Health inspection·May 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review facility failed to follow its policy and procedure (P&P) titled, Care Planning, by failing to: Residents Affected - Few Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) implemented Resident 5's untitled care plan (CP) for the potential for fluid volume overload (occurs when there is an excessive accumulation of fluid in the body) related to left and right lower extremities (limb) pitting edema, plus four [+ 4, severity of edema, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade +4: 8-millimeter (mm) of depression, rebounding in 2-3 minutes], and left upper extremity pitting edema plus one [+1, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 1: Immediate rebound with 2 mm pit]. As a result of this failure, facility staff were not applying Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs) to Resident 5's left and right legs as indicating in Resident 5's CP. Facility staff did not know when Resident 5 last wore the TED hose. LNs were not appropriately assessing and documenting Resident 5's pitting edema to the lower legs. Resident 5 experienced 6 out of 10 pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) to Resident 5's toes. These failures put Resident 5 risk for increased edema to the lower legs and complications such as decreased circulation (blood flow through the body) and infection. Cross Reference: F684 and F842 Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 2/16/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), heart failure (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 5's untitled care plan (CP), initiated 6/12/2024, the CP indicated Resident 5 had the potential for fluid volume overload related to left and right lower extremities (limb) pitting edema +4, and left upper extremity pitting edema +1. The CP goals indicated that Resident 5 would remain free of signs and symptoms of fluid overload as evidence by a decrease in or absence of edema. The CP interventions included for Resident 5 to (wear) TED hose stockings as ordered and Page 1 of 7 056118 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0656 may remove (them) during patient care. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5 Physician Telephone Order (TO), dated 11/14/2024, the TO indicated Resident 5 had an order to wear TED hose stocking to bilateral (both) lower extremities for leg swelling/edema. May remove during patient care. Residents Affected - Few During a review of Resident 5's medication administration record (MAR- a report that serves as a legal record of the medications and monitoring administered to a resident) dated 11/2024-5/2025, the MAR did not indicate TED hose were applied to Resident 5's bilateral lower extremities. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 2/21/2025, the MDS indicated Resident 5 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with upper and lower body dressing. The MDS indicated Resident 5 was taking diuretic medication (medications that promote the excretion of excess water and electrolytes [minerals] through the kidneys and out the body). During a concurrent observation and interview on 5/5/2025 at 12:46 pm, with Resident 5, in Resident 5's room, Resident 5's legs were observed. Resident 5 stated Resident 5 was supposed to be wearing TED hose but did not have them on. Resident 5 stated facility staff (unspecified) were not putting TED hose on him, and did not understand why. During an interview on 5/5/2025 at 1:26 pm, with LVN 2, LVN 2 stated compression socks (TED hose) were for the treatment of edema. LVN 2 stated when Resident 5 was not wearing the TED hose and LNs were not keeping track of the edema in Resident 5's feet and legs, Resident 5's edema could get worse and make Resident 5 sick. During a concurrent observation and interview on 5/5/2025 at 1:30 pm, with LVN 2, in Resident 5's room, Resident 5's legs were observed. LVN 2 stated Resident 5 was not currently wearing TED hose. LVN 2 stated Resident 5 had pitting edema to the lower legs. During a concurrent observation and interview on 5/5/2025 at 1:20 pm, with RN 1 and LVN 2, in Resident 5's room, Resident 5's legs were observed. RN 1 stated Resident 5 had +4 pitting edema in the left leg, and the right leg had the +3 pitting edema [the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 3: The pressure leaves an indentation of 5-6 mm that takes up to 60 seconds to rebound]. RN 1 stated Resident 5 was not wearing the TED hose. During a concurrent interview and record review on 5/16/2025 at 3:39 pm, with the Director of Nursing (DON), the DON stated (in general) it was important to follow CP interventions because it was essentially following physician orders. The DON stated that when LNs were not following CP interventions then the resident's condition could get worse by affecting breathing if fluid got into the lungs, causing the resident to weigh more, and could lead to hospitalization. A review of the facility's P&P titled, Care Planning, dated 10/24/2022, indicated for the facility To ensure that a comprehensive person-centered Care Plan is developed for each resident based on tire individual assessed need. The P&P indicated the resident has the right to receive the services and/or items included in the plan of care. 056118 Page 2 of 7 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record, review facility failed to follow its policy and procedure (P&P) titled, Physician Orders, and Care Planning (CP), for one of five sampled residents (Resident 5) by failing to: Residents Affected - Some 1. Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs] followed Resident 5's physician order, dated 11/14/2024 for Resident 5 to wear Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs). 2. Ensure licensed nurses implemented Resident 5's untitled CP, dated 6/12/2024. 3.Ensure Licensed Nurses were monitoring and documenting Resident 5 wearing the TED hose. As a result of these failures, facility staff were not applying TED hose to Resident 5's left and right legs. Facility staff did not know when Resident 5 last wore the TED hose. Resident 5 experienced 6 out of 10 pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) to Resident 5's toes. These failures put Resident 5 risk for increased edema to the lower legs and complications such as decreased circulation (blood flow through the body) and infection. Cross Reference: F656 and F842 Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 2/16/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), heart failure (occurs when the heart cannot pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 5's untitled care plan (CP), initiated 6/12/2024, the CP indicated Resident 5 had the potential for fluid volume overload related to left and right lower extremities (limb) pitting edema, plus four [+ 4, severity of edema, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade +4: 8-millimeter (mm) of depression, rebounding in 2-3 minutes] and left upper extremity pitting edema, plus one [+1, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 1: Immediate rebound with 2 mm pit]. The CP goals indicated that Resident 5 would remain free of signs and symptoms of fluid overload as evidence by a decrease in or absence of edema. The CP interventions included for Resident 5 to (wear) TED hose stockings as ordered and may remove (them) during patient care. During a review of Resident 5 Physician Telephone Order (TO), dated 11/14/2024, the TO indicated Resident 5 had an order to wear TED hose stocking to bilateral (both) lower extremities for leg swelling/edema. May remove during patient care. During a review of Resident 5's medication administration record (MAR- a report that serves as a 056118 Page 3 of 7 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some legal record of the medications and monitoring administered to a resident) dated 11/2024-5/2025, the MAR did not indicate TED hose were applied to Resident 5's bilateral lower extremities. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 2/21/2025, the MDS indicated Resident 5 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with upper and lower body dressing. The MDS indicated Resident 5 was taking diuretic medication (medications that promote the excretion of excess water and electrolytes [minerals] through the kidneys and out the body). During a concurrent observation and interview on 5/5/2025 at 12:46 pm, with Resident 5, in Resident 5's room, Resident 5's legs were observed. Resident 5 pulled up Resident 5's flat sheet to show Resident 5's lower legs. Resident 5 appeared to have 4+ pitting edema to both lower extremities. Resident 5 was not wearing the TED hose. Resident 5 stated Resident 5 was supposed to be wearing TED hose but did not have them on. Resident 5 stated facility staff (unspecified) were not putting TED hose on him, and Resident 5 did not understand why. Resident 5 stated it had been more than three weeks since facility staff applied the TED hose to both of Resident 5's legs. Resident 5 stated, I don ' t know if it's helping the edema because I do not get to wear them. Resident stated, I can't build up a tolerance to wear them because no one is consistently putting them on me. Resident 5 stated Resident 5 had told facility staff (unspecified) Resident 5 was supposed to be wearing TED hose, but no one listened to Resident 5. During a concurrent interview and record review on 5/5/2025 at 1:26 pm, with LVN 2, Resident 5's TO, dated 11/14/2024 was reviewed. LVN 2 stated that because of the way Resident 5's physician order was transcribed (converting a spoken or handwritten order into a typed or digital format), LNs did not have to document if Resident 5 was wearing the TED hose. LVN 2 stated compression socks (TED hose) were for the treatment of edema. LVN 2 stated when Resident 5 was not wearing the