Gladstone Sub-acute And Rehab Center

F-F580

Findings:

During a review of Resident 40's Admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including type 2 diabetes mellitus (an adult-onset long-term condition in which the body has trouble controlling blood sugar) with diabetic neuropathy (a type of nerve damage that can occur when you have diabetes), unspecified, heart failure, unspecified and gastro-esophageal reflux disease (GERD, a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]).

During a review of Resident 40's Dietary Nutritional Assessment/Progress Note (DNAPN), dated 6/23/2023,

the DNAPN indicated Resident 40 requested to have a hamburger for lunch and no grease on Resident 40's food.

During a review of Resident 40's History and Physical Examination (H&P), dated 12/16/2023, the H&P indicated Resident 40 had the capacity to understand and make decisions.

During a review of Resident 40's Minimum Data Set (MDS, an assessment and screening tool), dated 3/22/2024, the MDS indicated, Resident 40's cognitive (ability to think and process information) skills for daily decision making were intact. 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. Assistance may be provided throughout the activity or intermittently.) with eating.

During a review of Resident 40's untitled and undated food preference ticket (FPT), the FPT indicated Resident 40 disliked milk, mild products, gravy, fried foods, mayonnaise, tuna sandwich and orange juice and liked hamburgers, peanut butter, apple slices, and small salads.

During a review of Resident 40's DNAPN, dated 3/22/2024, the DNAPN indicated Resident 40 requested to have burgers for lunch and dinner, no mayonnaise, and requested to have fried eggs for breakfast cooked on

a non-stick pan (no grease). The DNAPN indicated Resident 40 had stomach issues and could not have any kind of grease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0803 During a review of Resident 40's Progress Note (PN), dated 3/24/2024, titled Interdisciplinary Team [IDT] Monthly Weight Variance [MWV] the notes indicated Resident 40 weight 130.2 lbs. The notes indicated; the Level of Harm - Minimal harm or RD met with Resident 40 who reported did not want to lose further weight. The notes indicated Resident 40 potential for actual harm was a very selective eater and wanted foods with little to no oil due to Resident 40 experiencing diarrhea.

Residents Affected - Some During a review of Resident 40's PN-IDTMWV, dated 4/14/2024, the notes indicated Resident 40's current body weight was 127.6 lbs., and Resident 40 was below Resident 40's goal weight of 130 to 140 lbs. The notes indicated Resident 40 declined nutritional alternative options (unspecified), wanted fried eggs cooked without cooking spray or oil, and reported having episodes of diarrhea when eating fats due to Resident 40 missing Resident 40's gallbladder (body organ that breakdown oil or fat).

During a review of Resident 40's PN, dated 5/19/2024, note text: consult + monthly weight review, the notes indicated Resident 40's current body weight was 125.4 lbs. and was below Resident 40's goal weight. The notes indicated Resident 40 wanted nuts, the RD explained to Resident 40 that the facility did not carry nuts and Resident 40 confirmed Resident 40 was not interested in buying his own nuts.

During a review of Resident 40's Order Summary Report (OSR), active orders as of 6/11/2024, the OSR indicated, a physician's order dated 4/15/2024 for CCHO (consistent, constant, or controlled carbohydrate, diet to manage carbohydrate [basic food group broken into sugars in the body] consumption), NAS (no added salt) diet regular texture, regular consistency, Low Fat/Chol (cholesterol, type of fat), chopped meats (no milk), double protein with meals.

