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Complaint Investigation

Glendale Post Acute Center

November 13, 2025 · Glendale, CA · 250 N. Verdugo Road
Citations 2
CMS Rating 1/5
Beds 136
Provider ID 055523
Healthcare Facility
Glendale Post Acute Center
Glendale, CA  ·  View full profile →
Inspection Summary

GLENDALE POST ACUTE CENTER in GLENDALE, CA — inspection on November 13, 2025.

Found 2 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.

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Inspection Findings

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During a review of the facility's undated P&P titled, Intravenous Administration of Fluids and Electrolyte, the P&P indicated to Notify physician, supervisor, and on coming shift of complications. of treatment and report other information in accordance with. professional standards of practice.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Glendale Post Acute Center

250 N.

Verdugo Road Glendale, CA 91206

SUMMARY STATEMENT OF DEFICIENCIES

During a phone interview with MD 1 on [DATE] at 1:00 pm, MD 1 stated that she assessed Resident 1 on [DATE] and found the resident to be debilitated (in a very weakened or feeble state), unresponsive, and edematous (swollen with an abnormal accumulation of fluid in the tissues).

MD 1 further stated Resident 1 was drowsy and ordered labs to be drawn after that assessment.

During a phone interview on [DATE] at 1:41 p.m, RN 2 stated she was unable to start an IV for Resident 1 and contacted the third-party IV provider at 6:00 p.m. on [DATE].

However, an IV nurse was not available until 7:00 a.m. the next day. RN 2 did not notify the physician about the delay and instead endorsed the information to RN 3.

During a concurrent record review and interview with RN 4 on [DATE][FC2] at 4:02 pm, Resident 1's Progress Notes from [DATE] to [DATE] were reviewed. RN 4 stated that a resident with a CIC for low potassium should be monitored for abnormal heartbeat by palpating (feeling) the resident's pulse and auscultating (listening to) cardiac sounds with a stethoscope. RN 4 further stated that the progress notes did not show documentation of licensed nurses monitoring Resident 1 for abnormal heartbeat.

During a phone interview with the Director of nursing (DON) on [DATE] at 4:22 pm, the DON stated that if a resident required an IV line and the RN supervisor or the IV Nurse is unable to place one, the RN supervisor is responsible for notifying the doctor for further orders with options to send the resident to the hospital if they are unstable or placing an order for a PICC line/midline.

The DON stated RN 3 should have attempted to establish an IV for Resident 1 at least two to three times to start the D5W IV fluids.

The DON further stated Resident 1 had elevated sodium levels of 158 and high sodium levels have the potential to cause seizures, dehydration, and kidney issues if left untreated.

During a phone interview with the Director of nursing (DON) on [DATE] at 4:22 pm, licensed nurses are expected to notify the physician and initiate a CIC for critical labs.

The DON stated it was a delay in care when LVN 1 failed to act right away on Resident 1's low potassium.

The DON further stated that residents with low potassium can experience cardiac complications.

The DON further stated the licensed nurses should have notified the doctor promptly for low potassium and other abnormal labs to provide interventions as soon as possible.

During a concurrent record review and interview with the DON on [DATE] at 4:25 pm, Resident 1's PN for the dates [DATE] to [DATE] were reviewed.

The DON stated that RN 3 did not document that she tried to start an IV for Resident 1 when she should have instead of waiting for the IV Nurse to come in the morning.

During a review of the facility's Job Description titled Registered Nurse Supervisor, the job description indicated the RN will make sound independent decisions when circumstances warrant such action and their essential duties and responsibilities included passing out medications when needed.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDALE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GLENDALE POST ACUTE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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