Glendale Healthcare Center
GLENDALE HEALTHCARE CENTER in GLENDALE, CA — inspection on February 20, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on Resident 1's weight of 161 pounds (lbs- a unit of weight), the LAL setting should have been at level 3.
During the survey observation, Resident 1's LAL setting was found to be set at level 4.
This failure had the potential to cause further worsening of Resident 1's pressure injuries. A misconfigured mattresses that is not aligned with the resident's weight may also compromise the resident's stability while in bed, increasing the risk of accidents or injury.
During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including a Stage 3 pressure injury (Full-thickness loss of skin.
Dead and black tissue may be visible) of the right lower back and unstageable pressure injuries (a wound covered by slough [dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds] or eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off] that makes the depth impossible to determine) on his left heel and sacrum.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1 had severely impaired cognition (significant difficulty with memory and orientation) and required maximal assistance (helper does more than half the effort) for turning left and right, and dependent on staff (helper does all of the effort) for most cares such as toileting and bathing.
The MDS also indicated Resident 1 was at risk of developing pressure injuries.
During a review of Resident 1's untitled Care Plan (CP) initiated on 12/14/2025 and revised on 2/19/2026, the CP indicated Resident 1 was at risk of pressure injury development related to fragile skin, immobility, aging process, and disease process.
The CP indicated interventions to use a low air loss mattress for wound management: Setting 3 (135 lbs - 170 lbs).
During a review of Resident 1's Current Weights and Vitals dated 2/20/2026, the document indicated Resident 1's weight on 2/1/2026 was 161 lbs.
During a review of the facility's undated low air loss manufacturer's guidelines titled, DermaFloat LAL (Low Air Loss) Model: Comfort Adjust Setting, the guidelines indicated to: Select the highest or most firm Comfort Adjust setting.
For residents 135 lbs to 170 lbs, set to 3.
Document comfort setting on pump label provided and re-evaluate comfort setting as needed. If a resident requests a comfort setting that falls outside the parameters provided, then provide education and document setting and rationale in plan of care.
During an observation on 2/18/2026 at 10:48 AM, Resident 1's low air loss mattress was observed. A label to the top right corner of the LAL machine indicated, Setting: 3.
The Comfort Adjust settings indicated numbers 1, 2, 3', 4, and 5.
The number 4 on the Comfort Adjust setting of the machine was lit up with a blue light.
During an interview with the Director of nursing (DON) on 2/19/2026 at 10:38 AM, the DON stated the label at the top of the LAL machine indicated what setting the LAL should be set to.
The DON further explained that Resident 1's LAL setting was set to 4 but should have been set to 3 per the resident's weight and the LAL manufacturer's guidelines.
The DON stated that not setting the LAL appropriately can cause more harm than good and can cause further skin breakdown for the resident.
The DON stated she usually checked the residents' LAL settings to ensure they were appropriate, however she did not do that today.
During a review of the facility's Policy and Procedure (P&P) titled Support Surface Guidelines, revised 2/2024, the P&P indicated: Redistributing support surfaces were to promote comfort for all bed- or chairbound residents, promote circulation, and provide pressure relief reduction.
Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface such as. air-loss. when lying in bed.
555609 02/20/2026
Glendale Healthcare Center 1208 S.
Central Ave Glendale, CA 91204
increases the risk of vomiting and aspiration pneumonia, which could negatively affect the residents'
during tube feeding and at least 1 hour after feeding.
555609 02/20/2026
Glendale Healthcare Center 1208 S.
Central Ave Glendale, CA 91204
for nursing staff were established and monitored by nursing leadership with input from the medical
555609 02/20/2026
Glendale Healthcare Center 1208 S.
Central Ave Glendale, CA 91204
During a concurrent interview with Dietary Services Supervisor (DSS) she stated that water temperature varies during usage and should be 120 F at the beginning of dishwashing.
During a concurrent record review, a poster issued by the manufacturer of the dishwashing machine placed on the wall facing where DA1 was working indicated It is recommended that 140 F water be used.
Report to your supervisor if it is lower than 120 F or higher than 160 F.
