Health inspection·June 27, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) was within reach for one of one sampled resident (Resident 74), in accordance with Resident 74's multiple care plans (CP).This failure had the potential to result in Resident 74 not having Resident 74's needs met in a timely manner and/or injury to Resident 74 if Resident 74 was unable to alert staff during an emergency.Findings:During a review of Resident 74's admission Record (AR), the AR indicated, Resident 74 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - long standing lung disease causing difficulty in breathing) with (acute [sudden onset]) exacerbation and anxiety disorder (a group of mental disorders characterized by intense, excessive, and persistent worry and fear about everyday situations), unspecified.During a review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/24/2024, the MDS indicated, Resident 74's cognition (ability to understand and process information) was moderately impaired. The MDS indicated, Resident 74 had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The MDS indicated, Resident 74 required substantial/maximal assistance (helper does more than half the effort) to setup or clean-up assistance (helper sets up or cleans up) from staff for activities of daily living (ADL, term used in healthcare that refers to self-care activities) such as eating and toileting. The MDS indicated Resident 74 was always incontinent (no episodes of continent [ability to control the release of bodily waste]) of urine and bowel movements.During a review of Resident 74's History and Physical (H&P), dated 10/4/2024, the H&P indicated, Resident 74 had the capacity to understand and make decisions.During an observation on 6/24/2025 at 9:03 AM, inside Resident 74's room, Resident 74 was lying in bed getting a breathing treatment through a mask. Resident 74's head of the bed was up and the call light was hanging over the headboard. Resident 74 stated, Resident 74 could not reach the call light, where is it?! Resident 74 stated, Resident 74 yelled for help staff, staff! when Resident 74 could not find or reach the call light.During a concurrent observation and interview on 6/24/2025 at 9:07 AM with Certified Nursing Assistant (CNA) 3, in Resident 74's room, Resident 74 was lying in bed getting a breathing treatment through a mask. Resident 74's head of the bed was up and the call light was hanging over the headboard. CNA 3 stated Resident 74's call light should be within Resident 74's reach so Resident 74 did not have to yell for help because that could bother the other residents. CNA 3 stated Resident 74 used the call light a lot. During a review of Resident 74's CPs, the following CPs were reviewed:- Focus, mood problem, date initiated 3/24/2025.-Focus, the use of psychotropic medications (medication that affects behavior, mood, thoughts, or perception), date initiated 4/2/2024.-Focus, impaired functional abilities, date initiated 4/2/2024.-Focus, at risk for fall(s) and/or further fall(s), date initiated 4/2/2024.-Focus, use of bilateral 1/2 pipe covered side rails while in bed as enabler (facilitate safe bed mobility) or as a repositioning device and safety for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking blank stares, and loss of consciousness), date initiated 4/2/2024.-Focus, bladder and bowel function, date initiated 4/2/2024.All CPs reviewed indicated for Resident 74's call light to be within reach and to be answered promptly.During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, date revised 11/1/2017, the P&P indicated, to provide a mechanism for residents to promptly communicate with nursing staff. The P&P indicated, call cords would be placed within the resident's reach in the resident's room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 2 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of three resident's (Resident 57, 85, and 60) advanced directives were obtained according to the facility's policy and procedure (P&P) titled, Advance Directives, dated 4/30/2021.a. Resident 57's advanced directive was not found in the Resident's medical record.b. and c. Resident 85 and Resident 60, the facility failed to provide written information about Advance Directives (AD, legal document which specifies the health-relation actions in accordance with the resident's wishes, that is obtained when the resident is able to make decisions for oneself).This deficiency had the potential to result in the resident's or resident representative's wishes not being followed and the potential to undermine Residents 85 and 60's right to formulate an AD and to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.Findings:a. During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was admitted to the facility on [DATE] with multiple diagnoses including hepatic encephalopathy (a brain dysfunction that can occur in people with severe liver disease) and emphysema (a chronic disease in which the small air sacs in the lungs [the alveoli] become damaged; characterized by difficulty breathing.)During a review of Resident 57's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/5/2025, the MDS indicated Resident 57 had severely impaired cognition (ability to understand and process information) and was dependent on staff for personal hygiene and rolling from left to right.During a review of Resident 57's Acknowledgement of Signatures (AS), dated 