Arbor Glen Care Center

of Needs, undated, the P&P indicated that it was the policy of the facility to provide accommodation of

Examples of Accommodation of needs but is not limited to the following:

Bed Size Room and Roommates Devices to Use Special Diet Location of placement in the facility Showers Call lights, etc.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During an interview on 2/6/2025 at 4:31 PM, with Registered Nurse (RN) 1, RN 1 stated accurate fall risk assessments were essential for preventing injuries, ensuring effective care, improved patient outcomes, tailored fall risk care plans, and maintained ethical and legal standards.

During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, revised 12/2023, the P&P indicated: -It is the policy of the facility that resident's will be assessed, and the findings documented in their clinical health record.

These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, strengths and needs will be identified. -Assessment information will be used to develop, review, and revise the resident's comprehensive care plan.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a review of the facility's policy and procedure (P&P) titled, admission Practice, revised 01/2011, the P&P indicated, it was the policy of the facility to assure that appropriate medical and financial records were provided to the facility prior to or upon the resident's admission.

During a review of the facility's P&P titled, PASARR, revised 01/2024, the P&P indicated, it was the policy of the facility to ensure that each resident was properly screened using the PASARR specified by State.

The P&P indicated, a PASARR should be completed on every resident upon admission.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Planning dated 10/2022, the P&P indicated it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During an observation on 2/5/2025 from 8:30 AM to 12:07 PM and from 12:30 PM to 3 PM, Resident 62 was in bed, lying on her back.

During an interview on 2/6/2025 at 1:59 PM with the Activities Director, the Activities Director (AD) stated the facility provides one to one (1:1) activities to residents who stay inside their room and would not join group activities.

The Activities Director (AD) stated the Activities Staff (AS) would conduct 1:1 room visits between 8:30-9 AM and 1:30-2 PM.

The Activities Director was unable to provide proof or documentation of activities provided to Resident 62.

The Activities Director stated the AS do not document activities provided to residents (in general).

During the same interview, the AD stated the documentation of 1:1 room visits would be the angel rounds documentation conducted by different department heads.

During an interview on 2/6/2025 at 2:05 PM, the Director of Admissions stated they do not provide activities to the residents and would check the residents (in general) for any concerns during the angel rounds.

The DA provided a copy of the Angel Rounds.

During an interview and record review on 2/5/2025 at 2:10 PM, there was no admission Activities Assessment for Resident 62.

The AD stated there was an activity preference assessment on the MDS.

The MDS dated [DATE] was reviewed with the AD, the staff assessment of daily and activity preferences was blank.

The AD stated based on the assessment, it would not guide the AS on what activities would be meaningful for Resident 62.

During a review of the facility's Policy and Procedure titled Quality of Life, Activities Program dated 3/2019.

The P&P indicated it is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a concurrent interview and record review on 2/6/25 at 9:55 a.m. with the Director of Nursing (DON), Resident 42's BMBC and MAR were reviewed.

The DON stated, Resident 42 had some blood in the stool and Resident 42 was transferred to the GACH on 2/5/25.

The DON did not want to use the word constipation but the DON stated, Resident 42 was having bm before LVN 4 administered the Dulcolax suppository.

The DON stated, LVN 4 was not following the physician's orders.

The DON stated, the DON did not know what LVN 4's nursing judgement was and why LVN 4 administered the Dulcolax suppository.

The DON stated, staff should have documented Resident 42 refused the MOM and staff should have notified the physician that Resident 42 refused the MOM and Resident 42 had been having bm you got to let them know.

The DON stated, it was important to notify the physician so the doctor can decide what he wants to do.

During a review of Resident 42's undated care plan (CP - provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]), titled [Resident 42] has constipation r/t (related to) decreased mobility, medication side effects, pain, the CP indicated, interventions included to administer medications as ordered, monitor medications for side effects of constipation and keep physician informed of any problems.

During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, revised 11/2024, the P&P indicated, any change in a resident's condition manifested by a marked change in physical or mental behavior would be communicated to the physician.

During a review of the facility's undated P&P titled, Specific Medication Administration Procedures, the P&P indicated, medications were administered as prescribed in accordance with good nursing principles and practices.

The P&P indicated, note any allergies or contraindications the resident may have to drug administration.

The P&P indicated, if resident refused medication, document refusal on MAR or TAR (Treatment Administration Record).

