Arbor Glen Care Center

F-F693

Findings:

During a review of Resident 3's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems).

During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of

the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube.

During a review of Resident 3's Admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition.

During a review of Resident 3's physician's order (PO), dated 3/7/25, the PO indicated to provide [brand name] tube feeding via feeding pump machine (enteral feeding pump, a medical device used to deliver tube feeding directly to the stomach) to Resident 3 to run at 55 milliliters (ml, unit of measure) per hour to provide 1100 ml in 24 hours.

During an observation on 3/20/25 at 5:20 am inside Resident 3's room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3's tube feeding machine at the bedside read, holding, which indicated Resident 3's tube feeding was on hold and not running or infusing.

During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3's room, no other staff went inside Resident 3's room while CNA 3 provided care to Resident 3 inside the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 0726 During a concurrent observation and interview on 3/20/25 at 5:28 am inside Resident 3's room, Resident 3's tube feeding machine at the bedside read, running, which indicated Resident 3's tube feeding was infusing. Level of Harm - Minimal harm or CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run after CNA 3 provided care to Resident potential for actual harm 3.

Residents Affected - Few During a subsequent interview on 3/20/25 at 5:29 am in Station 1 nurses' station with CNA 3, CNA 3 stated CNAs were not supposed to turn residents' tube feeding machine on and off. CNA 3 stated licensed nurses were supposed to turn residents' tube feeding machine on and off for the CNAs. CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run because CNA 3 did not want the tube feeding machine alarm to wake the residents up. CNA 3 stated an alarm would go off after the tube feeding machine was on hold for some time.

During an interview on 3/20/25 at 5:50 am with CNA 4, CNA 4 stated CNAs were allowed to put tube feeding machines on hold, but not allowed to turn tube feeding machines on or off. CNA 4 stated it was common practice for CNA 4 to put residents' tube feeding machine on hold when CNA 4 provided care to the resident and then put the tube feeding machine to run after CNA 4 provided care to the resident.

During an interview on 3/20/25 at 6:24 am Licensed Vocational Nurse (LVN) 5, LVN 5 stated CNAs must not touch tube feeding machines because they could accidentally change the setting on the tube feeding machines. LVN 5 stated only licensed nurses could turn tube feeding machines on, off, on hold, and/or run.

During an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs were not allowed to put tube feeding machines on, off, on hold, and/or run. The DSD stated only licensed nurses must turn tube feeding pumps on, off, on hold, and/or run. Before CNAs provided care to the resident, CNAs must notify the licensed nurse assigned to the resident to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. If the licensed nurse assigned to the resident was busy, CNAs must ask another licensed nurse to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. The DSD stated CNAs were not trained on how to operate tube feeding machines and operating tube feeding machines did not fall under the CNAs scope of practice. The DSD stated during new hire orientation and during yearly skills check, CNAs were taught not to disconnect any machines or equipment connected to residents and/or to turn machines or equipment connected to residents on or off.

During an interview on 3/20/25 at 9:25 am with the DSD, the CNA Job Description and the CNA Comprehensive Clinical Competency Review - Skills Checklist for CNA 3 and CNA 4 were reviewed with the DSD. The DSD stated feeding tubes and tube feeding machines were not included in the competency review and skills check.

During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated CNAs must not turn tube feeding machines on or off. The DON stated providing tube feeding was considered medication/treatment administration and was not in the CNAs scope of practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 0726 According to the California Health and Safety Code Section (d) (3), Certified nurse assistant means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs Level of Harm - Minimal harm or basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, and potential for actual harm is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision Residents Affected - Few of a registered nurse, as defined in Section 2725 of the Business and Professions Code, or a licensed vocational nurse, as defined in Section 2859 of the Business and Professions Code.

During a review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube, dated 2/8/21, the P&P indicated it was part of the facility's Licensed Nurse Procedures. The P&P indicated, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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** 34273 potential for actual harm Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Residents Affected - Few Precautions (EBP- an infection control strategy in nursing homes that expands the use of personal protective equipment [PPE], specifically gowns and gloves, during high-contact resident care to prevent the spread of infection) for one of 13 sampled residents (Resident 3).

This failure had the potential to spread infections to the residents, staff, and visitors that could lead to hospitalization and/or death.

Findings:

During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems).

During a review of Resident 3 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications).

During a review of Resident 3 ' s Admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition.

During an observation on 3/20/25 at 5:20 am inside Resident 3 ' s room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3 ' s tube feeding machine at the bedside read, holding, which indicated Resident 3 ' s tube feeding was on hold and not running or infusing. CNA 3 did not have an isolation gown on.

During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3 ' s room, there was a sign posted on the outside wall next to the doorway to Resident 3 ' s room which indicated Resident 3 was on EBP.

