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Inspection visit

Health inspection

GLENDORA HEALTH CARE CENTERCMS #36603610 citations on this visit
10 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 4. Observation on 11/14/22 at 11:43 A.M. of lunch revealed the dining room was chilly. There were three thermostats. There were two thermostats located next to the kitchen, one read 68-degrees F and the other read 70-degree F. There was another thermostat located on the opposite side of the room that read 62-degrees F. Resident #93 was wearing a short sleeve shirt with her arms crossed over her body. Interview on 11/14/22 at 11:40 A.M. with Dietary Aide #647 verified the room was cold. He stated the dining room was cold yesterday. Interview on 11/14/22 at 11:46 A.M. with Resident #2 revealed the room was cold and stated it was like this every year. Interview on 11/14/22 at 12:04 P.M. with Resident's #38 and #93 stated the dining room was cold; they stated they were not sure when it started to get cold. 5. Observation on 11/18/22 at 10:58 A.M. of the dining room revealed there was church services being held with Resident's #10, #18, #38 and #94. The thermostat on the far end of the dining room read 58-degrees F. Based on observation and interview the facility failed to properly maintain comfortable temperatures throughout the facility. This affected eleven residents (Residents #16, #19, #20, #23, #26, #31, #34, #37, #40, #95 and #96) residing on the memory care as well as ten (Residents #2, #10, #18, #21, #32, #35, #38, #93 #94, and #193) outside of the memory care unit. The facility census was 39. Findings include: 1. Observation of the memory care unit on 11/14/22 beginning at 9:11 A.M. revealed Residents #16 and #19's room was cold. State Tested Nursing Assistant (STNA) #654 confirmed the room was cold and stated the unit had been cold for a few days when she was present. Observation of thermostat outside of the resident's room revealed a reading of 65 degrees Fahrenheit (F). Residents #16 and #19 were not interviewable. Further interview with STNA #654 revealed the shower room was also cold and she was running the hot water in an attempt to heat it up prior to giving Resident #96 a shower. Observation at time of interview revealed the shower room was cold and there was hot water running. Eleven Residents #16, #19, #20, #23, #26, #31, #34, #37, #40, #95 and #96 resided on the memory care unit. Interview on 11/14/22 at 10:04 A.M. with STNA #654 stated Maintenance Employee #620 came through with a temperature gun a little while ago and took a temperature reading in front of one of the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 16 Event ID: 366036 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some heating units and it registered 70 degrees F. STNA #654 stated she asked him to go into Residents #16 and #19's room to obtain a temperature, and Maintenance Employee #620 stated, I will later; I'm busy right now. 2. Observation on 11/14/22 of temperature readings performed via a temperature gun with Maintenance #620 beginning at 12:07 P.M. revealed Residents #16 and #19's room was 66 degrees F, the shower room was 60 degrees F, Resident #40's room was 63 degrees F, Residents #37, and #31's room was 65 degrees F, Resident #34's room was 67 degrees F, Resident #26's room was 65 degrees F, Resident #23's room was 67 degrees F, Resident #95's room was 68 degrees F, Resident #96's room was 67 degrees F, Resident #39's room was 67 degrees F, and the hallway on the memory care unit was 67 degrees F. Interview on 11/14/22 at 1:03 P.M. with Administrator revealed they were aware of the facilities boiler system not functioning properly and stated they were working to have a temporary unit brought in until the repairs could be completed on the boiler system. 3. Observation on 11/15/22 at 1:56 P.M. revealed during a resident council meeting, Activities Director #642 brought Resident #193 into the common dining area, and the resident stated he was cold. Activities Director #642 then gave Resident #193 his jacket. During the resident council meeting numerous residents (Resident's #2, #10, #21, #32, #35, #38, #93 and #193) expressed to Activities Director #642 they were also cold. Observation of the thermostat in the dining area revealed a temperature reading of 62 degrees F which was verified with Activities Director #642. Interview on 11/15/22 at 3:18 P.M. with Maintenance #620 revealed the facilities boiler system had malfunctioned in May 2022. Maintenance #620 stated the facility had obtained an estimate to repair the unit on 06/03/22 and stated due to the equipment not being available until November 2022, the repairs were unable to be performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident assessments were accurate. This affected one resident (Resident #144) of 16 residents (Resident #1, Resident #4, Resident #6, Resident #11, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96 and Resident #97) reviewed for accuracy of assessments. The facility census was 39. Residents Affected - Few Findings include: Medical Record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, Type II diabetes, depression, and chronic respiratory failure. