Glendora Health Care Center

Inspectors wroteBased on review of the medical record, interview with the staff, and review of facility policy, the facility failed to ensure the mail was delivered daily to Resident #1. This affected one resident (#1) out of three residents reviewed for resident rights; however it had the potential to affect all the residents in the facility. The facility census was 41. Findings Include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included borderline personality disorder, schizoaffective disorder bipolar type, asthma, obstructive sleep apnea, hypertension, obsessive compulsive disorder, insomnia, and anxiety disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition and no behaviors. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of the medical record, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to protect Resident #27 from abuse and video recording by an agency staff member. This affected one resident (#27) of three reviewed for abuse. Findings Include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes, hypertension, depression, heart failure, mild dementia, neuropathy, major depressive disorder, anxiety disorder, and hyperlipidemia. The resident resided on the [NAME] Hall. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #27 had intact cognition and had physical and verbal behaviors towards others. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure the resident's received the proper portion size on the diet tickets. This affected Resident #20 and had the potential to affect eight other residents who were to receive ground chicken salad for the meal. The facility census was 38.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to properly label and store frozen food items in the facility kitchen. This deficient practice had the potential of affecting all residents residing in the facility. The facility census was 36. Findings Include: An observation during the initial kitchen tour on 02/10/25 from 12:40 P.M. to 12:55 P.M. revealed a plastic bag with 10 frozen pork fritters sitting on top of a cardboard box on the second shelf of the freezer. The plastic bag had no date when it had been opened and/or placed in the freezer. The bag was not sealed but loosely wrapped. An interview on 02/10/25 at 12:50 P.M. with [NAME] #218 confirmed the wrapped up open plastic bag with 10 frozen pork fritters was not dated when it had been opened and/or placed in the freezer. [...]

Inspectors wroteBased on medical record review, observation, interview and facility policy review the facility failed to properly maintain breathing treatment (nebulizer) tubing and medication delivery device (mask) by not changing, cleaning and securing in a bag prior to and following administration of medication. This deficient practice affected two residents (Residents #22 and #23) of two residents reviewed for respiratory care. The facility census was 36. Findings Include: 1. A review of Resident #22's medical record revealed the initial admission date of 07/24/24 and a re-admission date of 10/15/24 with diagnoses including but not limited to opioid abuse, acute respiratory infection, anxiety and shortness of breath. Resident #22 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15 dated 12/18/24. [...]

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to store and monitor medications in a safe manner. This had the potential to affect all residents residing in the facility. The facility census was 36.

Inspectors wroteBased on observation, interview, review of the temperature logs, and review of facility policy, the facility failed to ensure food items were stored and labeled appropriately, refrigerator temperatures were monitored and recorded, and spoiled foods were discarded appropriately. This had the potential to affect all 36 residents in the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to maintain infection control practices to include Enhanced Barrier Precautions (EBP) for six residents, Resident #5, #8, #9, #12, #27, and #187 of six residents reviewed for EBP and the facility failed to ensure infection control practices were maintained during laundry services which had the potential to affect all 36 residents residing at the facility and the facility failed to disinfect the glucometer used to assess Resident #138's blood sugar prior to and after use. This affected one resident, Resident #138 of one resident reviewed for blood sugar assessments. The facility census was 36.

Inspectors wroteBased on observation and interview, the facility failed to maintain comfortable temperatures on the [NAME] unit and South unit and failed to maintain resident equipment in good repair. This affected three residents (#6, #22, and #24) of three reviewed for environment The facility census was 36.

Inspectors wroteBased on observation, interview, activity calendar review, activity director job description review and record review, the facility failed to provide individualized activities in accordance with assessments for five residents (#9, #12, #22, #27, and #32) of six residents reviewed for activities. The facility census was 36.

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure psychotropic medications were only administered when needed, failed to ensure approval for gradual dose reductions were addressed in a timely manner, and failed to ensure monitoring of target symptoms were documented. This affected three (Residents #10, #21 and #27) of five residents whose records were reviewed for medication use.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to ensure call lights were in place in three restrooms that were available for resident's use. This had the potential to affect seven residents, Resident #2, #3, #6, #15, #19, #28, and #30 who were identified by the facility as independent with mobility and transfers. The facility census was 36.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure a resident's code status was consistent amongst documents. This affected one (Resident #21) of 16 residents reviewed for advanced directives.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure residents and their representatives were provided a summary of the baseline care plan. This affected one (Resident #32) of four residents reviewed for baseline care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure individualized care plans were developed for two (Residents #1 and #6) of 14 residents reviewed for comprehensive care plans. The facility census was 36.

Inspectors wroteBased on record review and interview, the facility failed ensure care plan revision for one resident, Resident #34 to reflect current functional abilities and weight bearing status. This affected one resident (Resident #34) of three residents reviewed for care plan revision. The facility census was 36.

Inspectors wroteBased on observations, medical record review, and interview, the facility failed to implement fall interventions per resident care plans for one (Resident #12) of three residents reviewed for accidents. The facility also failed to ensure one resident, Resident #1 received thickened liquids as ordered. This affected one resident, Resident #1, of three residents reviewed for nutrition. The facility census was 36.

