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 30 of 43 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 31 of 43 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50016

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure one of two sanitation buckets (bucket 1) in the kitchen had adequate amount of quaternary sanitizing solution (an ammonium solution used for sanitizing surfaces) for the disinfection of key areas in the kitchen utilized to prepare resident's food.

This deficient practice placed the residents at increased risk of infections and could have impacted the health and safety of residents.

Findings:

During an observation on 2/3/2025 at 8:57 AM, the [NAME] (CK) checked the quaternary sanitizing solution and used a quaternary test strip for two sanitation buckets located in the kitchen. The CK placed the test strip

in bucket 1 for 10 seconds. The strip indicated 100 ppm (ppm-parts per million, unit of measurements). The CK placed the quaternary test strip in bucket 2 for 10 seconds, the strip indicated 300 ppm.

During an interview and record review on 2/3/2025 at 9:05 AM, with the CK, the CK stated the quaternary test strip was used to check if the sanitizing solution was effective. The CK stated the strip should be in the solution for at least ten seconds before the results were checked. The CK stated the quaternary solution should be between 200ppm to 400ppm to ensure the sanitizing solution was effective and strong enough to disinfect. The CK stated sanitation bucket 1 was out of range with a reading of 100 ppm and the result indicated a reduced effectiveness in the sanitizing solution.

During an interview on 2/3/2025 at 11:49 AM, with the Registered Dietician (RD), the RD stated the sanitation buckets were rechecked and the RD determined sanitation bucket 1 had too many washcloths in

the bucket which affected the effectiveness of the quaternary sanitizing solution. The RD stated the efficacy of the solution could have been compromised if there were too many washcloths in the solution. The RD stated if the washcloths were too dirty or heavily soiled, they could absorb the disinfectant solution reducing

the potency needed to kill germs.

During an interview on 2/6/2025 at 1:10 PM, with the Director of Dining Services (DDS), the DDS stated ensuring proper quaternary solution levels was critical for preventing cross contamination (process by which bacteria can be transferred from one area to another) because if the disinfectant was not at the correct strength, it may not effectively kill harmful microorganisms, like bacteria (living organism that can cause an infection) and viruses, that can spread between surfaces. The DDS stated maintaining proper quaternary sanitizing solution levels ensured the disinfectant was strong enough to kill germs, lowering the risk of cross-contamination and kept the environment clean and safe for the residents.

During a review of the undated Hydrion QT-10 test strip instructions, the instructions indicated to immerse

the test strip paper for ten seconds in the sanitizing solution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 43 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 0812 During a review of the undated [NAME] Chemicals the manufacturer's instructions indicated to test sanitizing solution to assure proper solution strength between 200 ppm-400 ppm. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, dated 2018, the P&P indicated: Residents Affected - Few -The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 43 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 40913 potential for actual harm Based on interview and record review, the facility failed to ensure a Director of Nursing (DON) attended the Residents Affected - Few Quality Assurance Performance Improvement quarterly meeting.

This deficient practice had the potential to affect residents' physical, mental and psychosocial well-being.

Findings:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 43 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42307 potential for actual harm Based on observation, interview and record review, the facility failed to implement the facility's policy and Residents Affected - Some procedure (P&P) titled, Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, for nine of nine sampled residents (Residents 42, 235, 236, 234, 23, 61, 237, 40 and 46) by failing to:

a. Ensure unlabeled personal toiletries were not stored inside Residents 42, 235, 236 and 234's [NAME] n' [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms).

b. Ensure staff was wearing and/or changed personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) during care for Residents 61 and 237 who were in contact isolation (a set of precautions that help prevent the spread of germs from a resident to others by separation of residents with an infection from residents without an infection).

c. Ensure Certified Nursing Assistant 2 (CNA 2) was wearing PPE upon entering Resident 40 and Resident 46's room when Residents 40 and 46 were on contact precautions for Candida Auris (C. auris - is an emerging fungus that can cause severe, often multidrug-resistant, infections. It spreads easily among patients in healthcare facilities).

These deficient practices had the potential to result in cross contamination and/or the development and transmission of disease (an illness or sickness) and infection for Residents 42, 235, 236, 234, 23, 61, 237, 40 and 46, other residents, staff and visitors.

Findings:

a1. During a review of Resident 42's Admission Record (AR), the AR indicated, Resident 42 was admitted to

the facility on [DATE REDACTED] with multiple diagnoses including unspecified intracapsular fracture (a partial or complete break in the bone within the joint capsule) of right femur (thigh bone), subsequent encounter for closed fracture (simple fracture - a broken bone with the skin still intact) with routine healing, muscle weakness (generalized), and old myocardial infarction (MI - heart attack).