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During an observation on 2/6/25 at 8:48 a.m. with TN 1 and the Wound Consultant (WC), during

(centimeters, a unit of measurement) x .7 cm x .3 cm on Resident 32's right heel. Resident 32 had a small 1 cm x 8 cm moist wound draining very small clear drainage with purplish discoloration around the wound edges on Resident 32's right trochanter (bone of your hip) area.

During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, revised 01/2025, the P&P indicated, the use of LAL, alternating-pressure mattress or other types of mattresses as prescribed by physician was to prevent skin breakdown and to treat pressure ulcers.

The P&P indicated, one of the instructions for use of the LAL mattress was to attach tubing to the pump connectors and plug into appropriate electrical outlet.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During an interview on 2/6/2025 at 4:31 PM, with RN 1, RN 1 stated LVNs might not be responsible for performing all basic care tasks, their role included ensuring patient safety and well-being, especially in emergency or urgent situations. RN 1 stated when a resident attempted to get out of bed and a CNA was unavailable, the LVN must intervene to protect the patient from harm and provide the necessary care until further support was available.

During a review of the facility's P&P titled, Fall Risk Assessment, revised 5/2007, the P&P indicated any resident identified as high risk will have a prevention protocol initiated and documented on the care plan.

The P&P indicated Prevention protocol examples, but not limited to: Provide supervision.

During a review of the facility's P&P titled, Fall Management System, revised 1/2022, the P&P indicated it is the policy of the facility to provide an environment that remains as free of accident hazards as possible.

The P&P indicated it is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

emergencies following emergency protocols.

The P&P indicated, one of the equipment in administering

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

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], 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.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

dated 2018, the P&P indicated:

effectiveness of the solution.

-The food & nutrition worker will place the solution in the appropriate bucket labeled for its contents and will test concentration of the sanitation solution. -The solution will be tested at least every shift or when the solution is cloudy. -The solution will be replaced when the reading is below 200 ppm.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a concurrent record review of the QAPI Sign in Sheet and interview on 2/6/2025 at 5:30 PM, there was no Director of Nursing among the attendees.

The Administrator stated there was no DON during the QAPI meeting om 1/24/2025.

During an interview on 2/6/20255 at 5:40 PM, the Administrator stated the DON needed to be in all the QAPI meetings.

The DON is the head of the nursing department, so she needs to be in the planning and monitoring nursing related services.

The Administrator stated he needed to have an acting DON attend the QAPI meeting when the previous DON left.

During a review of the facility's 2025 Quality Assurance and Performance Improvement Plan (QAPI), the plan indicated the department heads who had been named to the QAPI leadership team and indicated what their individual roles within the program entailed, including the DON as the clinical care sub-committee leader.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a review of Resident 46's AR, the AR indicated the facility admitted Resident 46 on 6/19/23, with diagnoses that included urinary tract infection (UTI, an infection in the urinary system that could include the kidneys, bladder and urethra), acute respiratory failure (Respiratory failure is a serious condition that happens when your lungs cannot get enough oxygen into your blood).

During a review of Resident 46's Physician Order dated 6/23/2023, the order indicated contact isolation precautions for C. auris.

During an observation on 2/4/2025 at 3:30 PM, CNA 2 entered the room which had a contact precaution sign on the door. CNA 2 was not wearing a gown and gloves while carrying two pitchers of water. CNA 2 dropped off the pitchers then took the used pitchers from both Resident 40 and Resident 46's table and left the room.

During a follow up interview on 2/4/2025 at 3:32 PM, CNA 2 stated CNA 2 would wear a gown and gloves only when providing care.

During an interview on 2/4/2025 at 3:58 PM, the IPN stated when a resident (in general) was on contact precautions, staff needed to wear a gown and gloves every time staff would enter the room of the resident on contact precautions.

The IPN stated Resident 40 and Resident 46 were both on contact precautions for C. auris, staff needed to wear PPE before entering Resident 40 and 46's room.

The IPN stated C auris would get passed easily and the staff needed to wrap the contaminated tray and pitcher when coming from a contact isolation room.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a review of Resident 72's OSR, the OSR indicated an order, dated 1/13/2025, for Ampicillin Sodium (an ABX), three grams (G, unit of measurement), given IV every 6 hours (q6h).

During a review of Resident 72's IVMAR, the IVMAR indicted Resident 72 was administered Ampicillin Sodium 3G q6h on 2/1/2025, 2/2/2025, 2/3/2025, 2/4/2025, 2/5/2025 and 2/6/2025.

