff did not don a gown on when assisting R45 with cares. Finding Include: The Facilities Policy titled, Enhanced Barrier Precautions revised 11/2024, documents: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug, resistant organisms. Policy explanation and compliance guidelines: . 4. High-contact resident care activities include: . G. Device care or use: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that foods were prepared in a way that prevented the risk of foodborne illness for 5 of 10 sampled residents (R2, R5, R7, R8, R10). Interview with residents foud that juices from the chicken served on 11/16/24 was red and touched all other foods on their plates. There was no investgation to determine what may have happened/how the food could have been under cooked, the number of residents who may have been affected, or to determine what steps need to be taken in order to avoid potential food borne illness.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to identify resident concerns as grievances and failed to provide a written response/resolution after receiving a grievance for 2 of 10 sampled residents (R2 and R3).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to serve food that was palatable, at the appropriate temperature, for two of seven residents (Residents (R) 12 and R13) who were asked about food palatability out of 11 sample residents. This failure had the potential to affect resident meal intakes.

Inspectors wroteBased on staff interviews and record review, the facility failed to monitor the delivery of narcotic medication for one of three residents (Resident (R)1) reviewed for medications in a total sample of nine residents. On 03/04/24, R1 no longer had any Oxycodone at the facility, needed a new prescription from the Physician, and the medication was not available until 03/08/24. This practice has the potential to affect residents' pain management.

Inspectors wroteBased on observation, staff interview, and facility documentation review the facility failed to ensure food was served at palatable temperatures for two of nine sampled residents (Resident (R) 1 and R4) on one ([NAME] unit) of four units. This failure has the potential for decreased meal intake.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable, and medications were stored in safe and secure storage (including proper temperature controls) for 1 medication room and 2 medication carts (Dover and [NAME] Medication carts) reviewed. Insulin's were were not labeled with residents' name and were not dated when opened. Expired stock medications were found in the medication room and medication cart and the refrigerator temperature, which stored medications, was below 36 degrees.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure food was stored and prepared safely, for 71 of 75 Residents who eat food prepared by the kitchen. *The low temp dish machine did not properly sanitize dishes. *Food held in the food warmer on [NAME] Hall did not have a holding temperate taken prior to service of the meal. Staff plating the food did not wear a hair restraint. *Unit refrigerators located in the activity room and [NAME] Hall did not have a temperature log and were not having temperatures taken on a regular basis. Open food was not dated in the refrigerator on [NAME] Hall.

Inspectors wroteBased on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring a resident with a possible change of condition for 1 Resident (R422) of 12 Residents reviewed for change of condition. *R422 had abnormal vital signs recorded and a blood pressure medication held related to the vital signs. The nurse on duty did not update the physician regarding R422's abnormal vital signs and there was no documented follow up regarding the change in condition.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R13) of 6 residents received adequate supervision to prevent accidents for residents at risk with swallowing guidelines. * R13 was assessed to have a pureed nectar thick diet due to swallowing concerns and was observed taking another resident's dessert. This dessert was not part of R13's approved consistency for diet and swallowing guidelines.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 4 sampled residents (R13) reviewed for falls failed to provide adequate assistance during a transfer. R13 was to be transferred with the assist of 2 staff and per a therapy recommendation, those staff were to use a gait belt and pivot transfer. On 8/12/23, staff transferred R13 with a sit to stand lift without assistance. R13 fainted and fell out of the sit to stand lift resulting in a laceration to the head requiring sutures.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food was served at a palatable temperatures for 3 of 8 residents. Residents on the Oakland Unit complained that breakfast foods were often cold which was confirmed during a test tray evaluation.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure injuries, promote healing of pressure injuries, and prevent infection of pressure injuries for 4 (R274, R57, R63, and R55) of 6 residents reviewed for pressure injuries. *R274 developed a Moisture Associated Skin Damage (MASD) area to the sacrum on 9/8/2022 and the Care Plan was not revised with interventions to prevent further damage. The MASD progressed into an Unstageable pressure injury on 10/3/2022. The Unstageable pressure injury required hospitalization on 10/6/2022 due to infection and osteomyelitis requiring intravenous antibiotics where it was determined to be a Stage 4 pressure injury. [...]

