Arbor Glen Care Center

F-F550

Findings:

During a review of Resident 233's Admission Record, the AR indicated Resident 233 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including heart failure (condition that develops when one's heart does not pump enough blood to meet the body's needs) and type 2 diabetes (-a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 233's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025,

the MDS indicated Resident 233 had intact cognition (ability to reason, think, plan) and required substantial or maximum assistance (helper does more than half the effort) for toileting hygiene and toilet transfers.

During an interview on 2/5/2025 at 11 AM with Resident 233's Family Member (FM), the FM stated the FM observed multiple times when Resident 233 had to wait 30 minutes to one hour for Resident 233's soiled brief to be changed.

During an interview on 2/6/2025 at 3:42 PM with the FM, the FM stated this morning around 9 AM, Resident 233 had soiled herself with feces and pressed Resident 233 the call light for assistance. The FM stated Resident 233 was not changed until 11AM.

During an interview on 2/6/2025 at 4 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated the facility was short staffed at times especially during the evening and night shifts. CNA 4 stated the previous night on 2/5/2025 CNA 4 was assigned to care for eighteen residents which was difficult and unusual. CNA 4 stated

the average amount of residents CNA 4 normally cared for was 10 to 11 residents which was manageable.

During a review of the facility's 11-7 AM CNA Assignment (CNAA), dated 2/5/2025, the CNAA indicated five CNAs were responsible for the care of 90 residents. Four out of Five CNAs were assigned to care for 18 residents each.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 056360 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056360 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 2/6/2025 at 4:05 PM with Resident 233, Resident 233 stated Resident 233 was supposed to go to physical therapy at 9 AM but was unable to because Resident 233 had soiled Resident Level of Harm - Minimal harm or 233's diaper. Resident 233 stated the Physical Therapist pressed the call light for Resident 233 to be potential for actual harm changed. Resident 233 stated no staff came into the room to change Resident 233's soiled diaper until 11 AM. Resident 233 stated Resident 233 often had to wait a long time to get help from staff (in general). Residents Affected - Some Resident 233 stated Resident 233 did not always press the call light because Resident 233 was worried about bothering the staff because the staff was always so busy.

During a review of Resident 39's AR, indicated Resident 39 was admitted to the facility on [DATE REDACTED] with diagnosis that included Alzheimer's disease (disease causing memory loss and other mental functions), generalized muscle weakness, and abnormal posture.

During a review of a History and Physical Reports (H&P), dated 11/4/2024, the H&P indicated Resident 39 did not have the capacity to understand and make decisions.

During a review of Resident 39's MDS dated [DATE REDACTED], the MDS indicated Resident 39 needed maximal assist (helper does more than half the effort) with personal hygiene (maintain body hygiene) sit to stand, and chair to bed transfers.

During an observation on 2/6/2025 at 4:10 PM, CNA 4, CNA 5, and CNA 6 were observed passing water from a cart located in the hallway. During the same observation, Resident 39 was observed sitting on her wheelchair in the facility hallway, following CNA 4, CNA 5, and CNA 6, stating help, help, while pointing down

the hallway. CNA 4 turned to address Resident 39, stated not right now, I am busy. CNA 4 then turned her back to Resident 39 and continued to pass water.

During an interview with CNA 6, on 2/6/2025 at 4:14 PM, CNA 6 stated CNA 6 would not have turned CNA 6's back from Resident 39. CNA 6 stated Resident 39 was confused and just wanted some assistance. CNA 6 stated I feel bad for Resident 39.

During an interview with CNA 5, on 2/6/2025 at 4:17 PM, CNA 5 stated CNA 5 should not have told Resident 39 I'm busy. CNA 5 stated CNA 5 should have asked another CNA to help Resident 39. CNA 5 stated Resident 39 deserved service, help, and [to be treated with] dignity.

During an interview with the Director of Nursing (DON), on 2/6/2025 at 4:20 PM, the DON stated the facility should treat all residents with compassion and empathy. The DON stated, all residents should be treated with dignity, even the confused residents.

During a review of the facility's policy and procedure, titled Resident Rights: Dignity and Respect, revised 1/2025, indicated it was the policy of the facility that all residents be treated with kindness, dignity and respect.

During a review of the facility's policy and procedure (P&P), titled Nursing Administration - Staffing, Adequate, dated 10/2014, the P&P indicated the facility maintains adequate staff on each shift to assure that

the resident's needs are met.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 056360