During an interview on 3/20/25 at 5:29 am with CNA 3, CNA 3 stated EBP must be observed when providing care to residents with G-tubes because residents who have G-tubes were more at risk for infection. CNA 3 stated staff must wear an isolation gown when providing care to Resident 3. CNA 3 stated CNA 3 forgot to put on an isolation gown when CNA 3 walked inside Resident 3 ' s room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs must follow EBP when providing care to residents with tubes, ports, or wounds because residents with Level of Harm - Minimal harm or tubes, ports, or wounds were more at risk for getting an infection. potential for actual harm

During an interview on 3/20/25 at 9:06 am with the Infection Prevention Nurse (IPN), the IPN stated staff Residents Affected - Few needed to follow EBP when providing care to residents with tubes, wounds, catheters and with any type of device which required protection from infection. Staff must put on mask, gown, and gloves when providing care to residents on EBP. The IPN stated it was important for staff (general) to follow EBP so that residents do not get infections.

During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated it was important for all staff to put on masks, gown, and gloves when providing care to residents on EBP to protect

the residents from infection.

During a review of the facility ' s policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 1/2025, the P&P indicated, Enhanced Barrier Protection (EBP) is used in conjunction with standard precautions and expand use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization of MDROs) . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 056360

F-F726

Findings:

During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems).

During a review of Resident 3 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications).

During a review of Resident 3 ' s Admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 0693 During a review of Resident 3 ' s physician ' s order (PO), dated 3/11/25, the PO indicated to provide [brand name] tube feeding to Resident 3 to run at 55 milliliters (ml, unit of measure) per hour for 20 hours to provide Level of Harm - Minimal harm or 1100 ml/1650 calories in 24 hours via feeding pump machine (enteral feeding pump, a medical device used potential for actual harm to deliver tube feeding directly to the stomach).

Residents Affected - Few During an observation on 3/20/25 at 5:20 am inside Resident 3 ' s room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3 ' s tube feeding machine at the bedside read, holding, which indicated Resident 3 ' s tube feeding was on hold and not running or infusing.

During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3 ' s room, no other staff went inside Resident 3 ' s room while CNA 3 provided care to Resident 3 inside the room.

During a concurrent observation and interview on 3/20/25 at 5:28 am inside Resident 3 ' s room, Resident 3 ' s tube feeding machine at the bedside read, running, which indicated Resident 3 ' s tube feeding was infusing. CNA 3 stated CNA 3 turned Resident 3 ' s tube feeding machine to run after CNA 3 provided care to Resident 3.

During a subsequent interview on 3/20/25 at 5:29 am in Station 1 nurses ' station with CNA 3, CNA 3 stated CNAs were not supposed to turn residents ' tube feeding machine on and off. CNA 3 stated licensed nurses were supposed to turn residents ' tube feeding machine on and off for the CNAs. CNA 3 stated CNA 3 turned Resident 3 ' s tube feeding machine to run because CNA 3 did not want the tube feeding machine alarm to wake the residents up. CNA 3 stated an alarm would go off after the tube feeding machine was on hold for some time.

During an interview on 3/20/25 at 5:50 am with CNA 4, CNA 4 stated CNAs were allowed to put tube feeding machines on hold, but not allowed to turn tube feeding machines on or off. CNA 4 stated it was common practice for CNA 4 to put residents ' tube feeding machine on hold when CNA 4 provided care to the resident and then put the tube feeding machine to run after CNA 4 provided care to the resident.

During an interview on 3/20/25 at 6:24 am Licensed Vocational Nurse (LVN) 5, LVN 5 stated CNAs must not touch tube feeding machines because they could accidentally change the setting on the tube feeding machines. LVN 5 stated only licensed nurses could turn tube feeding machines on, off, on hold, and/or run.

During an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs were not allowed to put tube feeding machines on, off, on hold, and/or run. The DSD stated only licensed nurses must turn tube feeding pumps on, off, on hold, and/or run. Before CNAs provided care to the resident, CNAs must notify the licensed nurse assigned to the resident to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. If the licensed nurse assigned to the resident was busy, CNAs must ask another licensed nurse to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. The DSD stated CNAs were not trained on how to operate tube feeding machines and operating tube feeding machines did not fall under the CNAs scope of practice. The DSD stated during new hire orientation and during yearly skills check, CNAs were taught not to disconnect any machines or equipment connected to residents and/or to turn machines or equipment connected to residents on or off.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 0693 During an interview on 3/20/25 at 9:25 am with the DSD, the CNA Job Description and the most current CNA Comprehensive Clinical Competency Review - Skills Checklist for CNA 3 and CNA 4 were reviewed with the Level of Harm - Minimal harm or DSD. The DSD stated feeding tubes and tube feeding machines were not included in the competency review potential for actual harm and skills check.

Residents Affected - Few During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated CNAs must not turn tube feeding machines on or off. The DON stated providing tube feeding was considered medication/treatment administration and was not in the CNAs scope of practice.

According to the California Health and Safety Code Section (d) (3), Certified nurse assistant means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, and is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision of a registered nurse, as defined in Section 2725 of the Business and Professions Code, or a licensed vocational nurse, as defined in Section 2859 of the Business and Professions Code.

During a review of the facility ' s P&P titled, Gastrostomy Tube, dated 2/8/21, the P&P indicated it was part of

the facility ' s Licensed Nurse Procedures. The P&P indicated, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 056360 Department of Health & Human Services Printed: 09/04/2025 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 03/20/2025

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34273

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure appropriate staff provided proper care and maintenance for one of three sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach).

This failure had the potential for Resident 3 to not receive appropriate feeding tube nutrition and care by trained and competent staff.

Cross reference