During a review of Resident 42's History and Physical (H&P), dated 1/11/25, the H&P indicated, Resident 42 was alert, oriented x 3 (referring to person, place and time) and not in distress or having acute (sudden) concerns except occasional constipation (when a person has difficulty passing stool [poo]).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 43 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 0880 During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/25, the MDS indicated, Resident 42's BIMS (Brief Interview for Mental Status - an assessment tool used by facilities Level of Harm - Minimal harm or to screen and identify memory, orientation, and judgement status of the resident) Summary Score was intact. potential for actual harm The MDS indicated, Resident 42 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding Residents Affected - Some or having a bowel movement). The MDS indicated, Resident 42's ability to shower/bath self (the ability to bathe self, including washing, rinsing, and drying self) was not attempted due to medical condition or safety concerns. The MDS indicated, Resident 42 was occasionally incontinent (involuntary loss of urine or stool) [less than 7 episodes of incontinence] of bowel and had no constipation.

a2. During a review of Resident 235's AR, the AR indicated, Resident 235 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including muscle weakness (generalized), difficulty in walking, not elsewhere classified and urinary tract infection (UTI - an infection in the bladder/urinary tract).

During a review of Resident 235's H&P, dated 1/22/25, the H&P indicated, Resident 235 currently possessed

the general capacity to make Resident 235's own decisions.

During a review of Resident 235's MDS, dated [DATE REDACTED], the MDS indicated, Resident 235's BIMS Summary Score was intact. The MDS indicated, Resident 235's ability for toileting hygiene and shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self) was not attempted due to medical condition or safety concerns. The MDS indicated, Resident 235 was frequently incontinent of urine (7 or more episodes of urinary incontinence) and bowel (2 or more episodes of bowel incontinence).

a3. During a review of Resident 236's AR, the AR indicated, Resident 236 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, muscle weakness (generalized), and heart failure, unspecified.

During a review of Resident 236's H&P, dated 1/29/25, the H&P indicated, Resident 236 had the capacity to understand and make decisions.

a4. During a review of Resident 234's AR, the AR indicated, Resident 234 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including cellulitis (a skin infection that causes swelling and redness), type 2 diabetes mellitus with other skin ulcer (a small open sore or wound generally found in the stomach or on the skin) and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).

During a review of Resident 234's H&P, dated 1/26/25, the H&P indicated, Resident 234 had the capacity to understand and make decisions.

During a review of Resident 234's MDS, dated [DATE REDACTED], the MDS indicated, Resident 234's BIMS Summary Score was intact. The MDS indicated, Resident 234 required substantial/maximal assistance with toileting hygiene. The MDS indicated, Resident 234's ability for shower/bathe self was not attempted due to medical condition or safety concerns. The MDS indicated, Resident 235 was frequently incontinent of urine and bowel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 43 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 0880 During a concurrent observation and interview on 2/3/25 at 10:36 a.m. with Certified Nursing Assistant (CNA) 5, an opened, unlabeled 220 ml (milliliters - a unit of measurement) bottle of PeriFresh Rinse Free Perineal Level of Harm - Minimal harm or Cleanser and an opened 8 fl oz (fluid ounce - a unit of volume used for measuring liquid) bottle of [NAME] potential for actual harm Shampoo & Body Wash were stored on the sink inside the [NAME] n' [NAME] restroom shared by Residents 42, 235, 236 and 234. CNA 5 stated, the PeriFresh Rinse Free Perineal Cleanser and the [NAME] Shampoo Residents Affected - Some & Body Wash were supposed to clean the private (the genital organs on the outside part of the body) and to clean the body. CNA 5 stated, the personal toiletries were supposed to be labeled with the resident's (in general) name and bed number and kept at the resident's bedside table for infection control.

During an interview on 2/4/25 at 4:02 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated, anything used for personal should always be labeled, not kept in public spaces or shared. The IPN stated keeping personal belongings at the bedside for dignity and of course, infection control. The IPN stated, I wouldn't want anybody using mine.

b1. During a review of Resident 23's AR, the AR indicated, Resident 23 was originally admitted to the facility

on [DATE REDACTED] and last readmitted on [DATE REDACTED] with multiple diagnoses including type 2 diabetes mellitus without complications, pneumonia (an infection/inflammation in the lungs) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly into the stomach common for people with swallowing problems) status.

During a review of Resident 23's MDS, dated [DATE REDACTED], the MDS indicated, Resident 23's BIMS Summary Score was intact. The MDS indicated, Resident 23 required substantial/maximal assistance to dependent with self-care. The MDS indicated, Resident 23 was always incontinent (no episodes of continence) of urine and bowel.