Inspectors wroteBased on medical record review, review of pharmacy recommendations, policy review and interview, the facility failed to ensure all pharmacy recommendations were addressed by physicians. This affected one (Resident #27) of five residents reviewed for medication use.

Inspectors wroteBased on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were administered in accordance with physician orders and policy. This affected two (Residents #15 and #138) of seven residents observed receiving medication. Two errors of 30 opportunities for error were identified resulting in a medication error rate of 6.6%.

Inspectors wroteBased on medical record review, review of infection surveillance records, policy review and interview, the facility failed to address use of a prophylactic antibiotic for a resident with recent use of multiple antibiotics. This affected one (Resident #27) of five residents revealed for medication use.

Inspectors wroteBased on observation, medical record review, review of a facility investigation, facility fall policy review, facility assessment review and interviews, the facility failed to provide adequate supervision to Resident #1, who had a diagnosis of dementia with intermittent confusion and resided on the facility secured memory care unit on 06/08/24 to prevent a fall into a shallow pond outside the facility. This resulted in Immediate Jeopardy and actual harm on 06/08/24 when Resident #1 was unattended/unsupervised outside and fell into a pond. Upon assessment, the resident's hair and clothing were wet and she was observed to be coughing. The resident was subsequently transferred to the hospital for evaluation and treatment of aspiration (of pond water). Resident #1 returned from the hospital with an order for an antibiotic. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to maintain sufficient levels of staff on the secured care unit to meet the supervisory and total care needs of all residents. This affected two residents (#1 and #2) and had the potential to affect the 11 residents residing on the facility secured memory care unit.

Inspectors wroteBased on observation, interview and policy review, the facility failed that kitchen staff wore hair restraints while serving food and in the kitchen. This had the potential to affect all 30 residents who received food from the facility. No residents were identified as receiving nothing by mouth (NPO). The facility census was 30.

Inspectors wroteBased on record review, interview and facility policy, the facility failed to ensure that Resident #33 was free from verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. This had the potential to affect all 30 residents that resided in the facility. The facility census was 30.

Inspectors wroteBased on record review, staff interview and facility policy, the facility failed to implement its abuse policy to appropriately protect Resident #33 from verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. The facility census was 30.

Inspectors wroteBased on record review, interview and facility policy, the facility failed to complete an investigation of an allegation of verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. The facility census was 30.

Inspectors wroteBased on observation and interview the facility failed to properly maintain comfortable temperatures throughout the facility. This affected eleven residents (Residents #16, #19, #20, #23, #26, #31, #34, #37, #40, #95 and #96) residing on the memory care as well as ten (Residents #2, #10, #18, #21, #32, #35, #38, #93 #94, and #193) outside of the memory care unit. The facility census was 39.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure resident records were accurate. This affected four residents (Resident #6, Resident #11, Resident #39, and Resident #144) of 20 residents whose medical records were reviewed for accuracy. The facility census was 39.

Inspectors wroteBased on record review and interview the facility failed to ensure resident assessments were accurate. This affected one resident (Resident #144) of 16 residents (Resident #1, Resident #4, Resident #6, Resident #11, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96 and Resident #97) reviewed for accuracy of assessments. The facility census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident care plans were comprehensive. This affected two residents (Resident #6, and Resident#11) of 16 residents (Resident #1, Resident #4, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96, and Resident #97) whose care plans were reviewed. The facility census was 39. Findings Include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure antibiotic treatment was administered in a timely manner and failed to ensure a physician's order was updated and canceled timely when it no longer pertained to the resident. This affected one resident (Resident #40) of three reviewed for antibiotic treatment and one resident, (Resident #11) of 19 residents reviewed for accuracy of physician orders. The facility census was 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall risk assessments were accurate, failed to ensure fall investigations were complete and thorough, and failed to ensure fall mats were in place. This affected three residents (Resident #6, Resident #19, and Resident #144) of four resident's reviewed for accidents. The facility census was 39.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure State Tested Nursing Assistant (STNA) #657 was adequately trained to apply a resident's splint. This affected one resident (Resident #11) of three residents who were ordered a splint. The facility census was 39.

Inspectors wroteBased on record review and interview the facility failed to ensure the rationale for why a gradual dose reduction was not approved was documented in the physician's notes. This affected one resident (Resident #6) of five residents (Resident #1, Resident #34, Resident #40, and Resident #144) reviewed for unnecessary medications. The facility census was 39.

Inspectors wroteBased on record review and interview the facility failed to ensure psychotropic medications were only ordered with an appropriate diagnosis. This effected one (Resident #144) of five residents reviewed for psychotropic medications. The facility census was 39.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure proper hand hygiene was maintained during a wound dressing change. This affected one resident (Resident #144) of two residents reviewed for wound care. The facility census was 39.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a clean, comfortable and homelike environment for all residents. This affected three residents (#12, #32 and #136) of 16 residents whose rooms were observed. The facility census was 35.