Glendora Grand, Inc

F-F656

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility.

During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 1/26/25, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, toileting hygiene, lower body dressing, and personal hygiene. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, and with putting on/taking off footwear. The MDS indicated Resident 1 ' s did not have any skin conditions.

During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of

the resident), dated 3/28/2025, the H&P indicated Resident 1 can make needs known but cannot make medical decisions.

During a review of Resident 1 ' s General Acute Care hospital (GACH) 1 ' s Emergency Department Provider Notes (EDPN), dated 3/21/2025, the EDPN indicated Skin: Rubber band embedded in the left wrist that appears infected.

During a review of GACH 1 History of Present Illness (HPI), dated 3/21/2025 at 1:04 p.m., the HPI indicated Resident 1 had an infection related to an embedded bracelet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 056079 Department of Health & Human Services Printed: 08/29/2025 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 056079 B. Wing 04/10/2025

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

Glendora Grand, Inc 805 W. Arrow Hwy. 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 0726 During an interview on 4/9/2025 at 1:00 p.m. with LVN 1, LVN 1 stated LVN 1 was assigned to Resident 1 on 3/20/2025. LVN 1 stated LVN 1 noticed a foul smell coming from Resident 1 ' s body, but did not know where Level of Harm - Minimal harm or the smell was coming from. LVN 1 stated a full body assessment of a resident was not within LVN 1 ' s potential for actual harm scope of practice. LVN 1 stated LVN 1 did not check/assess other area on Resident 1 ' s body nor notify Resident 1 ' s foul smell to LVN 1 ' s supervisor/Registered Nurse (RN). LVN 1 stated Resident 1 was given Residents Affected - Few a shower on 3/20/2025. LVN 1 stated LVN 1 noticed the smell from Resident 1 the following day (3/21/2025). LVN 1 stated LVN 1 notified RN 1 of the smell, so LVN 1 and RN 1 went to Resident 1 ' s room. LVN 1 stated LVN 1 was instructed by RN 1 to give Resident 1 a shower. LVN 1 stated LVN 1 notified RN 1 that a shower was given to Resident 1 on 3/20/2025 but the smell did not go away.

During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON),

the DON stated the facility has LVN ' s who perform weekly body checks and when LVN ' s notice anything unusual, LVN ' s are to report to RNs for further assessment of residents. The DON stated the DON was not aware of the wound until the date of transfer to GACH 1 (3/21/2025).The DON stated the LVN 1 and RN 1 did not assess/check Resident 1 ' s skin condition as indicated in the facility ' s policy.

During a review of the facility ' s P&P titled, Skin Assessment, undated, the P&P indicated, it is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for

the promotion of healing of various skin conditions, including pressure ulcers. This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toes, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed. The assessment may also be performed after a change of condition or after any newly identified pressure ulcer.

During a review of the facility ' s P&P titled, Charge Nurse Job Description, undated, the P&P indicated, LNs provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by

the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Required Qualifications, A Nursing Degree from an accredited college or university or a graduate of an approved LPN/LVN program., Current unrestricted license as a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) in practicing state. Major Duties and Responsibilities Observes for changes in residents ' status, notifying the physician and resident ' s family or representative and documenting accordingly. Reports any incidents or unusual occurrences to the supervisor, unit manager, assistant director or nursing or director of nursing and participates in the investigative process as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 056079

F-F726

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/25, the MDS indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, The MDS indicated Resident 1 did not have any skin conditions.

During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of

the resident), dated 3/28/2025, the H&P indicated Resident 1 was able to make needs known but could not make medical decisions.

During a review of Resident 1's Nursing Weekly Assessment (NWA), dated 3/19/2025, the NWA indicated Resident 1 ' s skin was intact.

During a review of Resident 1 ' s EMS run report (a standardized document used by emergency medical service care providers), dated 3/21/2025 and timed at 11:25 a.m., the report indicated, the emergency medical technicians (EMTs) arrived at the facility on 3/21/2025 at 11:30 a.m., and was at Resident 1 ' s bedside to evaluate Resident 1 at 11:31 a.m. The EMS run report indicated, the EMTs noticed swelling to (left) arm, upon exposing arm, EMT noted a hospital bracelet and personal bracelets cutting into Resident 1 ' s skin and showing signs and smell of infection with discharge coming from the wound (on the left wrist).