5/5/2025, the AS indicated Resident 57's representative selected an Advanced Directive had been executed for Resident 57.During an interview on 6/25/2025 at 10:15 AM with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 57's advanced directive was not in the resident's chart.During an interview on 6/26/2025 at 4:16 PM with the Assistant Director of Nursing (ADON), the ADON stated Social Services was in charge of obtaining advance directives from residents and their representatives. The ADON stated the advance directive should be in the resident's chart so nurses would know how to treat the resident and respect the resident's and family's wishes.During an interview on 6/27/2025 at 11:35 AM with the Social Services Assistant (SSA), the SSA stated after a recent conversation with Resident 57's family, the SSA discovered that Resident 57 did not have an advance directive. The SSA stated it was important to clarify if an advance directive was in place in case of an emergency to ensure consents, treatments and wishes were honored.During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 4/30/2021 the P&P indicated at the time of admission, admission Staff or designee will inquire about the existence of an Advance Directive, including whether the resident has requested or is in possession of an aid-in-dying drug. If no Advance Directive exists, the Facility provides the resident with an opportunity to complete the Advance Directive Form upon resident request. A copy of the Advance Directive is maintained as part of the resident's medical record. b. During a review of Resident 85's AR, the AR indicated, Resident 85 was originally admitted to the facility on [DATE] with diagnoses of hypertensive heart (long-term condition that develops from chronic high blood pressure) and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively) with Heart failure (a condition where the heart cannot pump enough blood to meet the body's need) and with tage 5 chronic kidney disease or end stage renal disease (most severe stage of chronic kidney disease-unable to adequately filter waste and excess fluid from blood).During a review of Resident 85's History and Physical (H&P), dated 5/10/2025, the H&P indicated, Resident 85 had the capacity to understand and make decisions. During a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 3 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 had a Brief Interview for Mental Status (BIMS) score of 14 which indicates intact cognitive function. During a review of Resident 85's CP, titled, .Full Code, date initiated on 10/8/2024, the CP indicated interventions to honor wishes. During a review of Resident 85's Acknowledgment of Signatures, form dated 3/27/2025, the Acknowledgment of Signatures indicated, Resident 85 had not signed the document and instead was Resident 85's son via telephone. During a review of Resident 85's Acknowledgment of Signatures, formdated 6/24/2025, the Acknowledgment of Signatures indicated, Resident 85 had signed the document. During an interview on 6/25/2025, at 9:15 am, with Resident 85, Resident 85 stated, I signed the paper, and I make decisions for myself.During a concurrent interview and record review, on 6/25/2025, at 3:12 pm, with Social Services Assistant (SSA), the Acknowledgement of Signatures form, dated 3/27/2025 and 6/24/2025 were reviewed. The Acknowledgement of Signatures indicatedthey were originally signed by Resident 85's son then by Resident 85. SSA stated Resident 85 was not able to sign because of being in dialysis (medical treatment that cleans blood when the kidneys are unable to do so, effectively acting as an artificial kidney) and needed to close the chart. c. During a review of Resident 60's AR, the AR indicated, Resident 60 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems) and Type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin [a hormone that regulates blood sugar levels] or cannot properly use the insulin it produces, leading to high blood sugar levels). During a review of Resident 60's History and Physical (H&P), the H&P indicated Resident 60 had the capacity to understand and make decisions. During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60 had a Brief Interview for Mental Status (BIMS) score of 15 which indicates intact cognitive function. During a review of Resident 60's CP, titled, .Full Code, date initiated on 7/6/2024, the CP indicated interventions to honor wishes. During a review of Resident 60's Acknowledgment of Signatures form, dated 10/16/2024, the Acknowledgment of Signatures form indicated, Resident 60 had not signed the document and instead was Resident 60's brother via telephone. During a review of Resident 60's Acknowledgment of Signatures form, dated 6/24/2025, the Acknowledgment of Signatures indicated, Resident 60 had signed the document. During an interview on 6/24/2025, at 3:30 pm, with Resident 60, Resident 60 stated, the document was signed by me. During a concurrent interview and record review, on 6/25/2025, at 3:12 pm, with SSA, Acknowledgement of Signatures, dated 10/16/2024 and 6/24/2025 were reviewed. The Acknowledgement of Signatures indicated, they were originally signed by Resident 60's brother then by Resident 60. SSA stated, Resident 60 would have family meetings, and I would request from them phone consent in order to close the chart. Both Resident 85 and 60 had the capacity to sign. During a