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had impaired cognition and required extensive assistance for mobility and total assistance with transfers. Resident #144 had no falls in the past 90 days. Review of the nurses note dated 10/26/22 at 3:10 P.M. revealed Resident #144 was admitted to the facility from the hospital for a post-surgical left great toe amputation. The resident had an order for non-weight bearing status to the left foot. Review of the fall assessment tool dated 10/26/22 revealed there was no change in mobility. The assessment scored a three, indicating a low risk for falls. Review of the fall risk assessment dated [DATE] revealed Resident #144 ambulates with problems and with devices. The assessment scored 18 indicating a high risk for falls. Interview with the Director of Nursing (DON) on 11/17/21 at 2:30 P.M. stated she was not sure why the two assessments were different. The DON verified the fall assessment tool dated 10/26/22 was inaccurate. Resident #144 was admitted from the hospital for an amputation of left toe and was non weight bearing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident care plans were comprehensive. This affected two residents (Resident #6, and Resident#11) of 16 residents (Resident #1, Resident #4, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96, and Resident #97) whose care plans were reviewed. The facility census was 39. Findings Include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive assistance of two staff for most activities of daily living including, bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #6's physician orders revealed on 10/27/22 the physician ordered for the staff to encourage the resident to wear a right arm splint up to eight hours a day. Review of the plan of care dated 01/21/22 revealed Resident #6 had an activities of daily living self-care performance deficit related to activity intolerance related to hemiplegia, limited mobility, limited range of motion, and a stroke. Interventions included: check nail length and trim and clean on bath day and as necessary; extensive assistance by staff with bathing/showering; extensive assistance of one to two staff for repositioning; allow the resident sufficient time for dressing and undressing; encourage the resident to fully participate if possible; praise all efforts of self-care and physical/occupational therapy as ordered by the physician. However, there was no intervention for the resident to wear the splint on her right arm. Further review of Resident #6's other care plans also did not include the use of the arm splint. Interview with the Director of Nursing on 11/17/22 at 12:30 P.M. verified the Resident #6's plan of care failed to include the residents right arm splint. 2. Review of the medical record revealed Resident #11 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, enterocolitis due to clostridium difficile, bipolar disorder, fibromyalgia, anxiety disorder, metabolic encephalopathy, and history of urinary tract infections. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. Functionally, Resident #11 required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the accident/incident report revealed Resident #11 had three falls in the past year, 04/03/22, 06/11/22 and 10/14/22. Further review of the fall investigations revealed all three falls occurred in the resident's room by her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the fall plan of care dated 09/08/20 revealed Resident #11 had potential for falls related to impaired balance, muscle weakness, mental illness, and use of certain medications. Interventions included: educate the resident to ask for assistance; assist as needed; bed in lowest position; call light within reach; and Hoyer (mechanical) lift for all transfers. Further review of Resident #11's falls revealed the falls occurred in the resident's room. There were no personalized interventions in place regarding protection of the resident from the falls that occurred in the resident's room. Interview with the Director of Nursing on 11/17/22 at 12:30 P.M. verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure antibiotic treatment was administered in a timely manner and failed to ensure a physician's order was updated and canceled timely when it no longer pertained to the resident. This affected one resident (Resident #40) of three reviewed for antibiotic treatment and one resident, (Resident #11) of 19 residents reviewed for accuracy of physician orders. The facility census was 39. Residents Affected - Few Findings include: 1. Review of Resident #40's medical records revealed an admission date of 08/19/22 with diagnoses including dementia and schizophrenia. Review of laboratory results dated [DATE] revealed Resident #40 had a urine specimen collected on 09/25/22 and the results were reported on 09/28/22. Further review revealed the results were faxed to the physician on 09/30/22 at 2:29 P.M. Urine results were reported Resident #40 was positive for a Escherichia coli (E-coli) (bacterial infection). Review of the progress note dated 09/30/22 at 2:41 P.M. authored by Licensed Practical Nurse (LPN) #628 revealed the physician was notified of Resident #40's lab results. The progress note did not include any orders that were received. Review of the progress note dated 10/03/22 at 5:19 P.M. authored by LPN #649 revealed orders were received to administer Keflex (antibiotic) 500 milligrams (mg) twice a day for seven days. Review of the physician orders dated 10/03/22 revealed Resident #40 was ordered Keflex 500 mg twice a day. Review of Medication Administration Record (MAR) revealed Resident #40 received Keflex beginning on 10/04/22 and ending on 10/10/22. Interview on 11/16/22 at 1:39 P.M. with Registered Nurse (RN) #611 confirmed the residents lab results were reported on 09/28/22 and were not faxed over to the physician until 09/30/22. RN #611 was unable to provide an explanation of the timing between the results and physician notification. RN #611 was also unable to provide an explanation regarding the antibiotic first dose being administered on 10/04/22. RN #611 stated the results should have been reported on 09/28/22 and the antibiotics should have been given after the lab results were reported. