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Deficiency Records for Glendora Canyon Transitional Care Unit
A list of the most recent deficiencies for Glendora Canyon Transitional Care Unit. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Glendora Canyon Transitional Care Unit. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-09-05 | 2024-09-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-20 | 2024-09-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-20 | 2024-09-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-20 | 2024-09-16 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-06-20 | 2024-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-04 | 2024-04-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-04 | 2024-04-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-09 | 2024-03-07 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-28 | 2023-12-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-27 | 2023-11-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-11-20 | N |
| 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. | Health | 2023-10-27 | 2023-11-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-27 | 2023-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-11-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-27 | 2023-11-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-27 | 2023-11-20 | N |
| 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. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-27 | 2023-11-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-27 | 2023-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-11-20 | N |
| 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. | Health | 2023-10-27 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-11-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-11-01 | 2023-11-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-11-01 | 2023-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-01 | 2023-11-20 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-11-01 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-10-27 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-21 | 2023-10-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-24 | 2023-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-24 | 2023-08-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-20 | 2023-08-04 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-07-12 | 2023-07-17 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-27 | 2023-05-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-27 | 2023-05-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-27 | 2023-05-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-27 | Y |
| 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. | Health | 2023-02-16 | 2023-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-03-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-25 | 2022-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-28 | 2022-09-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-02 | 2022-09-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-07-08 | Y |
| 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. | Health | 2022-05-06 | 2022-07-08 | Y |
| 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. | Health | 2022-05-06 | 2022-07-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-30 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-30 | 2022-06-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-30 | 2022-06-24 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-05-01 | 2022-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-11 | 2022-06-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-11 | 2022-06-11 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-04-12 | 2022-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-11 | 2022-05-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-04 | 2022-05-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-26 | 2022-04-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-26 | 2022-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-03-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-03-18 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-03 | 2022-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-07 | 2022-01-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-26 | 2021-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-26 | 2021-06-17 | N |
| 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. | Health | 2021-04-26 | 2021-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-26 | 2021-06-17 | N |
| 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. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-26 | 2021-06-17 | N |
| Post nurse staffing information every day. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-26 | 2021-06-17 | N |
| 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. | Health | 2021-04-26 | 2021-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-26 | 2021-06-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-26 | 2021-06-17 | N |
| 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. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-04-26 | 2021-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-26 | 2021-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-26 | 2021-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-26 | 2021-06-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-04-21 | 2021-05-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-12 | 2020-01-09 | N |
| 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. | Health | 2019-12-12 | 2020-01-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-12 | 2020-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-12 | 2020-01-09 | N |
| 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. | Health | 2019-12-12 | 2020-01-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-12 | 2020-01-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-12 | 2020-01-09 | N |
| 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. | Health | 2019-12-12 | 2020-01-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-12-12 | 2020-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-12 | 2020-01-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-12 | 2020-01-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-12-12 | 2020-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-12 | 2020-01-08 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-12-12 | 2020-01-08 | N |
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