review of the facility's P&P titled, Advance Directive, dated 4/30/2021, the P&P indicated, To provide residents with the opportunity to make decisions regarding their health care. Event ID: Facility ID: 056118 If continuation sheet Page 4 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the physician of a change of condition in one of one sampled resident (Resident 90) when Resident 90 removed his tracheostomy (self-decannulated (the removal of a tracheostomy tube [a curved plastic tube inserted into a surgically created opening in the neck to help with breathing] from a patient's airway) on 5/14/2025 and 5/28/2025.This deficiency had the potential to result in physical trauma to Resident 90's airway and infection.Findings:During a review of Resident 90's admission Record (AR), the AR indicated Resident 90 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following a cerebral infarction (stroke) affecting right dominant side and dementia (a gradual decline in mental ability usually caused by a brain disease).During a review of Resident 90's Respiratory Progress Notes (RPN) dated 5/14/2025, the RPN indicated an accidental decannulation occurred at 3:50 PM. A second RPN dated 5/28/2025 indicated an emergency tracheostomy tube change occurred at 12:30 PM due to accidental decannulation.During a review of Resident 90's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/30/2025, the MDS indicated Resident 90 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all the effort) with bathing and for rolling left and right on the bed.During an interview on 6/25/2025 at 3:44 PM with Respiratory Therapist (RT) 4, RT 4 stated Resident 90 had a habit of picking at medical devices including the tracheostomy tube. RT 4 stated RT 4 was not assigned to care for Resident 90 on 5/28/2025 but had walked into Resident 90's room and noted Resident 90's tracheostomy tube was beside Resident 90 on the bed. RT 4 stated Resident 90 did not appear to have any difficulty breathing and did not appear to be in any distress at the time of discovery. RT 4 stated a new tracheostomy tube was inserted with a second RT and was uneventful. RT 4 stated RT 4 did not contact Resident 90's physician because the resident's nurse would have been the person responsible for informing the physician of what happened. RT 4 stated RT 4 also did not document the occurrence because the RT assigned to Resident 90 was responsible for documenting what occurred.During an interview on 6/26/2025 at 3:09 PM with the Lead Respiratory Therapist (LRT), the LRT stated the nurse, or respiratory therapist could have contacted the physician when Resident 90 self-decannulated. The LRT stated no SBAR (Situation, Background, Assessment and Recommendation - a structured document that helps the team share information about the condition of the patient) was completed for the decannulation incidents on 5/14/2025 and 5/28/2025 and it should have been done to ensure the physician was notified of Resident 90's change in condition. LRT stated the physician should have been notified in case there was difficulty changing the tracheostomy tube and the physician may have decided to begin a trial for permanent decannulation since Resident 90 had not been found in distress. The LRT stated Resident 90 was permanently decannulated on 6/5/2025.During an interview on 6/26/2025 at 4:36 PM with the Assistant Director of Nursing (ADON), the ADON stated facility staff should have initiated an SBAR to ensure the physician was notified in case the physician wanted to implement any new orders and for resident safety.During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, dated 11/1/2017 the P&P indicated the licensed nurse will notify the resident's Attending Physician when there is an incident/ accident involving the resident. The Attending Physician will be notified timely with a resident's change in condition. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. Event ID: Facility ID: 056118 If continuation sheet Page 5 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 35) overbed light was in working condition in accordance with Resident 35's care plans (CP).This deficient practice could potentially make it difficult for Resident 35 to navigate Resident 35's surroundings, potentially increasing the risk of falls or result in accidents. Additionally, this deficient practice could also hinder the staff's ability to observe and monitor Resident 35 effectively, potentially leading to missed signs of distress or complications. Findings:During a review of Resident 35's admission Record (AR), the AR indicated, Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing) with (acute [sudden onset]) exacerbation and anxiety disorder (a group of mental disorders characterized by intense, excessive, and persistent worry and fear about everyday situations), unspecified.During a review of Resident 35's Minimum Data Set (MDS, an assessment and screening tool), dated 4/10/2024, the MDS indicated, Resident 35's cognition (ability to understand and process information) was moderately impaired. The MDS indicated, Resident 35 required partial/moderate assistance (helper does less than half the effort) to setup or clean-up assistance (helper sets up or cleans up) from staff for activities of daily living (ADL, term used in healthcare that refers to self-care activities).During a review of Resident 35's History and Physical