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes, depression, hemiplegia, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment. Resident #11 was totally dependent on two staff for toileting and personal hygiene and required extensive assistance of two staff for bed mobility, dressing, and eating. Review of a physician order dated 03/22/22 revealed an order for an ankle foot orthosis (AFO) the right lower extremity for Resident #11. The order did not include when the AFO was to be applied and how long the splint was to be worn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the months of April, May, June, July, August, September, October, and November of 2022 revealed no order for an AFO to the right lower extremity. Initial interview with Therapy Director #656 on 11/15/22 at 12:35 P.M. revealed the AFO for Resident #11's right extremity was ordered before she became the therapy director. When asked about the resident not wearing the AFO, she stated she knew that it was ordered but she was not sure where the leg splint was. Further interview with Therapy Director #656 and the Director of Nursing (DON) on 11/17/22 at 1:30 P.M. revealed the order was still on the resident's order sheet. They both verified the original order from 03/22/22 was not clarified and or updated since 03/22/22. They both stated they would discontinue the order today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall risk assessments were accurate, failed to ensure fall investigations were complete and thorough, and failed to ensure fall mats were in place. This affected three residents (Resident #6, Resident #19, and Resident #144) of four resident's reviewed for accidents. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the fall risk scores dated 04/03/22 and 08/14/22 state Resident #6 had no falls; however, the resident had falls on 04/03/22 and 06/11/22. Review of Resident #6's fall investigation for the fall on 04/03/22 revealed the investigation failed to include information on what interventions were already in place at the time of the fall including if the call bell was within reach; if Resident #6 had on non-skid footwear; was the resident's bed in low position; was the bed was locked. The investigation also failed to state if first aide was provided. Review of Resident #6's fall investigation for the fall on 06/11/22 revealed the investigation failed to include information on what interventions were already in place at the time of the fall including if the call bell was within reach; if Resident #6 had on non-skid footwear; was the resident's bed in low position; was the bed was locked. The investigation also failed to state if first aide was provided. Review of Resident #6's third fall investigation for the fall on 10/14/22 revealed investigation failed to include information on what interventions were already in place at the time of the fall including if the call bell was within reach; if Resident #6 had on non-skid footwear; was the resident's bed in low position; was the bed was locked. The investigation also failed to state if first aide was provided. Interview with the Director of Nursing (DON) and the Administrator on 11/17/22 at 2:15 P.M. verified the above findings. 2. Medical Record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, type II diabetes, depression, and chronic respiratory failure. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #144 had impaired cognition and required extensive assistance for mobility and total assistance with transfers. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 #144 had no falls in the past 90 days. Level of Harm - Minimal harm or potential for actual harm Review of the Baseline Care Plan dated 10/26/22 revealed Resident #144 had safety care related to falls and ambulation. Interventions included one staff to assist for transfers, staff to provide a wheelchair for mobility. The resident was non-weight bearing on the left foot. Residents Affected - Few Review of the fall investigation dated 11/02/22 revealed the State Tested Nursing Assistant (STNA) alerted the nurse that Resident #144 had fallen and was yelling out. The resident was found face down on the floor next to the empty bed in her room. The investigation contained no witness statement from the STNA who found the resident on the floor or the nurse on duty. Pertinent information missing included the last time the resident was checked, if the resident was incontinent, if the call light was activated, and extent of the injury. There was no evidence of the hospital discharge summary stating services provided while in the emergency room. Interview on 11/17/22 at 2:30 P.M. verified there were no witness statements taken from staff. The DON stated Resident #144 was sent back to the facility with a basic head injury sheet. There was no information on services provided or tests taken while in the emergency room. The DON stated the emergency room was contacted several times, and the summary was never faxed to the facility. The DON stated the Corporate Regional Nurse called the emergency room and received a verbal that all tests were negative. However, there was no documented evidence of tests performed and/or their results or any new orders. 