Glendora Canyon Transitional Care Unit

In the surveyor’s words

From the most serious findings on record at Glendora Canyon Transitional Care Unit, in the surveyor’s own words.

• Immediate jeopardy, patternF755Apr 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure three of twenty-three sampled residents (Resident 351, Resident 2, and Resident 501) received pharmaceutical services to meet the needs of each resident in a consistent manner in accordance with physician orders and facility's Med-Pass policy and procedures by failing to: 1. Ensure to administer Resident 351's twelve doses of [MEDICATION(S)] (medication used to treat [CONDITION(S)], a sudden, uncontrolled electrical disturbance in the brain) 150 milligrams (mg, unit of measurement) from 4/17/2021 to 4/23/2020 (six days and a half), three doses of [MEDICATION(S)] (medication to treat partial [CONDITION(S)]) 100 mg on 4/17, 4/21, on 4/22/2021, one dose of [MEDICATION(S)] (medication used to treat seizures) 100… […]

• Immediate jeopardy, patternF760Apr 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure three of twenty-three sampled residents (Resident 351, Resident 2, and Resident 501) were free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure the licensed nurses administered twelve doses of [MEDICATION(S)] (medication used to treat [CONDITION(S)] (a sudden, uncontrolled electrical disturbance in the brain) 150 milligrams (mg, unit of measurement) from 4/17/2021 to 4/23/2021, three doses of [MEDICATION(S)] (medication to treat partial [CONDITION(S)]) 100 mg on 4/17/2021, 4/21/2021, and 4/22/2021, one dose of [MEDICATION(S)] (medication used to treat seizures) 100 mg tablet on 4/17/2021, and six doses of [MEDICATION(S)]… […]

• Actual harm, isolatedF600Sep 17, 2025

  Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 2) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program to be free from abuse. As a result, on 8/23/2025 Resident 1 pushed Resident 2 and Resident 2 fell to the floor. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for an assessment and evaluation due to an unwitnessed fall. […]

• Actual harm, isolatedF580Oct 26, 2021

  Based on interview and record review, the facility staff failed to follow its own policy and procedure for Change in a Resident's Condition or Status, by failing to promptly (with little or no delay) notify Primary Care Provider 1 (PCP 1), the nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) and obtain the necessary orders for one of four sampled residents (Resident 1) who had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) that started on 8/14/2021. […]

• Actual harm, isolatedF698Oct 26, 2021

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who required hemodialysis (HD, process of removing excess water, substances, and waste products from the blood in people whose kidneys could no longer perform these functions) received HD care and services in accordance with the resident's care plan and the facility's own policies and procedures by failing to: 1. Notify Resident 1's Primary Care Physician 1 (PCP 1), Resident 1's nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) promptly (with little or no delay) regarding Resident 1's change in condition that started on 8/14/2021 and obtain the necessary orders to meet Resident 1's HD needs. 2. […]