During a review of Resident 23's H&P, dated 12/26/24, the H&P indicated, Resident 23 could make needs known but could not make medical decisions.

During a review of Resident 23's Order Summary Report (OSR), active order status as of 2/1/25, the OSR indicated, an order on 1/31/25 for Enhanced Barrier Precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs]): PPE required for high resident contact care activities, indication: indwelling medical device every shift.

b2. During a review of Resident 61's AR, the AR indicated, Resident 61 was originally admitted to the facility

on [DATE REDACTED] and last readmitted on [DATE REDACTED] with multiple diagnoses including muscle weakness (generalized), essential (primary) hypertension (HTN - high blood pressure) and hypothyroidism (underactive thyroid disease), unspecified.

During a review of Resident 61's H&P, dated 12/8/24, the H&P indicated, Resident 61 did not have the capacity to understand and make decisions.

During a review of Resident 61's MDS, dated [DATE REDACTED], the MDS indicated, Resident 61's cognitive skills (ability to think and process information) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 61 substantial/maximal assistance with toileting hygiene and shower/bathe self. The MDS indicated, Resident 61 was frequently incontinent of urine and bowel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 43 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 0880 b3. During a review of Resident 237's AR, the AR indicated, Resident 237 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including unspecified atrial fibrillation, urinary tract infection, site not specified Level of Harm - Minimal harm or and type 2 diabetes mellitus without complications. potential for actual harm

During a review of Resident 237's H&P, dated 1/19/25, the H&P indicated, Resident 237 was alert and Residents Affected - Some oriented x 3.

During a review of Resident 237's MDS, dated [DATE REDACTED], the MDS indicated, Resident 237's BIMS Summary Score was intact. The MDS indicated, Resident 237 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to substantial/maximal assistance with toileting hygiene and shower/bathe self. The MDS indicated, Resident 237 was frequently incontinent of bowel.

During a review of Resident 237's OSR, active orders as of 2/6/25, the OSR indicated, an order on 2/3/25 for contact isolation precautions for VRE (Vancomycin-resistant enterococci - a type of bacteria that is resistant to many antibiotics) in the urine every shift.

During an observation on 2/3/25 at 12:46 p.m. Residents 23, 61 and 237 were cohorted (grouped together)

in the same room. A Contact Precautions signage posted and a black trimmed colored 3-drawer PPE cart outside of Residents 23, 61 and 237's room.

During an interview on 2/4/25 at 4:02 p.m. with the IPN, the IPN stated, Residents 23, 61 and 237 who were cohorted in the same room were on contact precautions. The IPN stated Resident 237 was in contact isolation for VRE in the urine. Resident 23 was on EBP for GT (gastrostomy tube) and Resident 61 is nothing (not requiring to be on precautionary isolation). The IPN stated, Residents 237, 23 and 61 were treated for contact isolation precautions and the highest level precaution contact signage was posted. The IPN stated, staff would have to change PPE in between when providing care for Residents 23, 61 and 237.

During an observation on 2/5/25 at 7:55 a.m. in Resident 23, 61 and 237's cohorted room, CNA 2, CNA 8 and CNA 9 had PPE on while assisting/repositioning Resident 237 in bed to get ready for breakfast.

During a concurrent observation of CNAs 8 and 9 and interview with CNA 2 on 2/5/25 at 8:02 a.m., CNA 9 removed gloves without changing gown and donning (putting) new gloves after assisting Resident 237, CNA 9 went to set up Resident 61's breakfast tray then proceeded to assist CNA 8. CNA 8 removed gloves, set up Resident 237's breakfast tray and moving/adjusting Resident 237's bedside table while CNA 9 was carrying Resident 237's breakfast tray. CNA 9 placed Resident 237's breakfast tray on Resident 237's bedside table after CNA 8 set up Resident 237's bedside table. CNA 8 proceeded to sit at Resident 237's bedside to feed Resident 237 without wearing gloves. CNA 9 proceeded to feed Resident 61 without changing gown and donning gloves. CNA 2 stated staff (in general) was supposed to wear gown and gloves when in contact with residents in isolation so there would be no cross contamination. CNA 2 stated staff's understanding for the use of PPE was to protect staff.

During an interview on 2/5/25 at 12:37 p.m. with the IPN, the IPN stated, it was important to change PPE in between caring for residents in isolation for infection control and making sure the patients are safe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 43 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 0880 During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, last revised 3/2024, the P&P indicated, It was the policy to the facility to implement infection control measures to prevent Level of Harm - Minimal harm or the spread of communicable diseases and conditions. The P&P indicated, Residents on contact precautions potential for actual harm should be restricted to their rooms and restricted from participation in group activities. The P&P indicated, for staff to wear a gown and gloves for all interactions that may involve contact with the patient/resident or the Residents Affected - Some patient's/resident's environment.