3. Review of Resident #19's medical records revealed an admission date of 10/25/29 with diagnoses including dementia, cognitive deficits, and difficulty walking. Review of the care plan dated 07/18/22 revealed Resident #19 had a potential for falls related to dementia and poor safety awareness. Interventions included monitor out of bed activity. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition and required the use of a walker with ambulation. Resident #19 was unsteady. Review of the physician order dated 11/07/22 revealed Resident #19 was to have a fall mat to the exit side of bed. Review of the fall risk assessment dated [DATE] revealed Resident #19 had no falls within the last 90 days. Review of the fall risk assessment dated [DATE] revealed Resident #19 had one to two falls within the last 90 days. Review of the fall risk assessment dated [DATE] revealed Resident #19 had no falls within the last 90 days. Review of the fall risk assessment dated [DATE] revealed Resident #19 had no falls within the last 90 days. Review of the fall risk assessment dated [DATE] revealed Resident #19 had three or more falls within the last 90 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 08/20/22 revealed staff alerted the nurse Resident #19 had fallen out of bed and was observed on the floor on his right side. Resident #19 was unable to provide an explanation of the fall. Review of the progress note dated 09/09/22 revealed the nurse was notified Resident #19 rolled out of bed and was observed on the floor near his bedside. Review of the progress note dated 11/04/22 revealed Resident #19 was observed on the floor. Resident was assessed with no injuries noted, and the intervention was to place a fall mat beside the resident's bed. Observation on 11/14/22 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #654 confirmed Resident #19 did not have a fall mat on the floor beside his bed. STNA #654 was unable to state if the resident was to have a fall mat in place. Resident #19 was not interviewable. Observation on 11/15/22 at 8:08 A.M. revealed Resident #19 did not have a fall mat in place. Interview with STNA #625 at time of observation confirmed there was no fall mat in place. Observation on 11/16/22 at 7:54 A.M. revealed Resident #19 did not have a fall mat in place. Interview with STNA #625 at time of observation confirmed there was no fall mat in place. Interview on 11/16/22 at 11:03 A.M. with the DON revealed she was not aware of the documentation indicating Resident #19 had no falls on some of his fall assessments (listed above). The DON further denied being aware the resident did not have a fall mat in place. Observation on 11/16/22 at 11:32 A.M. revealed Resident #19 had a fall mat to the floor. STNA #625 stated she was not aware who or when the mat had been placed in the room, due to it was not there on observation made at 7:54 A.M. Review of the progress note dated 11/15/22 at 2:24 A.M. with Registered Nurse (RN) #611 on 11/16/22 at 1:39 P.M. revealed Licensed Practical Nurse (LPN) #655 had documented the fall mat was not available. RN #611 stated she was unable to state why LPN #655 had written that statement and stated LPN #655 was unable to contacted due she worked for agency. Review of the Treatment Administration Record (TAR) with RN #611 further revealed LPN #655 had documented the residents fall mats not being available on 11/07/22, 11/08/22 and 11/09/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure State Tested Nursing Assistant (STNA) #657 was adequately trained to apply a resident's splint. This affected one resident (Resident #11) of three residents who were ordered a splint. The facility census was 39. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes, depression, hemiplegia, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment. She was totally dependent on two staff members for toileting and personal hygiene. For bed mobility, dressing, and eating Resident #11 required extensive assistance of two staff. Observation on 11/15/22 at 7:30 A.M. revealed STNA #657 got Resident #11 changed and dressed for the day. When STNA #657 was asked about her arm splint, STNA #657 stated she did not know if Resident #11 wore an arm splint. This surveyor showed the STNA the arm splint on the resident's dresser. The STNA then stated she would put the arm splint on. She positioned the splint on the resident's lap and then elevated the resident's arm and placed the arm splint on the resident's arm and wrapped the bands around the middle arm and wrist to hold the splint in place. On the top of the splint were four circular bands which were for the resident to slide her fingers through. The STNA stopped repositioning the splint and looked at lists posted on the resident's closet door. She stated she didn't see the instructions on the door. She then went back to the resident and attempted to place the