During a review of Resident 40's Weights and Vitals Summary (WVS), effective date range 11/1/2023 to 6/30/2024, the WVS indicated, the following weights:

5/1/2024 125.4 lbs (pounds, a unit of weight)

4/25/2024 127.6 lbs

3/4/2024 130.2 lbs

2/5/2024 133.6 lbs

1/2/2024 134.4 lbs

12/4/2023 138.6 lbs

11/8/2023 142.6 lbs

The WVS indicated, Resident 40 progressively lost weight in the last six (6) months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0803 During an interview on 6/10/2024 at 11:42 PM with Resident 40, Resident 40 stated, Resident 40 could have [eat] a hamburger but only a bite. Resident 40 stated, Resident 40 could eat anything but no fat, butter, or Level of Harm - Minimal harm or grease. Resident 40 stated, Resident 40 got diarrhea if Resident 40 ate [anything with] grease and gas potential for actual harm accumulated around Resident 40's crotch (between the legs). Resident 40 stated Resident 40 was tired of arguing [regarding food preferences] Resident 40 felt like no [staff] were listening to Resident 40. Resident Residents Affected - Some 40 stated, I eat as much as I could and if I lose weight, I lose weight.

During a concurrent observation and interview on 6/12/2024 at 12:43 PM with Resident 40, Resident 40 was sitting at the side of Resident 40's bed on a wheelchair, there was a lunch tray that had a hamburger with about 2 bites eaten from the patty, an empty fruit bowl, and an empty glass of juice. Resident 40 stated, I ate as much as I can, I cannot eat anything on here [pointing to the lunch tray]. Resident 40 stated, Resident 40 ate the canned fruit and drank the juice, that's all I can eat. Resident 40 stated, the hamburger meat was oily and stated he liked the hamburger patty well done without any oil. Resident 40 stated Resident 40 did not have a gallbladder and anything Resident 40 ate that had oil went right through Resident 40. Resident 40 stated, I shit oil and it stinks. Resident 40 stated, I am blind, and I don't have a leg, so I need someone to clean me. Resident 40 stated Resident 40 got pain in Resident 40's stomach because the gas [due to greasy food] went up Resident 40's stomach and Resident 40 felt so uncomfortable. Resident 40 stated he avoided

the whole thing [eating greasy foods] and stated Resident 40 ate what Resident 40 could from served meals or, I just don't eat. Resident 40 stated Resident 40 has told them (unidentified staff members) so many times and stated he talked to everyone here [at the facility] that would listen - but you know what?, I'm tired of arguing, I just don't have the strength to argue anymore [and] I just eat what is given to me.

During an interview and concurrent record review of Resident 40's Dietary Nutritional Screening Assessment (DNSA) and chart, dated 12/21/2023, with the Registered Dietician (RD), on 6/12/2024 at 12:57 PM, the DNSA indicated Resident 40 disliked greasy foods, liked fried eggs (no oil or butter) for breakfast, and burgers for lunch and dinner. The RD stated Resident 40 experienced a weigh loss of 12.6% in six months.

The RD stated Resident 40 was offered nutritional alternative options, however, the RD could not remember

the kinds of alternative foods offered to Resident 40. The RD was unable to provide or locate documentation that indicated the types of food alternatives offered to Resident 40. The RD stated food alternative options and accommodating residents was important to help them be happy with what they were eating and to stay

in compliance with the ordered diet.

During an observation and concurrent interview with the cook (CK), on 6/12/2024 at 1:15 PM, the CK stated Resident 40 was the only resident at the facility who received a fried hamburger for lunch and dinner. The CK stated the CK fried [with oil] Resident 40's hamburger patty in a regular pan. A regular pan was observed with grease on the base of the pan. A non-stick pan was observed on top of the preparation table, clean, and unused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0803 During an interview with the Dietary Supervisor (DS), on 6/12/2024 at 1:19 PM, the Dietary Services Supervisor (DSS) stated Resident 40 had requested (date unidentified) a fried egg to be cooked in a Level of Harm - Minimal harm or non-stick-pan without oil or fat. The DSS stated the DSS informed Resident 40 that even on non-stick pans, potential for actual harm oil was needed to cook eggs. The DSS stated I cannot cook eggs without oil. The DSS stated the DSS gave Resident 40 a food alternative [well-done patty] and Resident 40 received a fried hamburger every day for Residents Affected - Some lunch and dinner. The DSS stated Resident 40 had requested a well-done hamburger patty to minimize oil content. The DSS stated there were other ways to cook a hamburger patty such as grilling or steaming the patty. The DSS stated it was important for the facility to respect the dietary preferences of the residents because that was a resident's right as long as it was compliant with the doctor's order.