40913

c1. During a review of Resident 40's Admission Record (AR), the AR indicated the facility admitted Resident 40 on 1/21/2021, with diagnoses that included immunodeficiency (weak immune system, allowing infections and other health problems to occur more easily) due to drugs, candidiasis (a yeast that lives in parts of the body, grows out of control).

During a review of Resident 40's Physician Order dated 6/6/2022, the order indicated to place Resident 40

on contact isolation for C. auris.

During a review of Resident 40's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/22/2025, the MDS indicated Resident 40 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity most activities and bed mobility.

c2. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 43 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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108 potential for actual harm Based on interview and record review, the facility failed to implement its antibiotic (ABX, medication used to Residents Affected - Some treat infections) stewardship program (efforts that ensure antibiotics are used only when necessary and appropriate) for three of seven sampled residents (Resident 10, Resident 72, and Resident 134) sampled residents. Residents 10, 72, and 134 did not meet McGreer's criteria (infection surveillance checklist to help determine appropriate antibiotic) for antibiotic use.

These deficient practices had the potential for unnecessary administration of antibiotics and lead to resistance (when the antibiotic can no longer kill the bacteria [living organism that can cause an infection]) to antibiotics for Residents 10, 72, and 134.

Findings:

A. During a review of Resident 10's Admission Record (AR), indicated Resident 10 was readmitted to the facility on [DATE REDACTED] with diagnosis that included sepsis (life-threatening complication of an infection), dementia (a group of conditions, decline in mental ability that interfere with daily activities) and generalized weakness.

During a review of Resident 10's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 11/22/2024, the MDS indicated Resident 10 had clear speech and had the ability to understand and be understood.

During a review of Resident 10's Order Summary Report (OSR), dated active as of 2/1/2025, the OSR included a physician's order, dated 1/31/2025, for Ertapenem Sodium (ABX used to treat a wide range of bacterial infections) 500 milligrams (mg, unit of measurement) given intravenous (IV, a soft flexible tube placed inside a vein, usually in the hand or arm and used to give a person medicine or fluids) at bedtime for seven days.

During a review of Resident 10's IV Medication Administration Record (IVMAR) for February 2025, the IVMAR indicted Resident 10 was administered Ertapenem Sodium 500 mg on 2/1/2025m 2/2/2025, 2/3/2025, 2/4/2025, 2/5/2025 and 2/6/2025.

During a review of Resident 10's care plan (CP), titled Diarrhea related to antibiotic use (Ertapenem Sodium), created on 2/4/2025, the CP's goal indicated Resident 10 would have reduced or no episodes of diarrhea.

During an interview with the Infection Prevention Nurse (IPN 2), and a concurrent record review of Resident 10's electronic and paper medical record (chart), on 2/6/2025 at 11:01 PM, IPN 2 stated the facility used McGreer's criteria for infection surveillance. IPN 2 stated an Infection Surveillance - V2 Form (ISV2F), was competed for every resident who was administered ABXs. IPN 2 stated Resident 10 did not have a ISV2F filled out for the use of Ertapenem Sodium. IPN 2 stated the form was never filled out to determine if Resident 10 met the criteria for the use of the antibiotic [Ertapenem Sodium]. IPN 2 stated any resident with

an ABX order must have ABX surveillance and the facility must determine if the resident met the criteria to deter the risks of resistance from happening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 43 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 0881 B. During a review of Resident 72's AR indicated Resident 72 was admitted to the facility on [DATE REDACTED] with diagnosis that included sepsis and generalized muscle weakness. Level of Harm - Minimal harm or potential for actual harm During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 1/12/2025, the MDS indicated Resident 72 was cognitively intact, had clear speech, and had the ability to Residents Affected - Some understand and be understood. The MDS indicated Resident 72 needed moderate assistance (staff does less than half the effort) with toilet and personal hygiene, lower body dressing, and with sit to stand (ability to stand/sit from a chair).

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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 43 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 0911 Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Few Based on observation and interview, the facility failed to ensure one out of 34 rooms had no more than 4 residents (room [ROOM NUMBER]) in the room.

This failure had the potential to result in lack of space and privacy for the residents residing in that room.

Findings:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 43 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 50016 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light was within reach Residents Affected - Some for one of one sampled resident (Resident 283).

This deficient practice had the potential to result in a delay or the inability for Resident 283 to obtain necessary care and services.

Findings:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 056360