TED hose and LNs were not keeping track of the edema in Resident 5's feet and legs, Resident 5's edema could get worse and make Resident 5 sick. LVN 2 stated LVN 2 had to document how much edema Resident 5 had in the MAR. During a concurrent observation and interview on 5/5/2025 at 1:30 pm, with LVN 2, in Resident 5's room, Resident 5's legs were observed. LVN 2 stated Resident 5 was not currently wearing TED hose. LVN 2 stated Resident 5 had pitting edema to the lower legs. LVN 2 stated LVN 2 needed to get an RN to determine how much edema Resident 2 had. LVN 2 stated LVN 2 was not sure how to assess the edema. LVN 2 stated LVN 2 wanted an RN's opinion for stating what Resident 5's edema status was. LVN 2 stated LVN 2 documented Resident 5's edema earlier in the morning on the day of the interview but did not remember what LVN 2 documented. During a concurrent observation and interview on 5/5/2025 at 1:20 pm, with RN 1 and LVN 2, in Resident 5's room, Resident 5's legs were observed. RN 1 stated Resident 5 had 4+ pitting edema in the left leg, and the right leg had plus three pitting edema [+3, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 3: The pressure leaves an indentation of 5-6 mm that takes up to 60 seconds to rebound]. RN 1 stated Resident 5 was not wearing TED hose. During a concurrent interview and record review on 5/5/2025 at 1:36 pm, with RN 1, Resident 5's TO, dated 11/14/2024 was reviewed. RN 1 stated the way Resident 5's order (for TED hose) was transcribed, LNs were not required to monitor or document when Resident 5 was or was not wearing the TED hose. 056118 Page 4 of 7 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RN 1 stated RN 1 did not know when the last time TED hose were applied to Resident 5 legs. RN 1 stated Resident 5 should be wearing the TED hose all the time, except during patient care, such as cleaning or changing Resident 5. RN 5 stated without keeping track of when and how long Resident 5 was wearing the TED hose, Resident 5's edema could get worse because RN 1 did not know the last time the TED hose were applied to Resident 5's legs. RN 1 stated TED hose are used to treat edema and help prevent it from getting worse. During an interview on 5/5/2025 at 2:04 pm, with Resident 5, Resident 5 stated Resident 5 felt pissed off because they (staff) were not doing what the doctor told them (staff) to do. Resident 5 stated, I feel like I'm never going to leave the facility because the staff do not do what they are told. Resident 5 stated Resident 5 was experiencing 6 out of 10 pain to Resident 5's toes. During a concurrent observation of Resident 5 and interview on 5/5/2025 at 2:13 pm, with Certified Nurse Assistant (CNA) 1, inside Resident 5's room. CNA 1 was observed applying TED to Resident 5's legs. CNA 5 stated CNA 5 took care of Resident 5, all the time. CNA 1 stated CNA 1 never put TED hose on Resident 5 before, and this was the first time CNA 1 was instructed to do so. During a concurrent interview and record review on 5/16/2025 at 3:39 pm, with the Director of Nursing (DON). The DON stated TED hose were compression stockings that helped with circulation in residents who had edema by aiding in taking the fluid out of the residents' legs. The DON stated when TED hose were being applied as ordered, TED hose were supposed to reduce edema, swelling and blood clots (a semi-solid mass of blood that forms within a blood vessel). The DON stated that when TED hose were not being used as ordered, then (in general) the residents could develop more swelling and the edema could get worse. The DON stated increased edema could cause discomfort and difficulty breathing due to fluid in the lungs, put the resident at risk for infections, and could lead to hospitalization. The DON stated it was important for LNs to follow the physicians' orders for relief of the resident's symptoms and patient safety. The DON stated the DON did not know the last time LNs were in-serviced on assessing for edema. During a review of the facility's P&P titled, Physician Orders, revised 5/1/2019, the P&P indicated the facility will ensure that all physician orders were complete and accurate. The P&P indicated treatment orders would include a description of the treatment, including the site, if applicable, the frequency and duration of the order (when appropriate). The P&P indicated whenever possible, the LN receiving the order will be responsible for documenting and implementing the order. The P&P indicated medication/treatment orders would be transcribed onto the appropriate resident administration record. The P&P indicated supplies/medications for the required to carry out the physician order would be ordered. A review of the facility's P&P titled, Care Planning, dated 10/24/2022, indicated for the facility To ensure that a comprehensive person-centered Care Plan is developed for each resident based on tire individual assessed need. The P&P indicated the resident