Inspectors wroteBased on observation and interview the facility did not ensure residents received services with reasonable accomodation of resident needs and preferences for 1 of 18 (R62) residents observed on survey. R62 waited an extended period of time for her call light to be answered. When staff answered R62's call light R62 requested to lay down in bed and staff declined to do so.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R5) of 1 residents received the appropriate intervention for low blood glucose. On 7/4/22, R5's medical record documents R5 was experiencing a hypoglycemic episode. The nurses note indicate R5's glucose level was 50 and R5 was very diaphoretic, unable to focus or answer and was moaning. The nurses note indicate 911 was called but other interventions to address R5's hypoglycemia were not attempted.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R28) of 6 Residents reviewed for accidents had their care plan interventions implemented. R28's call light was observed on the floor, behind the bed's head board and not in R28's reach according to R28's fall care plan.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents that were fed by enteral means or received medication through an enteral tube received appropriate treatment for 3 (R19, R63, and R66) of 4 residents reviewed with feeding tubes. *R19 received medication through the gastrostomy tube and tube placement verification was not done prior to administering the medication. *R63 and R66 had tube feeding supplies not always dated, were dated with a previous date; supplies were not changed daily as ordered.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R23) of 5 Residents reviewed. * R23's pulse was not taken two times a day prior to administering Metoprolol Tartrate Tablet 100 MG (milligrams) per physician orders.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 2 (R18 and R63) of 5 residents receiving psychotropic drugs received the appropriate for duration of an antianxiety and an antipsychotic medication had indications for use. * R18 was prescribed Seroquel (antipsychotic) without indications of use and without monitoring the specific behaviors for the medications. * R63 was prescribed Lorazepam PRN (as needed) without a duration of use for the medication.

Inspectors wroteBased on observation, interview and record review, the Facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection for 2 (R28 & R57) of 7 Residents. * CNA (Certified Nursing Assistant)-R was not wearing appropriate PPE (personal protective equipment) when changing R28's colostomy bag. R28 is on enhanced barrier precautions. R28 was observed not to have appropriate hand hygiene during cares. * CNA-R was not wearing appropriate PPE during continence cares for R57 who is on enhanced barrier precautions. R57 was observed not to have appropriate hand hygiene during cares.

Inspectors wrote2.) R32 was admitted to the facility on [DATE] with diagnoses of renal disease, dialysis dependent, and type 2 diabetes. The nurses note dated 8/8/22 indicates R32 was at the dialysis center located in the facility when R32 was complaining of chest pain. 911 was called and R32 was transported to the hospital. On 10/19/22, Surveyor asked Director of Nursing (DON) B for the written transfer notice R32 or R32's responsible party were given on 8/8/22. On 10/19/22, Surveyor was given the transfer and discharge notice form that indicates R32's responsible party was called and a message was left regarding the transfer to the hospital. There is no documentation R32 and/or R32's responsible party were given a written transfer notice. [...]

Inspectors wrote3.) R55 admitted to the facility on [DATE] and has diagnoses that include Acute Respiratory Failure with Hypoxia, Protein Calorie Malnutrition, Adult Failure to Thrive, Diabetes Mellitus Type 2, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Hypertensive Heart and Chronic Kidney Disease, Atrial Fibrillation, Dementia, Metabolic Encephalopathy and Chronic Diastolic Congestive Heart Failure. On 9/8/22, R55's medical record documents, Patient sent to [name of hospital] for low oxygenation, 73% with 5L (liters) of O2 (oxygen), BP (blood pressure) 140/80, HR (heart rate) 41-56, T (temperature) 96.7, BS (blood sugar) 127. Patient had clammy skin to touch. Also c/o (complained of) hard to breath. No chest pain. (Physician) was notified and ordered to send to the hospital for evaluation and treatment. POA (Power of Attorney) was notified. [...]