Glendora Canyon Transitional Care Unit

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review the facility failed to maintain a safe and comfortable room temperature in 2 of 2 resident shower rooms observed.This deficient practice had the potential to cause discomfort and unsafe conditions for residents who used the shower rooms.During a concurrent

observation and interview on 8/26/25 at 11:27 AM, with Certified Nurse Assistant 1 (CNA 1) the thermostat of the third-floor shower room showed 82 F. CNA 1 stated, It is hot and stuffy, not usually like this.During a concurrent observation and interview on 8/26/25 at 11:31 AM with Licensed Vocational Nurse 1 (LVN 1) the thermostat of the second-floor shower room, showed 85 F. LVN 1 stated the room feels hot and stuffy.

During an interview on 8/26/25 at 12:40 PM, with Maintenance Supervisor (MS), MS stated, Yes, the AC (air conditioner) has been acting up and it is scheduled to be repaired. MS stated that the temperatures are high in the shower rooms.A review of the facility's policy titled Homelike Environment, revised February 2021, indicated staff are to provide a safe, clean, comfortable, and homelike environment for residents. The policy indicated comfortable and safe temperatures (71 F - 81 F) must be maintained in resident areas, including bathing and shower rooms.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Glendora Canyon Transitional Care Unit

401 W. Ada Ave.

Glendora, CA 91741

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 potential for actual harm

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Resident 1's responsible party (RP, a person who is responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) was informed when Resident 1's blood sugar level was 480 and Resident 1 had to be given additional dose of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) on 5/17/2025 at 12:23 pm.2.

Resident 1's blood sugar level of 480 on 5/17/2025 was documented in Resident 1's medical record.3. An SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form was filled out on 5/17/2025 at 12:23 pm when Resident 1's blood sugar level was 480 and Resident 1 had to be given an additional dose of insulin.These failures resulted in Resident 1's RP not being informed of Resident 1's change in condition and had the potential for Resident 1 to receive inadequate monitoring, care, and treatment of Resident 1's high blood sugar.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/04/2024, and readmitted Resident 1 on 6/20/2025 with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 6/21/2025, indicated Resident 1 did not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/26/2025, the MDS indicated Resident 1's cognitive skills (the ability to think and process information) for daily decision making was severely impaired, and Resident 1 was dependent on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report (OSR), dated 9/3/2025, the OSR indicated there was a physician's order, dated 5/17/2025, to give Resident 1 one dose of

an injection of 3 units of insulin lispro (fast-acting insulin) for blood sugar of 480.During a review of Resident 1's Medication Administration Record (MAR) for the month of May 2025, the MAR indicated on 5/17/2025 at 12:23 pm, Resident 1 was given an injection of 3 units of insulin lispro (fast-acting insulin) due to blood sugar of 480.During a concurrent interview and record review on 9/3/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated any blood sugar level above 401 required a Change of Condition (COC) note or an SBAR Communication Form, a physician notification, and a family or RP notification. The DON reviewed Resident 1's medical record and was unable to find a COC note, a progress note, and or an SBAR Communication Form regarding Resident 1's blood sugar level of 480 on 5/17/2025. The DON was unable to find family or RP notification regardingDuring a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised on February 2021, the P&P indicated, Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.a nurse will notify the resident's representative when there is a significant change in

the resident's physical, mental, or psychosocial status.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet