Glendora Canyon Transitional Care Unit

During a review of Resident 1's AR, the AR indicated Resident 1 was admitted to the facility 6/8/2025 with diagnoses that included type 2 diabetes (a disease that results in elevated levels of glucose in the blood) and essential hypertension (high pressure of blood pushing against the wall of the arteries).

During a review of Resident 1's History and Physical (H&P) Examination, dated 6/9/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's SBAR Communication Form, dated 8/23/2025, the form indicated Resident 1 had a disagreement with [Resident 2] and Resident 1 pushed Resident 2.

During an interview on 8/28/2025 at 11 am with Resident 1, Resident 1 stated on 8/23/2025 (could not remember the time) Resident 1 had an altercation (a conflict that can range from verbal arguments to physical fights, occurring between two or more individuals receiving care) with Resident 2. Resident 1 stated Resident 2 was sitting across the hall and Resident 1 was walking into Resident 1's room when Resident 2 said something to Resident 1 and Resident 1 told Resident 2 to, shut up and mind his [Resident 2's] own business. Resident 1 stated Resident 2 was walking toward Resident 1 and, I pushed and dropped Resident 2 to the ground, and he [Resident 2] started yelling he [Resident 1] hit me.

During an interview on 9/2/2025 at 1 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 8/23/2025 at 11:30 am LVN 4 yelled out, Resident 2 is on the floor. LVN 3 stated, LVN 3 ran toward LVN 4 and when LVN 3 arrived Resident 2 was on the floor on Resident 2's left side, and Resident 1 was standing over Resident 2. LVN 3 stated Resident 1 told Resident 2, That is what you get they should have kicked you out a long time ago. LVN 3 stated Resident 2 did not respond to Resident 1, turned to LVN 3 and stated, My back and arm are hurting [pain unrated], call an ambulance because I do not feel I can get up from the floor. LVN 3 stated Resident 2 complained of 7 out of 10 pain on Resident 2's back and [right] arm.

During an interview on 9/2/2025 at 2:33 pm with LVN 4, LVN 4 stated LVN 4 heard a staff (unidentified) say Mister fell. LVN 4 stated LVN 4 rushed down the hallway and observed Resident 1 standing by Resident 1's room yelling and laughing at Resident 2 and stated, That is what you get you should not be here, yea I pushed him so what, I pushed him. Resident 2 was lying on the floor and stated, Help me, I can't get up.

During a review of the facility's P&P titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

The P&P indicated, this includes but is not limited to freedom from corporal punishment (the use of physical force to cause pain or discomfort as a way to discipline or correct a behavior), involuntary seclusion (keeping someone separated from others against their will), verbal, mental, sexual, or physical abuse.

The P&P indicated, the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to support the following objectives: 1.

Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: b. other residents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Glendora Canyon Transitional Care Unit

401 W.

Ada Ave.

Glendora, CA 91741

SUMMARY STATEMENT OF DEFICIENCIES