During a review and concurrent interview with IPN 2, on 2/6/2025 at 11:01 PM, Resident 72's Infection Surveillance -V2 (ISV2), dated 1/8/2025 was reviewed.

The documented indicated at least one McGreer's criteria must be present to start ABX treatment for cellulitis (infection in the skin), soft tissue, or wound infection. IPN 2 stated Resident 72's ISV2 was not completed. IPN 2 stated Resident 72's ISV2 did not indicated if Resident 72 met the criteria for ABX administration for cellulitis, soft tissue, or wound infection. IPN stated IPN did not follow up with Resident 72's physician regarding Resident 72 ABX use. IPN stated it was important to follow up with physician regarding ABX use to ensure criteria was met and to prevent ABX resistance.

C.

During a review of Resident 134's AR, the AR indicated Resident 134 was admitted to the facility on [DATE] with diagnosis that acute respiratory failure (not enough oxygen in the lungs), generalized muscle weakness, and diabetes (elevated blood sugar).

During a review of Resident 134's OSR, dated active as of 2/6/2025, the OSR indicated a physician's order, dated 2/4/2025, for Zosyn (an antibiotic) intravenous solution 3/0.375 mg IV q8h for pneumonia (infection that inflames the air sacs of the lungs).

During a review of Resident 134's IVMAR, the IVMAR indicted Resident 72 was administered Zosyn intravenous solution 3/0.375 mg IV q8h on 2/4/2025, 2/5/2025 and 2/6/2025.

During an interview with the IPN 2 on 2/6/2025 at 11:01 PM, and concurrent record review of Resident 134's ISV2 for Respiratory Tract Infections (RTI), dated 1/31/2025, IPN 2 stated Resident 134's ISV2F was in-complete. IPN 2 stated the ISV2 did not indicate if Resident 134 had McGreer's criteria needed to determine the need for ABX use. ICN 2 stated any resident with an ABX order must have ABX surveillance to determine if they met the criteria and to deter the risk of ABX resistance.

During a review of the facility's policy titled Antibiotic Stewardship, revised 12/2023, indicated it was the policy to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall infection prevention and control program which will promote appropriate use of antibiotic while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use.

This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment -related cost.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During an observation and interview on 2/6/2025 at 10:46 AM with Treatment Nurse (TN) 1, TN 1 stated there were six residents inside room [ROOM NUMBER].

During an interview on 2/6/2025 at 2:56 PM with the Administrator (ADM), the ADM stated when the ADM was first hired at the facility 8/2024, room [ROOM NUMBER] had five beds and five residents.

The ADM stated the facility added the sixth bed on 1/20/2025 and admitted the sixth resident to occupy the bed on 1/21/2025.

During an interview on 2/6/2025 at 4:42 PM with the ADM, the ADM stated the facility did not have a policy that indicated how many residents could be accommodated in a single room.

During a review of Resident 283's admission Record (AR), the AR indicated the facility admitted Resident 283 on 1/19/2025, with diagnoses including unspecified head injury, muscle weakness, and epilepsy (a brain disorder that causes seizures, which are abnormal electrical activity in the brain).

During a review of Resident 283's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/23/2025, the MDS indicated Resident 283 cognition (the ability to think and process information) was moderately impaired.

The MDS indicated Resident 283 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance with mobility.

During an observation on 2/3/2025 at 9:45 AM, Resident 283's call light was found on the floor and underneath Resident 283's bed.

The call light was not within the resident's reach.

During an interview on 2/3/2025 at 2:35 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 283's call light wasn't within reach. LVN 1 stated all call lights should be easily accessible to all residents. LVN 1 stated call lights within reach enhanced the resident's safety and well-being as it allowed residents to quickly alert staff if they need assistance, whether for medical attention, help with mobility, or addressing immediate needs. LVN 1 stated call lights within the resident's reach helped prevent and reduced the risk of accidents, such as falls.

During an interview on 2/6/2025 at 11:37 AM, with the Director of Nursing (DON), the DON stated staff should ensure call lights were always accessible to the residents.

The DON stated ensuring call lights were within reach promoted a safer, more dignified, and responsive care environment for all residents.

During a review of the facility's policy and procedure (P&P) titled, Call Light/Bell, undated, the P&P indicated it was the policy of the facility to provide the resident a means of communication with nursing staff.

The P&P indicated to leave the resident comfortable, place the call device within resident's reach before leaving room, and if the call/light bell is defective, immediately report this information to the unit supervisor.

056360 02/06/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

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.

056360

Form Approved OMB

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