resident's index finger through the band. She stopped and stated she did not know how to apply the splint and was not sure if she applied it correctly. The STNA stated she needed someone to help her. Physical Therapy Director #656 came into the resident's room and instructed the STNA on how to apply the splint. Interview with Physical Therapy Director #656 on 11/16/22 at 9:10 A.M. revealed she did not know the aide was not instructed on how to apply the splint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the rationale for why a gradual dose reduction was not approved was documented in the physician's notes. This affected one resident (Resident #6) of five residents (Resident #1, Resident #34, Resident #40, and Resident #144) reviewed for unnecessary medications. The facility census was 39. Findings include: Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of this resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. She required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the physician orders revealed on 08/15/21 Resident #6 was ordered trazodone 50 milligrams (mg) (antidepressant and sedative) at bedtime for insomnia. This order was still in effect today. Review of the pharmacy recommendation dated 05/11/22 for Resident #6 revealed the pharmacy recommended a gradual dose reduction of trazodone. This gradual dose reduction letter further stated if not recommended, please be sure documentation as to the rationale of why a gradual dose reduction was not recommended is present in the resident's chart. Review of the nursing progress notes, physician orders, and physician notes revealed no documentation in Resident #6's record stating why the gradual dose reduction of trazadone was not recommended. Interview with the Director of Nursing (DON) and the Administrator on 11/17/22 at 2:15 P.M. verified there was no documentation in Resident #6's medical record stating the rationale to why a gradual dose reduction was not recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure psychotropic medications were only ordered with an appropriate diagnosis. This effected one (Resident #144) of five residents reviewed for psychotropic medications. The facility census was 39. Finding include: Medical record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, type II diabetes, depression, chronic respiratory failure, heart failure, and anemia. There was no diagnoses for anxiety or insomnia. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had intact cognition and behaviors. The resident rejected evaluations and had wandering behaviors that had gotten worse. Review of the physician orders for November 2022 revealed orders for scheduled lorazepam one milligram (mg) for anxiety at bedtime. Trazodone 100 mg was scheduled at bedtime for insomnia. Interview on 11/17/22 at 2:30 P.M. with the Director of Nursing (DON) verified there was no documented evidence the physician had diagnosed Resident #144 with anxiety or insomnia for the lorazepam and trazodone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure resident records were accurate. This affected four residents (Resident #6, Resident #11, Resident #39, and Resident #144) of 20 residents whose medical records were reviewed for accuracy. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Functionally, she required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the fall risk assessment dated [DATE] stated Resident #6's last fall occurred on 04/03/33. This was inaccurate as the resident had a fall on 06/11/22. Interview with the Director of Nursing (DON) on 11/16/22 1:30 P.M. verified the above finding. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes, depression, hemiplegia, and dysphagia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and was totally dependent on two staff for toileting and personal hygiene. Resident #11 required extensive assistance of two staff for bed mobility and dressing. Review of the physician order revealed an order dated 03/22/22 for an ankle foot orthosis (AFO) to right lower extremity. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the months of April, May, June, July, August, September, October, and November of 2022 revealed no order for the AFO to the right lower extremity. Interview with Therapy Director #656 on 11/15/22 at 12:35 P.M. revealed the AFO for the resident's right extremity was ordered before she became the director. When asked about the resident not wearing the AFO, she stated she knew that it was ordered but was not sure where the AFO was. Further interview with the Therapy Director #656 and the DON on 11/17/22 at 1:30 P.M. revealed the order was still on the resident's order sheet. They both verified the original order from 03/22/22 was not clarified and/or updated since 03/22/22. They both stated they will discontinue the order today. 