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Health Inspection

Glendora Grand, Inc

August 2, 2024 · Glendora, CA · 805 W. Arrow Hwy.
Citations 2
CMS Rating 1/5
Beds 342
Provider ID 056079
Healthcare Facility
Glendora Grand, Inc
Glendora, CA  ·  View full profile →
Inspection Summary

GLENDORA GRAND, INC in GLENDORA, CA — inspection on August 2, 2024.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF657
evaluate. Few During a review of Resident 228's Physician's Assistant Wound Assessment Notes (PAWAN) dated affected

During a review of Resident 228's Admission Record (AR), the AR indicated the facility admitted Resident 228 on 2/23/2024 and readmitted on [DATE] with diagnoses that included type two diabetes mellitus (occurs when there was too much sugar in the blood), End Stage Renal Disease (ESRD- kidneys were damaged and unable to filter blood), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood).

During a review of Resident 228's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/4/2024, the MDS indicated Resident 228 had moderately impaired cognition (ability to think, learn, and understand).

The MDS indicated Resident 228 was at risk for developing PU due to occasionally moist skin and very limited mobility (ability to change and control body position).

During a review of Resident 228's Admission Body Assessment ([NAME]) dated 5/30/2024, the [NAME] indicated Resident 228 was admitted to the facility with an unstageable PU on the left hip which measured 1 cm. length by 1.5 cm width.

The [NAME] indicated Resident 228 had contractures (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the body part) of bilateral (both) knees, left elbow, and left wrist.

During a review of Resident 228's Braden Scale (BS, tool used to assess resident's risk for developing a PU) form, dated 5/30/2024, the BS form indicated Resident 228 was at risk to develop a PU due to occasionally moist skin and very limited mobility.

During a review of Resident 228's untitled CP for impaired skin integrity and risk of worsening of a PU dated 5/30/2024, the CP indicated for staff to provide treatment to Resident 228's PU as ordered by MD 1 and to report further skin breakdown to MD 1.

During a review of Resident 228's Non-Pressure Sore Skin Problem Report (NPSSPR) of the right hip dated 6/22/2024, the NPSSPR indicated there was open red and moist scratches on Resident 228's right hip.

During a review of Resident 228's Physician's Order (PO) dated 6/22/2024, the PO indicated for licensed staff (TXN 1 and TXN 3) to cleanse Resident 228's right hip open scratches/wounds with NS, pat (the wounds) dry and apply calmoseptine (moisture barrier) and cover (the wound) with Optifoam (non-adhesive dressing to create a proper environment for wound healing) every day for 14 days and re-evaluate.

056079

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056079 B.

Wing 08/02/2024

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

Glendora Grand, Inc 805 W.

Arrow Hwy.

Glendora, CA 91740

During a review of Resident 228's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems), dated 3/4/2024, the MDS indicated, Resident 228 had mild cognitive (ability to think, learn, and understand) impairments.

During a review of Resident 228's Short Term Problems CP for the right hip open scratches, dated 6/22/2024, the CP indicated, a goal for Resident 228 to have a decrease in risk for further problems.

The CP intervention included for staff to notify the Medical Doctor (MD) if treatment was not effective.

During a review of Resident 228's Non-Pressure Sore Skin Problem Report (NPSSPR) for the right hip dated 6/22/2024, the NPSSPR indicated, Resident 228 had open red and moist scratches on the right hip.

The NPSSPR indicated, on 7/24/2024, Resident 228's scratches on the right hip appeared macerated (skin is soft and breaking down) and white in color.

During a concurrent interview and record review on 8/2/2024 at 11:40 AM with the Director of Nursing (DON), Resident 228's NPSSPR dated 7/24/2024 was reviewed.

The DON stated the CP was not revised when Resident 228's scratch on the right hip turned white and was macerated (on 7/24/2024).

The DON stated the CP should have been revised to ensure the resident received proper treatment.

During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, the comprehensive care plan would be reviewed and revised by the facility after each comprehensive and quarterly MDS assessment.

The P&P indicated, the comprehensive care plan would include objectives and timeframes to meet the resident's identified needs.

The P&P indicated, the facility would monitor the resident's progress and alternative interventions would be documented as needed.

056079

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056079 B.

Wing 08/02/2024

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

Glendora Grand, Inc 805 W.

Arrow Hwy.

Glendora, CA 91740

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDORA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GLENDORA GRAND, INC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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