Glendale Adventist Medical Center DP/SNF

Based on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards and the facility's policy and procedures titled Food Storage for food service safety by ensuring the hospital food was properly labeled and dated with the product name, date product was opened or prepared and use by date by: An open box of Dark Chocolate Cocoa Mix with individually wrapped packets had no open date. 2. An open plastic container with lentils had no label to identify its contents or indicate the use-by date. 3. A multi-rack with metal trays that had food items without label or use-by-dated. 4. A bag of carrots with a large tear on the package had no label and use-by-date. These deficient practices placed the residents at the risk of widespread foodborne illness (infections caused by consuming contaminated food, beverages, or water containing harmful microbes, pathogens, or toxins). Findings: During an initial kitchen observation conducted with the Dietary Director (DD) on 8/13/2025 at 9:18 AM included the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 6 and 45) received appropriate treatment and services to prevent urinary tract infections (UTI a infection of the urinary tract that includes urethra, ureters, bladder and kidneys resulting when microorganism gets into the urine and travels to the urinary tract) by failing to ensure: 1. Resident 6's suction tubing that connects to Resident 6's Pure Wick System (PWS- an external female catheter use for urine collection for residents that are incontinent [no control] of bladder when urinating) was covered and placed in a plastic bag when disconnected from Resident 6 was not left on top of Resident 6's pillow and the urine collection cannister connected to the tubing was labeled or dated of the last time it was changed. 2. Resident 45's tubing that connects to Resident 45's [NAME] Fit (PF-external male catheter for urine collection for residents that are incontinent of bladder when urinating)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement facility's policy and procedure to prevent spread of infection for two of two sampled residents at risk or with infection by failing to: 1.Resident 34's nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was observed in her room without a plastic bag and a label or date of the last time it was changed. The facility's policy indicated to changed NC every 7 days. 2.Biomedical Technician (BT) did not perform hand hygiene and don (put on) PPE (Protective equipment and clothing such as gown and gloves used to prevent the spread of infectious organisms) before and after entering Resident 44's, who was placed on contact isolation (precautions taken in healthcare settings to prevent the spread of infections). These deficient practices had the potential to transmit infection (spread form one person to person or from contaminated surface or object) and result in widespread of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one sampled patient (Resident 1) received Keppra (seizure [uncontrolled shaking, loss of body movement, function, and consciousness] medication), when Resident 1 was placed on NPO (nothing by mouth) by the physician and there was no communication between staff and physician regarding Resident 1's alternatives to receiving the medication.This deficient practice may have contributed to Resident 1 having a seizure the following morning, when Resident 1 did not receive Keppra for over 12 hours.Findings:During a review of Resident 1's History and Physical (H&P), dated 6/27/2025, the record indicated Resident 1 was admitted to the facility with a history of glioblastoma (brain tumor with symptoms such as headaches, seizure, mood changes, and speech difficulty).During a review of Resident 1's Gastroenterology (physician who specializes in stomach and intestine conditions) Consultation, dated 7/21/2025, the record indicated Resident 1 had gastrointestinal (GI, stomach) bleeding. The record indicated a plan for Resident 1 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 153's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection). A review of Resident 153's Orders dated 8/14/24, Orders indicated Resident 153 was ordered a Dysphagia Diet (a diet for people who have difficulty swallowing). During a concurrent observation and interview on 8/17/24 at 8:48 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed standing while assisting Resident 153 to eat. LVN 1 stated, I'm not sure if we have to be sitting at the same level of the resident when we are helping to feed residents. If the nursing assistants are busy assisting residents with feeding and another resident that requires assistance with feeding, we help them feed the resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards and the facility ' s policy and procedure for food service safety by ensuring the hospital food were properly labeled and dated with the product name, date product was opened or prepared and use by date. The facility failed to: 1. Label and put an expiration date on a tub of cookies in the freezer. 2. [NAME] the jar of slaw with open date or use by date. 3. Label food in cart trays 4. Dispose of expired veggies in cart 5. Dispose of dirty cans of soda in the refrigerator 6. Dispose of bag of cabbage that had two expiration date labels. 