3. Review of the medical record for Resident #39 revealed an admission date of 07/19/22 with diagnoses including encephalopathy, supra ventricular tachycardia (SVT), type II diabetes, and major depressive disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #39 was cognitively intact. Functionally, Resident #39 required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. Resident #39 did not have any pressure ulcers or skin issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of this resident's skin assessment dated [DATE] revealed the resident was at risk for the development for a pressure ulcer. Review of the skin observation dated 10/21/22 revealed Resident #39 had a pressure ulcer to the sacrum measuring 6.0 centimeters (cm) by 5.0 cm and was classified as a suspected deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear). Review of the skin observation dated 10/23/22 revealed Resident #39 now had a mild right lower back pink raised area measuring 10.0 cm by 7.5 cm and moisture associated skin dermatitis on the sacral area. Interview with Wound Nurse (WN) #611 on 11/16/22 at 12:10 P.M. revealed Resident #39 never had a pressure ulcer. She then looked at the skin observation tool from 10/21/22 and stated it was inaccurate. Observation of peri care on 11/16/22 at 12:40 P.M. with Licensed Practical Nurse (LPN) #657 revealed Resident #39 had no redness, tenderness, or breaks in the skin. 4. Medical Record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, type II diabetes, depression, and chronic respiratory failure. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #144 had impaired cognition and required extensive assistance for mobility and total dependence with transfers. Review of the physicians' orders for November 2022 revealed an order for Vancomycin (antibiotic) given intravenous (IV) with a start date of 11/01/22 for 11 days at bedtime. There was an order to change the IV tubing and the cap with each use for infection control. Review of the MAR for November 2022 revealed the IV vancomycin was signed off daily from 11/01/22 through 11/11/22. Review of the TAR for November 2022 revealed the daily changing of the IV tubing and cap was signed of from 11/01/22 through 11/15/22. There was no IV antibiotic administered from 11/12/22 through 11/15/22. Interview with the DON on 11/17/21 at 2:30 P.M. verified the findings and stated she did not know why the IV tubing and cap change were signed off when the Vancomycin was completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure proper hand hygiene was maintained during a wound dressing change. This affected one resident (Resident #144) of two residents reviewed for wound care. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record revealed Resident #144 was admitted to the facility on [DATE] with diagnoses included osteomyelitis, type II diabetes, chronic respiratory failure, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 was cognitively intact. The resident rejected evaluations and had wandering behaviors that had gotten worse. Review of the plan of care dated 11/16/22 revealed Resident #144 had potential for skin impairment related to osteomyelitis, diabetes, and incontinence of bowel and bladder. Interventions included: educate the resident on causative factors and measures to promote and maintain skin integrity; observe the resident's skin and keep clean and dry; observe, ,document and report location, size and treatment of skin injury and report any changes; and obtain lab work as ordered by the physician. Review of Resident #144's physician orders revealed an order dated 11/09/22 to apply Betadine (antiseptic) to bilateral heels, allow to air dry, apply silver alginate to open areas only, apply thick pad and secure with Kerlix gauze until healed. The physician also ordered cleanse the left great toe surgical wound with normal saline, pat it dry, apply silver alginate, dry dressing, and secure with Kerlix gauze until healed. Observation of the dressing change on 11/17/22 at 7:15 A.M. with Wound Nurse #611 and State Tested Nursing Assistant (STNA) #652 revealed these dressings were changed according to the physician's order. During the dressing change it was observed that when the Wound Nurse #611 finished applying a clean dressing to the right heel ulcer she removed her gloves and then she put on clean pair of gloves and proceeded to remove the old dressing on the left foot and left heel. She again proceeded to remove her dirty gloves and put on clean gloves and proceeded to cleanse the wounds. After cleaning the wound, Wound Nurse #611 again removed her gloves and put on a clean pair of gloves and finished completing the dressing change. She did not wash her hands once during the changing of her gloves. Interview with Wound Nurse #611 on 11/17/22 at 8:00 A.M. verified she did not wash her hands in between changing her gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366036 If continuation sheet Page 16 of 16

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Citations

10 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

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

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

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

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

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

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0726GeneralS&S Dpotential for harm

    F726 - Nursing Services

    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.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

FAQ · About this visit

Common questions about this visit

What happened during the November 21, 2022 survey of GLENDORA HEALTH CARE CENTER?

This was a inspection survey of GLENDORA HEALTH CARE CENTER on November 21, 2022. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GLENDORA HEALTH CARE CENTER on November 21, 2022?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.