A list of the most recent deficiencies for Glendora Grand, Inc. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-09-22 | Y |
| Keep all essential equipment working safely. | Health | 2023-08-10 | 2023-08-30 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-09 | 2023-08-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-02 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-08 | 2023-07-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-09 | 2023-07-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-09 | 2023-07-11 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-06-09 | 2023-07-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-06-09 | 2023-07-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-09 | 2023-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-09 | 2023-07-11 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-06-09 | 2023-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-09 | 2023-07-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-11 | 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 | 2023-06-09 | 2023-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-09 | 2023-07-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-09 | 2023-07-11 | 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 | 2023-06-09 | 2023-07-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-09 | 2023-07-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-09 | 2023-07-11 | 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 | 2023-06-09 | 2023-07-11 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-06-09 | 2023-07-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-06-09 | 2023-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-06-09 | 2023-07-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-09 | 2023-07-11 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-04 | 2023-06-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-06-02 | Y |
| Have policies on smoking. | Health | 2023-05-04 | 2023-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-01 | 2023-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-04-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-30 | 2023-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2023-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-30 | 2022-12-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2022-12-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-30 | 2022-12-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2022-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2022-12-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-16 | 2022-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-26 | 2022-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-03 | 2022-08-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-30 | 2022-01-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-02 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-23 | 2021-03-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-23 | 2019-06-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-23 | 2019-06-26 | 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 | 2019-05-23 | 2019-06-26 | N |
| 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 | 2019-05-23 | 2019-06-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-23 | 2019-06-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-23 | 2019-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-23 | 2019-06-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-23 | 2019-06-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-23 | 2019-06-26 | 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 | 2019-05-23 | 2019-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-23 | 2019-06-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-23 | 2019-06-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-23 | 2019-06-26 | 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 | 2019-05-23 | 2019-06-26 | 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 | 2019-05-23 | 2019-06-26 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-05-23 | 2019-06-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-23 | 2019-06-26 | N |
| Keep all essential equipment working safely. | Health | 2019-05-23 | 2019-06-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-05-23 | 2019-06-26 | N |
| Have policies on smoking. | Health | 2019-05-23 | 2019-06-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-05-23 | 2019-06-25 | 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 | 2019-05-23 | 2019-06-25 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-23 | 2019-06-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-03 | 2018-08-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-07-03 | 2018-08-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-07-03 | 2018-08-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-07-03 | 2018-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-03 | 2018-08-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-07-03 | 2018-07-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-03 | 2018-07-31 | N |
| 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 | 2018-07-03 | 2018-07-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-03 | 2018-07-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-03 | 2018-07-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-03 | 2018-07-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-03 | 2018-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-03 | 2018-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-03 | 2018-07-31 | N |
| Keep all essential equipment working safely. | Health | 2018-07-03 | 2018-07-31 | N |