Examination (H&P), dated 10/17/2024, the H&P indicated, Resident 35 had the capacity to understand and make decisions.During a concurrent observation and interview on 6/24/2025 at 8:42 AM with Licensed Vocational Nurse (LVN) 2, Resident 35's overbed light had no pull cord switch (pull chain). A gold star sticker was on the overbed light. LVN 2 stated, the gold star sticker indicated Resident 35 was a fall risk. LVN 2 stated, Resident 35's overbed light should have the pull cord string to access the overbed light and to be able to see in the dark. LVN 2 stated, LVN 2 would call maintenance to fix the overbed light, but there is a wall switch to turn it on. During a concurrent observation and interview on 6/24/2025 at 8:46 AM with LVN 2, Resident 35's room had a switch on the wall located by the door that turned on the up light (the upper light of an overbed light that provides general room brightness) at the same time for both Resident 35 and Resident 35's roommate's (unidentified) overbed lights. LVN 2 stated, if staff used the wall switch, other residents (in general) would not like it cuz it's too bright or sometimes hard for them to sleep at night.During a concurrent observation and interview on 6/25/2025 at 8:03 AM with the Maintenance/Housekeeping Supervisor (MHS) in Resident 35's room, Resident 35's overbed light had no pull cord (pull chain). The MHS stated, there was no cord. The MHS stated no staff reported to the maintenance department about the missing pull cord. The MHS stated, it was important to have a working overbed light, so there was light and because this is their home and for staff to be able to see when the staff provided care at night, when they change the patient. The MHS stated, using the wall switch could be bad if Resident 35's roommate did not want the light on while sleeping.During a review of Resident 35's CP for [Resident 35] being at risk for fall, date initiated 10/16/2024, the CP indicated, one of the interventions was to ensure adequate lighting in Resident 35's room.During a review of Resident 35's CP for at risk of falls secondary to: generalized weakness, psychotropic ( medications used to treat mental health disorders, alter neurotransmitters [transmit messages from neurons to muscles] in the brain) meds, and unsteady gait (pattern of a person's walk), date initiated 10/29/2024. The CP indicated one of the interventions was to keep environment well-lit and hazard free.During a review of the facility's policy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 6 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete procedure (P&P) titled, Maintenance Services, date revised 11/1/2017, the P&P indicated, the Maintenance Department maintained all areas of the building, grounds, and equipment. The P&P indicated, the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.During a review of the facility's P&P titled, Resident Rights, date revised 5/1/2023, the P&P indicated, all residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility.During a review of the facility's P&P titled, Resident Rights - Accommodation of Needs, date implemented 5/1/2023, the P&P indicated, the facility ensured to provide an environment and services that met residents' individual needs. Event ID: Facility ID: 056118 If continuation sheet Page 7 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately monitor one of one sample resident (Resident 91) psychotropic (drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings and behavior) medications by failing to indicate specific anxious behavior and monitor side effects of lorazepam (medication used to treat anxiety.)This failure had the potential to result in Resident 91 receiving unnecessary medication and experiencing adverse (unwanted) effects from lorazepam.Findings:During a review of Resident 91's admission Record (AR), the AR indicated Resident 91 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (condition where the inability of the lungs to oxygenate the blood leads to dangerously low oxygen levels in the body) and dependence on ventilator (when one cannot breathe on their own and relies on a machine to support their respiratory function.)During a review of Resident 91's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/21/2025, the MDS indicated Resident 91 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) for toileting and personal hygiene.During a review of Resident 91's Order Summary Report (OSR) with active orders as of 6/26/2025, the OSR indicated Resident 91 had a physician order dated 6/21/2025 to give lorazepam (medication used to treat anxiety) 0.5 milligrams (mg - unit of weight) via gastrostomy tube (GT - tube inserted through the abdomen into the stomach for nutrition, fluids, and medications) every six (6) hours as needed for anxiety for 14 days manifested by restlessness.During a review of Resident 91's Care Plan (CP - a form where one can summarize a person's health conditions, specific care need, and current treatments) dated 6/23/2025, the CP indicated to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness every shift.During a concurrent interview and record review on 6/26/2025 at 1:34 PM with Licensed Vocational Nurse (LVN) 5, Resident 91's Medication Administration Record (MAR) dated from 6/1/2025 to 6/30/2025 was reviewed. LVN 5 stated Resident 91 had on and off anxiety and in general and was able to mouth the word anxiety, to indicate