has the right to receive the services and/or items included in the plan of care. 056118 Page 5 of 7 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to provide documentation of resident status and care given by nursing staff for one of five sampled residents (Resident 5), according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to: Ensure the licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) documented when Resident 5 wearing the Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs) when Resident 5 had a physician order, dated 11/14/2024 for Resident 5 to wear TED hose to bilateral (both) lower extremities for leg swelling/edema. As a result of this failure, facility staff were not applying TED hose to Resident 5's left and right legs. Facility staff did not know when Resident 5 last wore the TED hose. LNs were not documenting Resident 5's TED hose application. These failures put Resident 5 risk for increased edema to the lower legs and complications such as decreased circulation (blood flow through the body), and infection. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 2/16/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), heart failure (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 5 Physician Telephone Order (TO), dated 11/14/2024the TO indicated Resident 5 had an order to wear TED hose stocking to bilateral lower extremities for leg swelling/edema. May remove during patient care. During a review of Resident 5's medication administration record (MAR- a report that serves as a legal record of the medications and monitoring administered to a resident) and treatment administration record (MAR- a report that serves as a legal record of the treatments and monitoring administered to a resident) dated 11/2024-5/2025, the MAR did not indicate TED hose were applied to Resident 5's bilateral lower extremities. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 2/21/2025, the MDS indicated Resident 5 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with upper and lower body dressing. The MDS indicated Resident 5 was taking diuretic medication (medications that promote the excretion of excess water and electrolytes [minerals] through the kidneys and out the body). During a concurrent interview and record review on 5/5/2025 at 1:26 pm, with LVN 2, Resident 5's TO was reviewed. LVN 2 stated because of the way Resident 5's order was transcribed (converting a spoken or handwritten order into a typed or digital format), LNs did not have to document if Resident 5 was wearing the TED hose. LVN 2 stated compression socks (TED hose) were for the treatment of edema. 056118 Page 6 of 7 056118 05/05/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0842 Level of Harm - Minimal harm or potential for actual harm LVN 2 stated when Resident 5 was not wearing the TED hose and LNs were not keeping track of the edema in Resident 5's feet and legs, Resident 5's edema could get worse and make Resident 5 sick. During a concurrent observation and interview on 5/5/2025 at 1:30 pm, with LVN 2, in Resident 5's room, Resident 5's legs were observed. LVN 2 stated Resident 5 was not currently wearing TED hose. Residents Affected - Few During a concurrent interview and record review on 5/5/2025 at 1:36 pm, with RN 1, Resident 5's TO was reviewed. RN 1 stated the way Resident 5's order (for TED hose) was transcribed, LNs were not required to monitor or document when Resident 5 was or was not wearing the TED hose. RN 1 stated RN 1 did not know when the last time TED hose were applied to Resident 5 legs. RN 1 stated Resident 5 should be wearing the TED hose all the time, except during patient care, such as cleaning or changing Resident 5. RN 5 stated without keeping track of when and how long Resident 5 was wearing the TED hose, Resident 5's edema could get worse because RN 1 did not know the last time the TED hose were applied to Resident 5's legs. RN 1 stated TED hose are used to treat edema and help prevent the edema from getting worse. During an interview on 5/16/2025 at 3:39 pm, with the Director of Nursing (DON), the DON stated TED hose were compression stockings that helped with circulation in residents who had edema by aiding in taking the fluid out of the residents' legs. The DON stated LNs were not accurately documenting or monitoring when Resident 5's TED hose were applied. The DON stated inaccurate documentation could interfere with treatment and orders. During a review of the facility's P&P titled, Documentation- Nursing, revised 11/1/2027, the P&P indicated the purpose was to provide documentation of resident status and care given by nursing staff. The P&P indicated nursing documentation would be concise, clear, pertinent, and accurate. The P&P indicated MAR and TAR were completed with each medication or treatment completed. The P&P indicated nursing documentation included treatments completed and documented as per physician order. 056118 Page 7 of 7