Glendora Health Care Center

In the surveyor’s words

From the most serious findings on record at Glendora Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 3, 2024

  Based 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). […]

• Immediate jeopardy, isolatedF744Aug 1, 2022

  Based on observation, record review, review of facility staff statements, review of the Centers for Medicare and Medicaid (CMS) guidance related to sexual activity and consent, review of the facility Alzheimer's and Dementia policy and procedure manual and staff, resident, family and Physician (#120) interviews, the facility failed to ensure comprehensive assessments were completed and individualized interventions were initiated for Resident #32 and Resident #35, who had impaired cognition and resided on the facility's secured memory care unit to address the resident's total behavioral and psychosocial care needs and to address the capacity of the residents to engage in consensual sexual activity. […]

• No harm, potential for more than minimal, widespreadF761Sep 24, 2024

  Based 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. Findings include: 1. Observation on [DATE] at 3:43 P.M. with the Director of Nursing (DON) of the west medication storage room revealed two boxes (100 per box) of bisacodyl (10 milligram) suppositories. Each partially used box had an expiration date of ,d+[DATE]. The DON confirmed the suppositories were a stock medication for residents as needed and they were expired. Observation of the refrigerator revealed multiple boxes of influenza vaccines (stock), six tuberculin vials (stock) 28 haldol injections vials and multiple resident insulin pens. 2. […]

• No harm, potential for more than minimal, widespreadF812Sep 24, 2024

  Based 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. Findings include: 1. On 09/15/24 at 9:41 A.M., during the initial tour of the kitchen, the following were observed in the dry storage room: one opened bag of raspberry gelatin mix with no label indicating the open date, one open bag of dry pasta unsealed and with no label indicating the open date, one open bag of dry pasta with a paperclip holding it closed and no label indicating the open date, two plastic storage containers labeled bread crumbs… […]

• No harm, potential for more than minimal, widespreadF880Sep 24, 2024

  Based 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. Findings include: 1. Record review for Resident #12 revealed an admitted [DATE]. […]