Resident 91 was feeling anxious. LVN 5 further indicated that Resident 5's restlessness was manifested by a high pulse rate and repeating phrases. LVN 5 stated the resident's nurse should monitor Resident 91 for anxious behavior every shift and if lorazepam is administered, the nurse needs to monitor for effectiveness and side effects of the medication. LVN 5 stated LVN 5 did not see that Resident 91's MAR indicated side effects were being monitored. LVN 5 stated it is important to monitor for side effects of a given medication to make sure the resident is not experiencing unwanted effects. LVN 5 stated potential side effects of lorazepam were nausea, vomiting and increased drowsiness.During an interview on 6/26/2025 at 1:52 PM with Certified Nurse Assistant (CNA) 5, CNA 5 stated CNA 5 was not aware of Resident 91 having restlessness and restlessness might manifest as feeling weak.During an interview on 6/26/2025 at 1:57 PM with Registered Nurse Supervisor (RNS) 5, RNS 5 stated when a physician orders a psychotropic medication, the physician's order will include the name of the drug, dose, frequency, diagnosis and behavior. RNS 5 stated the behavior indicated needed to be specific. RNS 5 stated restlessness may be manifested as being unable to stay still, fidgeting and not looking relaxed. RNS 5 stated restlessness was not a specific behavior because restlessness could look different to different people. RNS 5 stated it was important to have a specific behavior to monitor to be able to identify why the resident is on lorazepam and if the medication was effective. RNS 5 stated Resident 91's MAR did not have side effect monitoring implemented and it was important to monitor the side effects of lorazepam because the side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 8 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete effects could be detrimental to the resident's health. RNS 5 stated some potential side effects of lorazepam could be respiratory depression and Resident 91's breathing could slow down significantly.During an interview on 6/26/2025 at 4:20 PM with the Assistant Director of Nursing (ADON) the ADON stated it was important to monitor medication side effects to ensure the resident is not experiencing a potentially dangerous effect. The ADON stated lorazepam is a sedative (class of drugs that slow down brain activity and depresses the central nervous system) and could lead to increased lethargy (feeling unusually weak or tired). The ADON further stated restlessness is not a specific indication of anxiety and a specific indication was needed to ensure the resident was getting treated correctly and the medication was effective.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 5/17/2024, the P&P indicated nursing was responsible to monitor psychotropic drug use daily noting any adverse effects (i.e. EPS, Tardive dyskinesia, excessive dose or distressed behavior) medication will be written on the Medication Administration Record (MAR) with the following information: i. Medication, dose, and time of administration ii. Manifestations for the drug i.e. hitting others, etc. iii. Side effects of the drug, i.e. drooling, dry mouth, abnormal gait, etc. Event ID: Facility ID: 056118 If continuation sheet Page 9 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observation, interview, and record review, the facility failed to ensure that one (1) of two (2) sampled residents (Resident 41) had a completed and accessible Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) ) Level II evaluation available in the medical record, as required for individuals with newly evident or possible serious mental disorder, intellectual disability (ID), developmental disability (DD), or related conditions (RC). This failure resulted in Resident 41's specialized behavioral health and support needs not being clearly identified to staff, potentially impacting care planning and delivery of services. Findings:During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted Resident 41 on 8/17/2024, and re-admitted the resident on 10/9/2024, with diagnoses including chronic respiratory failure (when the airways that carry air to the lungs become narrow and damaged), epilepsy (a condition where a person's brain experiences abnormal electrical activity, leading to recurring seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), and unspecified psychosis (when a person exhibits symptoms of psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] but the specific cause or type of psychosis has not been identified).During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 41's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 41 was dependent (helper does all of the effort) on facility staff (in general) with activities of daily living (ADLs activities such as bathing, dressing and toileting a person performs daily) and with mobility. During a review of Resident 41's medical records (both physical chart and electronic health record (EHR), the PASARR Level I screening, dated 7/10/2024, indicated a negative result for serious mental illness (SMI) and a positive result for intellectual disability/developmental disability/related conditions (ID/DD/RC). The required PASARR Level II evaluation was not found in either the physical chart or the EHR.During a concurrent interview and record review on 6/25/2025 at 10:30 PM, Resident 41's medical