During an interview with the Assistant Director of Nursing (ADON) and Resident 40 at Resident 40's bedside,

on 6/12/2024 at 4:09 PM, Resident 40 stated, I wanted nuts such as cashews or almonds. They [the facility] no longer provided meals that I wanted, like big salads and fresh fruits. I love fruits and salads! I don't want anything fried or sauces on my food.

During an interview with the ADON on 6/12/2024 at 4:20 PM, the ADON stated Resident 40 was awake, alert, and oriented. The ADON stated Resident 40's food wishes were ordinary, manageable, and could easily be provided by the facility. The ADON stated food preferences were not followed [for Resident 40] by

the kitchen [staff] and stated this was a factor that could contribute to [further] weight loss and unwanted weight loss could affect Resident 40's health due to the lack of nutrition for Resident 40's body.

During an interview and concurrent record review of Resident 40's FPT with the DSS, on 6/12/2024 at 4:36 pm, the DSS stated the FPT did not indicate Resident 40 could not tolerate oil, preferred the hamburger patties well done, and liked fried eggs [cooked on a non-stick pan]. The DSS stated specifics indicated in the FPT were important because the kitchen cooks based [meal preparation] on resident likes and dislikes indicated on the FPT.

During a review of the facility's P&P titled, Unplanned Weight Loss,' release date 4/2018, indicated the purpose of the procedure is to provide appropriate interventions for any unplanned weight loss. The P&P included fundamental information that indicated, 6 months - 10% weight loss is significant; greater than 10% is severe weight loss.

During a review of the facility's P&P titled, Nutrition & Weight Variance Committee), dated 11/1/2017, the P&P indicated to ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels . Objectives of the P&P may include but not limited to assessing changes in diet, food preferences and increased caloric intake.

During a review of the facility's policy titled Resident Rights - Accommodation of Needs, dated 5/1/2023, the P&P indicated to ensure that the facility provides an environment and services that meet the resident's individual needs. The P&P indicated residents' individual needs and preferences are accommodated to the extent possible . and to accommodate a resident's individual needs and preferences, facility staff will assist

the resident in maintaining independence, dignity, and well-being to the extent possible according to their wishes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0803 During a review of the facility's undated document titled, Department of Food and Nutrition Services Consultant (Consultant Dietician) Job Description, indicated the registered dietician (RD) provides Level of Harm - Minimal harm or consultation to the facility for the purpose of providing nutrition care and oversight of the operations of the potential for actual harm Department of Food and Nutrition Services, which will result in optimal health of the resident/patient. The RD evaluates the nutritional needs of resident/patients and documents in the nutritional record, evaluates and Residents Affected - Some monitors the food service department to assure that the department is providing adequate acceptable quality food.

During a review of a facility undated document titled, Dietary Manager [DM] Job Description, the document indicated the DM's principal responsibilities were to ensure the meals were served according to expressed resident preferences, implements and revises menus to meet resident's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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** 48729

Residents Affected - Some Based on observation, interview, and record review, the facility failed to remove one unopened expired milk carton and 22 apples, received [DATE REDACTED], from one of one walk-in refrigerator (Refrigerator 1).

This failure had the potential to result in food poisoning (illness caused by food contaminated with bacteria [living organism that can cause an infection]) from serving spoiled foods to the residents who were able to consume the food items.

Findings:

During a concurrent observation and interview on [DATE REDACTED] at 9:45 AM with the Dietary Services Supervisor (DSS) in the facility's Refrigerator 1, there was a clear plastic bin that contained 22 red apples labeled received on [DATE REDACTED] and opened on [DATE REDACTED]. The DSS stated the label was correct and the fruit was received

on [DATE REDACTED].