During a review of Resident 1 ' s GACH 1 ' s Emergency Department Provider Notes (EDPN), dated 3/21/2025, the EDPN indicated Skin: Rubber band embedded in the left wrist that appears infected.

During a review of GACH 1 History of Present Illness (HPI), dated 3/21/2025 at 1:04 p.m., the HPI indicated Resident 1 had an infection (on Resident 1 ' s left wrist) related to embedded bracelets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 056079 Department of Health & Human Services Printed: 08/29/2025 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 056079 B. Wing 04/10/2025

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

Glendora Grand, Inc 805 W. Arrow Hwy. 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 an interview on 4/9/2025 at 1:00 p.m. with LVN 1, LVN 1 stated LVN 1 was assigned to Resident 1 on 3/20/2025. LVN 1 stated LVN 1 noticed a foul smell coming from Resident 1 ' s body, but did not know where Level of Harm - Actual harm the smell was coming from. LVN 1 stated a full body assessment of a resident was not within LVN 1 ' s scope of practice. LVN 1 stated LVN 1 did not check/assess other area on Resident 1 ' s body nor notify Residents Affected - Few Resident 1 ' s foul smell to LVN 1 ' s supervisor/Registered Nurse (RN). LVN 1 stated Resident 1 was given

a shower on 3/20/2025. LVN 1 stated LVN 1 noticed the smell from Resident 1 the following day (3/21/2025). LVN 1 stated LVN 1 notified RN 1 of the smell, so LVN 1 and RN 1 went to Resident 1 ' s room. LVN 1 stated LVN 1 was instructed by RN 1 to give Resident 1 a shower. LVN 1 stated LVN 1 notified RN 1 that a shower was given to Resident 1 on 3/20/2025 but the smell did not go away.

During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON),

the facility policy and procedure (P&P) titled, Skin Assessment, was reviewed. The P&P indicated the procedural guidelines in performing the full body skin assessment. The policy explanation and compliance guidelines indicated a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed. The policy indicated the assessment may also be performed after a change of condition or after any newly identified pressure ulcer/ (localized damage to the skin and underlying tissue caused by sustained pressure) wound. The DON stated the policy indicated, it is the facility ' s policy for staff (LVNs and RNs) to perform a full body skin assessment as part of our systematic approach for pressure ulcer/wound prevention and for the promotion of healing of various skin conditions. The DON stated the LVN 1 and RN 1 did not assess/check Resident 1 ' s skin condition as indicated in the facility ' s policy.

During an interview and record review on 4/10/2025 at 3:00 p.m. with LVN 1, LVN 1 stated, LVN 1 was to assess Resident 1 further on 3/20/2025 when LVN 1 first noticed the smell coming from Resident 1 ' s body. LVN 1 stated when the EMS arrived at the facility on 3/21/2025, one of the members from the EMS (EMT 1) asked where the smell was coming from. LVN 1 stated EMT 1 was preparing to take Resident 1 ' s blood pressure when EMT 1 noticed Resident 1 ' s bracelets (on Resident 1 ' s left wrist). LVN 1 stated the beaded bracelets, and the hospital arm band (on Resident 1 ' s left wrist) were cut off and LVN 1 witnessed the items (the beaded bracelets and the hospital arm band) falling to the floor. LVN 1 stated LVN 1 did not see Resident 1 ' s wrist due to all the EMS staff huddling around Resident 1, but LVN 1 heard them (EMS staff) said, oh this is where the smell is coming from, and LVN 1 saw EMT 1 wrap Resident 1 ' s left arm with gauze. LVN 1 stated once the EMT 1 cut the bracelets off from Resident 1 ' s left wrist the smell got stronger, and it smelled like an infected wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 056079 Department of Health & Human Services Printed: 08/29/2025 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 056079 B. Wing 04/10/2025

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

Glendora Grand, Inc 805 W. Arrow Hwy. 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 44114

Residents Affected - Few Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) when foul (bad) smell was noticed on 3/20/2025 and 3/21/2025 from Resident 1.

This failure resulted in unnoticed and untreated infected wound to Resident 1 ' s left wrist.

Cross reference