7. Label and date meat package 8. Store ice machine scoop not on the ice. As a result of these deficient practices the residents had the potential to result in a widespread food-borne illnesses (an infection caused by consuming contaminated food, beverages and water than can happen during food processing, production, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services for one of eight sampled residents (Resident 149) who was at risk for developing blood clot by failing to apply sequential compression device (SCD- a device use on the legs to promote blood circulation and prevent blood clot to develop) as ordered by the physician. This deficient practice had the potential to cause a deep vein thrombosis (DVT; blood clot that forms in a deep vein, often in the legs, from lack of blood circulation and potentially cause pulmonary embolism (PE is when a blood clot breaks off from inside a vein and travels to the lungs and causes respiratory distress), heart attach (heart stop functioning) and stroke (interruption of blood flow to the brain) Findings: During a review of Resident 149's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease that results in blood sugar being too high), morbid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for one of one sampled residents (Resident 8) by failing to label Resident 8's peripheral intravenous line (IV, a thin flexible tube was inserted through the skin into a small vein in the periphery to deliver fluid and medications) to indicate the date the IV was inserted. As a result of this deficient practice had the potential for the IV not to be changed timely and could result in phlebitis (inflammation/swelling of the vein) or develop infection in the peripheral IV site that could enter the blood stream and result in severe infection. Findings: 1. A review of Resident 8's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included obesity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. A review of Resident 235's admission Record indicated the facility admitted the resident on 8/1/2023. During a review of Resident 235's H&P, dated 8/2/2023, indicated the resident was confused and bedridden (confined to bed by sickness or old age), with diagnosis that included dementia and depression. During a concurrent observation and interview on 8/5/2023 at 1:47 pm, Resident 235 was lying in bed. Resident 235's Family 1 (FAM 1) stated, Resident 235 did not want to eat and would get angry when assisted to be fed. FAM 1 stated Resident 235 would usually eat homemade soup but refused to eat now. During a concurrent record review of Resident 235's Physician Orders and interview with MDSN 1 on 8/6/2023 at 10:17 am indicated, the physician ordered Resident 235 to receive Sertraline. The physician order for Resident 235 did not specify the indication for use, and the behavior and/or side effects to be monitored for the use of Sertraline. In an interview the MDSN 1 stated, there was no documented evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of 5 sampled residents ( Residents 136, 17, 21, 5 and 85) by failing to: 1. For Resident 136, there was no posting of a Contact Isolation (precautions to prevent transmission of infectious agents, which are spread by direct contact with the patient or the patient's environment) sign outside of resident room to remind staff and visitors to wear proper PPE (Personal Protective Equipment used to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) before entering the resident's room. 2. For Resident # 17, the peripheral IV line (a thin, flexible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need by ensuring the call light was within reach as indicated on the facility's policy and procedure, titled Answering of Call Lights and resident's Care Plan for one of one sampled resident (Resident 135) who was at risk for fall. This deficient practice had the potential for the resident not to receive or received delayed care to meet the necessary care and services that could result in fall and accident. Findings: During a review of Resident 135's admission Record indicated, the facility admitted Resident 135 on 7/29/2023. During a review of Resident 135's History and Physical (H&P), dated 7/30/2023, the record indicated, Resident 135's was alert, awake and oriented with diagnoses that included hypertension (high blood pressure), Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) and congestive heart failure (CHF, heart disease that affects pumping action of the heart muscle) and left upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a resident specific plan of care to prevent development and/or worsening Stage 2 pressure ulcer (a skin injury or ulcer resulting in partial-thickness skin loss with exposed open skin due to prolonged pressure or being in one position for prolong period) in accordance with the facility's policy and procedure for one of two sampled residents (Resident 89). Resident 89's plan of care did not indicate interventions on how often the resident will be repositioned and turned while in bed, how to keep resident clean and dry. This deficient practice resulted in Resident 89 not to receive the necessary care and services to prevent the worsening of pressure ulcer that could result in pain, discomfort, and wound infection. Cross reference to F686. Findings: A review of Resident 89's admission Record, indicated the facility admitted the resident on 6/29/2023. During a review of Resident 89's of H&P assessment, dated 6/26/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services consistent with facility's policy and procedure to prevent the development or worsening of pressure ulcer/injury (a skin injury due to friction or shear and for prolonged pressure by being in one position of a long period of time) for two of four residents (Resident 86 and 89) by failing to: 1. Ensure Resident 86 who was using a Low Air Loss Mattress (LAL - mattress composed of multiple inflatable air tubes that alternately inflate and deflate designed to prevent and treat pressure ulcers) was set in a correct setting based on the manufacturer's recommendation. 2. Ensure Resident 89 who had a Stage 2 pressure ulcer (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer.) was turned and repositioned, not left in supine (lying in on the back) for a long period while in bed. This deficient practice had the potential for Resident 86 to develop pressure ulcers, and for Resident 89 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of 2 sampled residents (Resident 21) with indwelling catheter (a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure, titled Care of Indwelling Catheter and the resident's Care Plan. This deficient practice had the potential for Resident 21 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and/or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in). Findings: During a review of Resident 21's admission Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.