The incident occurred on July 31, 2024, at Glendora Grand nursing home during a federal inspection. Licensed Vocational Nurse 6 was preparing 13 medications for Resident 124 when three pills fell to the floor. The nurse looked down, found the pills, picked them up, and put them back in the medication cup with the rest of the resident's medications.
Resident 124 received the cup and was about to put the medications in their mouth when the surveyor stopped them.
When questioned immediately afterward, the nurse admitted the mistake. "LVN 6 should not have given Resident 124 the medications that dropped on the floor," the nurse told the inspector. The nurse acknowledged the medications were contaminated and that the resident "could get sick from taking contaminated medications and could cause declination of health condition."
The nurse said the dropped medications should have been discarded.
Resident 124 had been admitted to the facility on May 15, 2024, with heart failure and a cancerous kidney tumor. The resident could speak clearly and understand others but required assistance with personal hygiene and transfers.
The Director of Nursing confirmed that nurses must discard medications dropped on the floor immediately. "This was for the residents' safety," the director said. "It was part of professional standard of practice to not give patients contaminated medications."
The facility's own medication administration policy, revised in 2023, requires medications to be administered "in a manner to prevent contamination or infection."
The contaminated medication incident was one of multiple pressure ulcer care failures inspectors found during their August 2 visit.
For Resident 228, who had diabetes, end-stage kidney disease, and required dialysis, treatment nurses repeatedly failed to provide ordered wound care for open scratches on the resident's right hip. The scratches developed in June 2024, but treatment nurses missed providing care on July 6, July 20, July 21, and July 25.
By July 24, the scratches had deteriorated into unstageable pressure ulcers on both hips. The right hip ulcer measured 5.5 centimeters long by 5 centimeters wide with a depth of 0.2 centimeters. The left hip ulcer measured 7 centimeters long by 4 centimeters wide with the same depth.
An unstageable pressure ulcer involves full-thickness tissue loss where the wound depth is covered by dead tissue, making it impossible to determine the true extent of damage.
Physician Assistant 1 identified these pressure ulcers on July 24 and gave verbal orders to clean them with normal saline and Betadine antiseptic, then cover with dressing. Treatment Nurse 3 failed to carry out these orders.
Treatment nurses also failed to notify Medical Doctor 1 when the pressure ulcers developed, despite the facility's care plan requiring staff to report further skin breakdown to the doctor.
Resident 228 had been assessed as at risk for developing pressure ulcers. The facility had a care plan dated May 30, 2024, specifically addressing impaired skin integrity and risk of pressure ulcer worsening. Treatment nurses failed to implement this plan.
The Director of Nursing acknowledged during the inspection that the care plan should have been revised when Resident 228's scratches turned white and became macerated on July 24. "The CP should have been revised to ensure the resident received proper treatment," the director said.
For Resident 231, staff failed to properly set a specialized pressure-relieving mattress. The Low Air Loss mattress was configured for a 325-pound person in static mode, but Resident 231 weighed only 158 pounds. The incorrect setting had the potential to cause skin breakdown.
A Low Air Loss mattress uses tiny holes to continuously blow air, causing the patient to float and reducing pressure on vulnerable skin areas.
Treatment nurses also failed to provide ordered care for Resident 80's Stage 4 pressure ulcer on the tailbone from July 25 through July 30. Stage 4 pressure ulcers involve full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone.
The facility's comprehensive care plan policy requires staff to review and revise care plans after each assessment, monitor resident progress, and document alternative interventions as needed. The policy states care plans should include objectives and timeframes to meet identified needs.
Inspectors found the facility failed to meet professional standards of quality for medication administration and pressure ulcer prevention and treatment. The violations affected multiple residents with serious medical conditions who relied on the facility for basic safety measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendora Grand, Inc from 2024-08-02 including all violations, facility responses, and corrective action plans.