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🔎 Glendora Grand Inc

Inspection Results


Inspection Overview

Glendora Grand Inc has been cited for a total of 161 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2025-05-15
Correction Date: 2025-05-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-04-10
Correction Date: 2025-04-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-04-10
Correction Date: 2025-04-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2025-04-10
Correction Date: 2025-04-30
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2025-02-26
Correction Date: 2025-03-14
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-02-26
Correction Date: 2025-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-02-26
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate foot care.

Survey Date: 2025-02-26
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-02-26
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-08-16
Correction Date: 2024-08-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-08-02
Correction Date: 2024-08-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-08-02
Correction Date: 2024-08-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-08-02
Correction Date: 2024-08-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-08-02
Correction Date: 2024-08-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-08-02
Correction Date: 2024-08-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-08-02
Correction Date: 2024-08-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-08-02
Correction Date: 2024-08-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2024-08-02
Correction Date: 2024-08-23
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2024-08-02
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-08-02
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Dispose of garbage and refuse properly.

Survey Date: 2024-08-02
Correction Date: 2024-08-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2024-08-02
Correction Date: 2024-08-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Survey Date: 2024-08-02
Correction Date: 2024-08-02
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Survey Date: 2024-08-02
Correction Date: 2024-08-26
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2024-08-02
Correction Date: 2024-08-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2024-08-02
Correction Date: 2024-08-23
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-08-02
Correction Date: 2024-08-09
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-06-25
Correction Date: 2024-07-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-04-26
Correction Date: 2024-05-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2024-04-26
Correction Date: 2024-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-04-26
Correction Date: 2024-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2024-04-26
Correction Date: 2024-05-20
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-04-26
Correction Date: 2024-05-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2024-04-26
Correction Date: 2024-07-01
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-03-21
Correction Date: 2024-03-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-09-20
Correction Date: 2023-09-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Keep all essential equipment working safely.

Survey Date: 2023-08-10
Correction Date: 2023-08-30
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-08-01
Correction Date: 2023-08-02
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

The resident has the right to receive notices in a format and a language he or she understands.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2023-06-09
Correction Date: 2023-08-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide routine and 24-hour emergency dental care for each resident.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2023-06-09
Correction Date: 2023-07-11
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-06-01
Correction Date: 2023-06-01
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-05-04
Correction Date: 2023-06-02
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-04
Correction Date: 2023-06-02
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Have policies on smoking.

Survey Date: 2023-05-04
Correction Date: 2023-06-02
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-04-05
Correction Date: 2023-04-14
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2023-03-30
Correction Date: 2023-04-05
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-12-14
Correction Date: 2023-01-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-11-30
Correction Date: 2022-12-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-11-30
Correction Date: 2022-12-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-11-30
Correction Date: 2022-12-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-11-30
Correction Date: 2022-12-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-11-30
Correction Date: 2022-12-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2022-10-16
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-08-03
Correction Date: 2022-08-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-07-26
Correction Date: 2022-08-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-11-30
Correction Date: 2022-01-26
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-08-02
Correction Date: 2021-10-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-03-23
Correction Date: 2021-03-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-01-29
Correction Date: 2021-02-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-12-17
Correction Date: 2020-12-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-27
Correction Date: 2020-09-03
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-07-16
Correction Date: 2020-09-15
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Observe each nurse aide's job performance and give regular training.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide routine and 24-hour emergency dental care for each resident.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Have policies on smoking.

Survey Date: 2019-05-23
Correction Date: 2019-06-26
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2018-07-03
Correction Date: 2018-07-31
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Allow residents to easily view the results of the nursing home's most recent inspection.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Let residents talk to and get information from agencies acting on their behalf.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Conduct initial and periodic assessments of each resident's functional capacity.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide necessary care and services to maintain or improve the highest well being of each resident .

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: B

Post nurse staffing information/data on a daily basis.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Store, cook, and serve food in a safe and clean way.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Quickly tell the resident's doctor the results of laboratory tests.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2017-07-11
Correction Date: 2017-08-01
Category: Administration Deficiencies
From Complaint: N


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