During a concurrent observation and interview on 2/18/2026 at 11:22 AM with the Maintenance Supervisor (MS) stated that there is second thermometer installed in the hot water inlet pipe behind the dishwashing machine which indicates the temperature of incoming water which should be at minimum 140 F. He states that the water heater is located on the second floor and is far enough to cause variations in heat when initiating the machine. MS states that incoming maintenance requests are made verbally and that he has not received any requests regarding low temperatures during the use of the dishwashing machine.
During an observation on 2/18/2026 at 11:45 AM the hot water inlet thermometer (instruments used to monitor water temperature) as it enters a system has been marked with a thick black line at 140 F to indicate the appropriate temperature prior to filling the water reservoir in the dishwasher.
During a concurrent interview, DSS reports that Diet Aides are supposed to drain and fill the machine once the inlet thermometer meets 140 F mark at minimum.
During an observation on 2/19/2026 at 8:30 AM, Dietary Aide 2 (DA2) was operating the dishwashing machine while the sink reservoir thermometer showed a temperature of 98 F. DA2 notified the Dietary Services Supervisor (DSS), who performed a drain-and-fill, resulting in a temperature increase to 105 F.
During a concurrent interview, the DSS stated the temperature should be at least 120 F to properly wash dishware and reduce the risk of crossˆcontamination.
Maintenance Staff (MS) was alerted and performed another drainˆandˆfill, draining the reservoir longer until the inlet thermometer reached 140 F and the reservoir reached 133 F. DSS stated staff had been educated on this procedure; however, she was unable to provide any inˆservice records at the time of request.
During a document review of the facility's Policies and Procedures titled Sanitation dated 11/2022 it states that dishwashing machines are operated according to manufacturer's instructions and indicates a wash temperature of 120 F.
During a document review of the manufacturer's Parts Manual dated 9/2016 it states that failure to provide adequate water temperature to the machine will cause the machine to function improperly.
During a document review of the manufacturer's Service Manual the operating procedures indicate that if water temperature gauge has not reached 120 F, drain water from the machine and continue to fill until proper temperature is attained.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555609 02/20/2026
Glendale Healthcare Center 1208 S.
Central Ave Glendale, CA 91204
During review of Resident 7's admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted with diagnoses that included pressure ulcer (skin injury due to prolonged unrelieved pressure) of sacral region , anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and end stage renal disease (person's kidneys cease functioning on a permanent basis).
During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 11/19/2025, Resident 7 cognitive skills (ability to make decisions) was moderately impaired.
The MDS indicated Resident 7 required set-up or clean-up assistance (helper sets up and clean up) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and personal hygiene.
During a review of Resident 7's order summary report, dated 11/16/2025 indicated, Resident to be placed on Enhanced Barrier Precautions due to Sacro coccyx wound.
During a review of Resident 7's care plan (CP) Resident requires Enhanced Barrier Precautions related to unhealed wound, dated 11/24/2025, intervention includes use of gown during high contact care activities such as brief changes.
During an observation on 2/18/2025 at 12:02 PM by Resident 7's doorway, was an EBP signage indicating to use gown when performing brief changes to the Resident.
During a concurrent observation and interview on 2/18/2025 at 12:05 PM with Certified Nurse Assistant (CNA) 1, in Resident 7's room (Resident 7 agreed to be observed during brief changing), observed CNA 1 touched and positioned Resident 7 to the side and changed the incontinent brief without wearing an isolation gown. CNA 1 stated, she forgot to wear a gown during her care, though she knows Resident 7 was on EBP isolation. CNA 1 stated, it is important to wear a gown when changing Resident 7's brief to prevent infection in the facility.
During an interview on 2/19/2026 at 11:58 AM with the Director of Nurses (DON), DON stated, she was aware CNA 1 touched and changed Resident 7 briefs without wearing an isolation gown. DON stated, Resident 7 was on EBP isolation because of her unhealed Sacro coccyx wound, so wearing a gown is important during close contact care such as changing briefs to protect Resident 7 and other residents in the facility to acquire MDRO's and negatively affect their overall health and quality of life. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2022, the P&P indicated: a) enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents, b) EBPs employ isolation gown use during high contact resident care activities, and c) examples of high contact resident care activities requiring the use of isolation gown for EBPs include: providing hygiene and changing briefs