Glendale Post Acute Center: Care Plan Failures - CA
The resident at the center of the incident, identified in inspection records as Resident 1, verbalized the confrontation to the facility's social worker. The responsible party who approached her, identified as RP 1, was visiting Resident 2, a different patient. The nature of the exchange, a directive about phone volume, was enough to unsettle Resident 1 to the point where staff felt something needed to be done.
What they did was limited. Facility staff conducted wellness checks for three days. The social worker said staff were supposed to continue monitoring Resident 1 to make sure she felt safe. No formal plan was put in writing. Nobody documented what staff should watch for when RP 1 came back to visit Resident 2. Nobody wrote down what to do if the situation escalated.
Nobody created a care plan.
When inspectors reviewed Resident 1's records during a visit on September 22, 2025, they found exactly that gap. The Director of Nursing, reviewing the care plans alongside the inspector at 12:51 in the afternoon, confirmed there was nothing in the file addressing the incident at all.
What the Director of Nursing said next is the detail that defines the inspection finding. "This incident was different," the DON told inspectors, "and we were not sure how to handle this."
The DON also acknowledged that a care plan should have been started, and that having one in place would have ensured staff knew to watch Resident 1 specifically during visits from RP 1. That acknowledgment came from the Director of Nursing during the inspection itself, not in the days after the incident when the information might have protected the resident.
The facility's own written policy, last revised in 2002, describes what a care plan is supposed to accomplish: a comprehensive, person-centered document with measurable objectives and timetables, addressing physical, psychosocial, and functional needs. The policy specifies that when a resident experiences a significant change, a care plan is to be developed within seven days. It also states that assessments are ongoing and that care plans are revised as conditions change.
The incident involving RP 1 and Resident 1 was not a medical event. There was no fall, no medication error, no wound. It was an interpersonal confrontation between a resident and the family member of another patient, inside a facility where Resident 1 lives and has no ability to simply leave. The social worker recognized it was significant enough to warrant three days of follow-up. The DON recognized, during the inspection, that it warranted a care plan. The facility never connected those two conclusions into action.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification is, in regulatory terms, among the lower tiers of severity. But the classification describes the outcome, not the reasoning behind the failure.
The DON's own words describe a facility that encountered an unfamiliar situation and stopped. Not a situation without precedent in long-term care, where residents and the families of other residents share close quarters, where tensions can develop, where a person who cannot easily relocate or advocate loudly for herself depends on staff to formalize protections on her behalf. Just a situation the facility said it did not know how to handle.
Three days of wellness checks ended. RP 1 continued to visit Resident 2. Whether anyone was watching when those visits happened, and whether Resident 1 felt safe during them, is not recorded anywhere in her file.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendale Post Acute Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
GLENDALE POST ACUTE CENTER in GLENDALE, CA was cited for violations during a health inspection on September 22, 2025.
The resident at the center of the incident, identified in inspection records as Resident 1, verbalized the confrontation to the facility's social worker.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.