During a concurrent interview and record review on [DATE REDACTED] at 9:49 AM with the DSS, the facility's Suggested Refrigerated Storage Guideline, dated 2018, was reviewed. The Suggested Refrigerated Storage Guideline, indicated to store apples for one month. The DSS stated the DSS would throw out the apples because even though they looked good, the apples could be bad on the inside. The DSS further stated the DSS would not serve the apples to the residents (in general) because it could make them sick.

During a concurrent observation and interview on [DATE REDACTED] at 9:53 AM with the DSS in the facility's Refrigerator 1, there was one of three unopened 1-gallon whole milk containers dated [DATE REDACTED]. The DSS stated the unopened milk dated [DATE REDACTED] expired [DATE REDACTED] and should not be in Refrigerator 1. The DSS further stated the milk would be thrown out immediately so it was not accidentally served to the residents because

the residents could get sick if the milk was consumed.

During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2018, the P&P indicated older perishable foods should be rotated to use the first in-first out method.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 056118

F-F803

Findings:

During a review of Resident 40's AR, the AR indicated Resident 40 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including type 2 diabetes mellitus (an adult-onset long-term condition in which the body has trouble controlling blood sugar) with diabetic neuropathy (a type of nerve damage that can occur when you have diabetes), unspecified, heart failure, unspecified and gastro-esophageal reflux disease (GERD, a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]).

During a review of Resident 40's History and Physical Examination (H&P), dated 12/16/2023, the H&P indicated Resident 40 had the capacity to understand and make decisions.

During a review of Resident 40's Minimum Data Set (MDS, an assessment and screening tool), dated 3/22/2024, the MDS indicated, Resident 40's cognitive (ability to think and process information) skills for daily decision making were intact. 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. Assistance may be provided throughout the activity or intermittently.) with eating.

During a review of Resident 40's Order Summary Report (OSR), active orders as of 6/11/2024, the OSR indicated, a physician's order dated 4/15/2024 for CCHO (consistent, constant, or controlled carbohydrate, diet to manage carbohydrate [basic food group broken into sugars in the body] consumption), NAS (no added salt) diet regular texture, regular consistency, Low Fat/Chol (cholesterol, type of fat), chopped meats (no milk), double protein with meals. The OSR indicated a physician's order, dated 12/17/2022 for Diuretics - monitor for the following: decreased po (oral) intake . every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0656 During a review of Resident 40's Medication Administration Record (MAR), dated June 2024, the MAR indicated, Diuretics - Monitor for the following: decreased po intake .and/or sunken eyes. The MAR indicated, Level of Harm - Minimal harm or staff documented 0 and indicated Resident 40 did no have decreased po intake or sunken eyes. potential for actual harm

During a review of Resident 40's Weights and Vitals Summary (WVS), effective date range 11/1/2023 to Residents Affected - Few 6/30/2024, the WVS indicated, the following weights:

6/3/2024 123.8 lbs (pounds, a unit of weight)

5/1/2024 125.4 lbs

4/25/2024 127.6 lbs

3/4/2024 130.2 lbs

2/5/2024 133.6 lbs

1/2/2024 134.4 lbs

12/4/2023 138.6 lbs

11/8/2023 142.6 lbs

The WVS indicated, Resident 40 progressively lost weight in the last six (6) months.

During an interview on 6/10/2024 at 11:42 PM with Resident 40, Resident 40 stated, Resident 40 could have (eat) a hamburger but only a bite. Resident 40 stated, Resident 40 could eat anything but no fat, butter, or grease. Resident 40 stated, Resident 40 got diarrhea if Resident 40 ate [anything with] grease. Resident 40 stated, Resident 40 was blind and did not remember which staff Resident 40 had spoken to regarding food dislikes. Resident 40 stated Resident 40 was tired of arguing [regarding food preferences] Resident 40 felt like no [staff] were listening to Resident 40.

During a concurrent observation and interview on 6/12/2024 at 12:43 PM with Resident 40, Resident 40 was sitting at the side of Resident 40's bed on a wheelchair, there was a lunch tray that had a hamburger with about 2 bites eaten from the patty, Resident 40 stated, I ate as much as I can. Resident 40 stated, Resident 40 ate the canned fruit and drank the juice, that's all I can eat. Resident 40 stated, the hamburger meat was oily.

