Arbor Glen Care Center

During the bed bath, Resident 2 cried out in pain three times. At 9:57 AM, Resident 2 stated, I've had 45 minutes of pain, Oh my God.

During an interview on 2/20/26 at 3:12 PM, the TN stated pain management is important prior to treatment to promote resident's comfort.

During an interview on 2/20/2026 at 4:26 PM, the Director of Nursing (DON) stated pain management was important prior to wound care treatment to ensure the resident would not be in pain and suffer during the procedure.

The DON stated the treatment nurse and the charge nurse need to communicate with each other to premedicate residents prior to wound care treatment.During a review of the facility's Policy and Procedure (P&P) titled Pain Management 5/2007, the P&P indicated, The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: Screening to determine if the resident has been or is experiencing pain.

Comprehensively assessing the pain.

Identifying circumstances when pain can be anticipated.

Developing and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals.

056360 02/20/2026

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/3/2021 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract) and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 3 had an active diagnosis of MDRO (multidrug-resistant organism or bacteria that resists many antibiotics, making infections difficult to treat).

The MDS indicated Resident 3's cognition (thinking, knowing, and being aware) was intact.

The MDS indicated Resident 3 was dependent on staff (in general) with showering/bathing and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort to complete the activity) with personal hygiene.During a review of Resident 3's Order Summary Report (OSR), the OSR indicated there was a physician's order, dated 8/12/2025, to place Resident 3 on Enhanced Barrier Precautions (EBP- gown and glove use when performing specific high-contact resident care activities for residents with wounds and/or indwelling medical device [inserted into the body and remain in place for an extended period]) due to indwelling urinary catheter (a flexible tube inserted and left inside the bladder to drain urine) and MDRO.b.

During a review of Resident 4' s AR, the AR indicated the facility admitted Resident 4 on 3/5/2025 with diagnoses that included infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, endocarditis.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was intact.

The MDS indicated Resident 4 was dependent on staff (in general) with showering/bathing.During an observation on 2/20/2026 at 10:43 AM, Certified Nursing Assistant 3 (CNA 3) was providing a bed bath to Resident 3.During an observation on 2/20/2026 at 11:04 AM, CNA 3 completed the bed bath for Resident 3. CNA 3 did not remove the protective gown CNA 3 used while CNA 3 provided care to Resident 3, took clean gloves from the box, and prepared all the items for Resident 4's bed bath.During a concurrent observation and interview on 2/20/2025 at 11:10 AM, CNA 3 closed the privacy curtains around Resident 4's bed and proceeded to provide a bed bath to Resident 4. CNA 3 stated CNA 3 would wear the same gown and only change gloves to care for Resident 3 and Resident 4 because Resident 3 was not on any precautions. CNA 3 stated the gown was just for prevention.

During an interview on 2/20/2025 at 4:43 PM, the Infection Prevention Nurse (IPN) stated Resident 3 was on EBP for a history of MDRO in the urine. EBP was to protect Resident 3 and other residents around Resident 3 from getting MDRO.

During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 3/2024, the P&P indicated, Enhanced Barrier Precautions used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident - to resident.

The P&P indicated the MDRO's for which the EBP applies include ESBL producing Enterobacterales.

Examples of high contact resident care activities requiring gown and gloves use for Enhanced Barrier Precaution include bathing/showering, dressing, providing hygiene, changing linens.During a review of the facility's P&P titled, Isolation and Prevention, dated 3/2024, the P&P indicated, Change gloves and gowns after each resident encounter and perform hand hygiene.