During an interview and concurrent record review on 6/13/2024 at 1:55 PM with the Assistant Director of Nursing (ADON), the ADON stated there was no completed CP that addressed weight loss for Resident 40.

The ADON stated, Resident 40 should have had a weight loss CP for staff to know what interventions that were realistic for Resident 40 could be done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0656 During a review of the facility's P&P titled, Care Planning, date revised 10/24/2022, the P&P indicated, to ensure that a comprehensive person-centered CP was developed for each resident based on their individual Level of Harm - Minimal harm or assessed needs. The P&P indicated, the CP served as a course of action where the resident (resident's potential for actual harm family and/or guardian or other legally authorized representative), resident's attending physician, and Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care Residents Affected - Few for residents) work [together] to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44027 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident Residents Affected - Few (Residents 17) was provided proper interventions for edema (swelling caused by too much fluid trapped in

the body's tissues) when the facility failed to elevate Resident 17's upper extremities (shoulders, elbows, wrists, or hands) to decrease edema as indicated in Resident 17's care plan (CP), titled, [Resident 17] is at Risk for Impaired Skin Integrity as evidenced by edema .

This failure had the potential to result in worsening or unresolved edema for Resident 17 and placed Resident 17 at an increased risk of developing blood clots and/or skin injuries, additionally, the failure had

the potential to result in a physical decline to Resident 17.

Findings:

During a review of Resident 17's Admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including chronic respiratory failure (when the lungs can't get enough oxygen into the blood), type 2 diabetes mellitus (a chronic, long standing, condition that affects the way the body processes blood sugar), and heart failure (condition in which the heart cannot pump enough blood to all parts of the body).

During a review of Resident 17's CP titled, [Resident 17] is at Risk for Impaired Skin Integrity as evidenced by edema to: right and left upper extremities, initiated 5/11/2024, the care plan's interventions indicated to elevate (allows the blood to circulate back to the heart without fighting gravity) Resident 17's arms and legs.

During a review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/17/2024, the MDS indicated Resident 17 was severely impaired (never/rarely made decisions)

in cognitive skills (ability to make daily decisions). The MDS indicated Resident 17 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing.

During an observation on 6/10/2024 at 10:55 AM, Resident 17 was asleep in bed, lying on Resident 17's back with the head of the bed (HOB) elevated. Resident 17's arms were at Resident 17's side and were flat

on the mattress and not elevated on pillows. Resident 17's fingers and forearms were swollen.

During an interview on 6/11/2024 at 2 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 17 had edema. LVN 1 stated interventions to treat Resident 17's edema included keeping Resident 17's arms and legs elevated with pillows to lessen the edema on Resident 17's legs and arms. LVN 1 stated if the facility staff did not keep Resident 17's arms and legs elevated then Resident 17 would be at an increased risk of getting blood clots.

During an interview on 6/11/2024 at 2:02 PM with Treatment Nurse (TN) 1, TN 1 stated if facility staff did not elevate Resident 17's arms then there was an increased risk for Resident 17 to develop blood clots in her arms and there was increased risk of skin breakdown. TN 1 stated Resident 17 should have a pillow under Resident 17's arms to keep Resident 17's arms elevated (facility practice to use pillows to elevate extremities).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0684 During a review of the facility's policy and procedure (P&P) titled, Care Standards, revised 11/1/2017, the P&P indicated, All residents shall receive necessary care and services to assist them in attaining or Level of Harm - Minimal harm or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with potential for actual harm a comprehensive assessment and plan of care.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 056118 Department of Health & Human Services Printed: 09/23/2025 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 056118 B. Wing 06/13/2024

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

Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure food preferences, such as nuts and foods that did not contain oil, were served and followed for one of one sampled resident (Resident 40) as indicated in the facility's policy and procedures (P&P).

This failure resulted in further weight loss to Resident 40 and had the potential to result in a physical decline to Resident 40.

Cross Reference