records, including both the physical chart and the EHR were reviewed with Medical Records (MR). MR stated that Resident 41's PASARR Level I screening result had been negative for SMI and positive for ID/DD/RC. MR explained that while the Level I screening had been uploaded into the EHR, the corresponding PASARR Level II evaluation was not located in the EHR or the physical chart. MR stated having the Level II evaluation readily accessible in the medical record was critical to ensure facility staff were informed of the resident's specialized support needs and could implement appropriate care plans and services in accordance with regulatory requirements.During an interview on 6/26/2025 at 1:08 PM with Assistant Director of Nursing (ADON), the ADON stated that having the PASARR Level II evaluation accessible in the resident's physical chart or EHR was essential so that nursing and interdisciplinary staff could review any behavioral health recommendations, therapy needs, or supervision requirements. The ADON stated without this document (PASARR Level II), staff may have overlooked critical elements of care necessary to meet Resident 41's specific needs.During a review of the facility's policy and procedure (P&P) titled Pre-admission Screening and Resident Review, dated 7/1/2023, the P&P indicated, A positive PASARR level I screen necessitates an in-depth evaluation of the individual by a level II contractor, known as PASARR Level II, which must be conducted prior to admission. The PASARR results are maintained in the resident's medical record. Event ID: Facility ID: 056118 If continuation sheet Page 10 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement individualized care plan interventions for three (3) of 3 sampled residents (Resident 8, 37, and 90). The facility failed to:A. Ensure padded landing mats were placed at the bedside for Resident 37, who was identified as a high fall risk.B. Implement fall precautions for Resident 8 in accordance with physician orders and the resident's care plan.C. Develop a care plan for Resident 90's scratching and skin-picking behavior.As a result, the facility failed to ensure that residents received care and services consistent with their identified needs and risks, which increased the potential for avoidable injuries, unmet psychosocial needs for Residents 8, 37, and 90. Findings: A. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted Resident 37 on 2/1/2025, and re-admitted the resident on 5/22/2025, with diagnoses including acute respiratory failure (when the lungs suddenly cannot get enough oxygen into the blood and/or cannot remove enough carbon dioxide [a colorless, odorless gas] from the blood), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and severe intellectual disabilities (when a person has certain limitations in mental functioning and in skills such as communicating, taking care of him or herself, and social skills). During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool), dated 5/26/2025, the MDS indicated Resident 37's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 37 was dependent (helper does all of the effort) with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and dependent with mobility. During a review of Resident 37's Fall Risk Assessment, dated 5/22/2025, the fall risk assessment for Resident 37 indicated a total score of 14, which classified the resident as high risk for falls. According to the assessment tool, a score above 10 meant the resident was at high risk for falls. During an observation on 6/23/2025 at 9:10 AM, Resident 37 was observed in bed with both legs dangling off the right side of the bed. The resident appeared restless. No floor mats were observed on either side of the bed. During an interview on 6/26/2025 at 10:09 AM, Respiratory Therapist (RT) 3 stated RT 3 was familiar with Resident 37 and had frequently observed Resident 37 to be restless and often dangling Resident 37's legs off the right side of the bed. RT 3confirmed that Resident 37 was considered at high risk for falls. During a concurrent interview and record review on 6/26/2025 at 10:30 AM, Resident 37's Care Plan Report was reviewed with Registered Nurse Supervisor (RNS) 5. RNS 5 stated that Resident 37 was identified as a high fall risk and the care plan included an intervention to provide padded landing mat at bedside to minimize injury in the event of a fall from bed, if appropriate. RNS 5 stated that Resident 37 was often restless and was known to dangle Resident 37's feet off the bed, which increased Resident 37's risk for falls. RNS 5 confirmed that being restless and dangling feet off the bed had been a consistent behavior for Resident 37. RNS 5 acknowledged that, based on Resident 37's known behavior and identified risk level, floor mats were an appropriate safety measure and should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 11 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0656 implemented as a precaution to help reduce the risk of injury. Level of Harm - Minimal harm or potential for actual harm During an interview of 6/26/2025 at 1:08 PM, the Assistant Director of Nursing (ADON) stated that implementing care plan interventions was essential, especially for residents identified as at high risk for falls. The ADON stated that interventions like floor mats are put in place to help prevent injury and should be consistently followed based on the residents' assessed needs and behaviors. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 11/1/2017, the P&P indicated, Based on the information gathered from the history and assessment of the resident, the Nursing Staff and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls .The Nursing Staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk for falls. B. During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with multiple diagnoses including acquired absence of the left leg above the knee, dementia (a gradual decline in mental ability usually caused by a brain disease). During a review of Resident 8's History and Physical (H&P) dated 3/6/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8's Care Plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments), dated 3/6/2025, the CP indicated to place the bed in the lowest position at resident's comfort and may have bilateral floor mats for safety. During a review of Resident 8's Order Summary Report (OSR) dated as of 6/26/2025, the OSR indicated an order to place bed in the lowest position dated 3/29/2025. The OSR indicated an order to place bilateral floormats for safety dated 4/1/2025. During a review of Resident 8's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 6/9/2025, the MDS indicated Resident 8 was dependent (helper does all the effort) on staff for the ability to change from a lying position to sitting on the side of the bed and to get on and off a toilet. During a concurrent observation and interview on 6/25/2025 at 9:37 AM with Certified Nurse Assistant (CNA) 6, Resident 8's bed and surrounding areas were observed. CNA 6 stated CNA 6 was not sure if Resident 8 was at risk for falls. CNA 6 stated placing the bed in the lowest position was one intervention staff implemented to prevent falls. CNA 6 further stated Resident 8 was not in the lowest position when CNA 6 first entered the room. CNA 6 stated Resident 8 had a floor mat on the left side of the bed and was not sure how long Resident 8 had the single mat. During an interview on 6/25/2025 at 10:10 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 8 was a high fall risk with a single floor mat on the left side so that if a fall occurred, the floor mat might prevent injury. During an interview on 6/26/2025 at 4:27 PM with the Assistant Director of Nursing (ADON), the ADON stated Resident 8 was on the facility's falling star program which is an indicator that the resident is at risk for falls. The ADON stated Resident 8's physician orders that included floor mats and low bed were preventive measures. The ADON nodded when asked if not implementing these interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 12 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0656 could increase the risk of falling with injury. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Fall Management Program dated 11/1/2017 the P&P indicated the interdisciplinary team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. Residents Affected - Some C. During a review of Resident 90's admission Record (AR), the AR indicated Resident 90 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes (condition in which the body cannot properly store or use sugar) hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke) affecting the right dominant side. During a review of Resident 90's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 5/30/2025, the MDS indicated Resident 90 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all the effort) for bathing and toileting hygiene. During an observation on 6/25/2025 at 9:30 AM, Resident 90 was observed with a dried scab on the left side of the nose. During an interview on 6/26/2025 and 12:29 PM with Treatment Nurse (TN) 2, TN 2 stated Resident 90 tended to scratch Resident 90's own face with the left hand. TN 2 stated the wound on Resident 90's nose was a self-inflicted scratch. TN 2 stated Resident 90 had previously re-opened old wounds on Resident 90's head by picking at dried scabs. TN 2 stated no CP had been developed for Resident 90's scratching/ picking behavior. TN 2 stated a CP should have been developed so all staff would be aware of Resident 90's behavior and ensure Resident 90 did not develop further skin injuries. During an interview on 6/26/2025 at 4:41 PM with the Assistant Director of Nursing (ADON), the ADON stated a CP should have been developed for Resident 90's scratching/picking behavior because CP's are used to direct care for potential problems and resident behaviors. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 10/24/2022, the P&P indicated each resident's comprehensive care plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 13 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to meet professional standards of care for one of three sampled residents (Resident 10) observed during medication administration by:1. Pushing medications through a gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach) with a g-tube syringe (a medical device used for feeding and medication delivery via g-tube) instead of administering the medications by gravity.2. Failing to administer Omeprazole per manufacturer's specifications through a g-tube.3. Failing to flush five milliliters (mL- a unit of liquid measurement) of water between medications administered through a g-tube.4. Failing to administer Pro-Stat (a protein supplement) per manufacturer's specifications through a g-tube to dilute the medication with water prior to administration.The failure to administer medications in accordance manufacturer's specifications, and standards of practice placed Resident 10 at risk to experience significant medical complications including g-tube dislodgement (where the g-tube comes out of the stomach) that could lead to leakage of stomach contents into the abdominal cavity, infection, and death. Cross Reference F760 and F759Findings:During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility 4/12/2025 with diagnoses that included, GERD, dysphagia, aphasia (condition that makes it hard to use and understand language), and gastrostomy tube. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2025, the MDS indicated Resident 10's cognitive skills for daily decisions making was severely impaired. The MDS indicated Resident 10 was totally dependent upon assistance of two or more staff for all activities of daily living (ADL, skills needed to live independently, such as eating, bathing, dressing, toilet use, personal hygiene, bed mobility, and transfer). During a review of Resident 10's care plans (CP) indicated the following:1.Resident 10's CP for GERD dated 4/14/2025, the CP indicated the goal was for Resident 10 to remain free of discomfort, complications or signs and symptoms related to diagnosis of GERD. The CP's interventions indicated to give medications as ordered and monitor/document side effects and the effectiveness [of the medications].?2.Resident 10 noted with GT (g-tube) replacement do to balloon deterioration, dated 6/6/2025, the CP indicated the GT would be replaced by the end of shift to ensure nourishment.During a review of Resident 10's OSR, active orders as of 6/25/2025, the OSR included the following orders:?a. Omeprazole oral capsule DR 20 mg, via g-tube one time a day for GERD. The order indicated, may open capsule, mix with apple juice. Do not crush granules, order date 4/12/2025.?b. Enteral feed order, every day shift, may flush tube with 5 ml of water between each medication, order date 4/12/2025.?During an observation of LVN 3's medication administration and interview on 6/25/2025 at 08:41 a.m., with LVN 3. LVN 3 was observed preparing the following medications for Resident 10:1. One tablet of Folic Acid (a vitamin) 400 micrograms (mcg- unit of measurement)2. One capsule of Omeprazole (medication used to reduce stomach acid) delayed release (DR- the medication will be released after a delayed time) 20 milligrams (mg- a unit of measurement)3. One tablet of Sodium Chloride (a salt supplement) 1 gram (g- unit of measurement)4. One tablet of Thiamin HCl (a supplement) 100 mg.5. 30 mL of Valproate Sodium (a medication used to treat seizures [sudden burst of electrical activity in the brain, can cause changes in behavior, movements, feelings and levels of consciousness]) oral solution 250 mg/ 5 mL.6. 30 mL of Pro-Stat.LVN 3 stated LVN 3 stated Resident 10 had a g-tube and the medications must be crushed or be in a liquid form to be administered to Resident 10. LVN 3 sprinkled the contents of the Omeprazole capsule into a medicine cup filled with 30 mL of water and let the medication sit while LVN 3 prepared Resident 10's medication. LVN 3 crushed the Folic Acid, Sodium Chloride, and Thiamin HCl tablets separately and placed the medications in individual medicine cups with 15 mL of water in each cup. LVN 3 was observed Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 14 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete placing 30 mL of Valproate Sodium into a medicine cup and 30 mL of Pro-Stat into a separate medicine cup. During observation on 6/25/2025 at 09:08 a.m., before administering medications individually, LVN 3 flushed the g-tube with 30 mL of water by pushing on a syringe plunger (a device consisting of a rubber cup on a long handle, used to clear blocked pipes by means of water pressure). LVN 3 administered Omeprazole DR mixture by pushing on the syringe plunger in the same manner. LVN 3 administered a second crushed medication (Folic Acid) via gravity, without flushing water between the medications.??LVN 3 administered a third medication (Sodium Chloride) via gravity without flushing water between the medications. LVN 3 was observed pushing the fifth medication mixture, 30 mL of Valproate Sodium, by pushing on the syringe plunger, followed by a 5 mL water flush. LVN 3 attempted to push the last medication, 30 mL of Pro-Stat, through the g-tube but was stopped by the surveyor. During an interview with RNS 2 on 6/25/2025 at 9:27 AM, Registered Nurse Supervisor (RNS 2) stated Pro-Stat should be diluted with at least 30 mL of water to make it easier to administer via gravity. RNS 2 stated medications given through a g-tube should be given by gravity and should never be forced down with a plunger because the g-tube could clog or burst and would have to be replaced. RNS 2 stated this could have affected Resident 10 because Resident 10 would not be able to receive medications or feedings while waiting for the tube to be replaced.During an interview with LVN 3 on 6/25/2025 at 09:45 AM, LVN 3 stated, I was nervous. LVN 3 stated Pro-Stat should have been mixed with water to make it go through the g-tube easier. LVN 3 stated LVN 3 should not have pushed any of the medications with the plunger because doing that [pushing the plunger] could cause harm to Resident 10. LVN 3 stated LVN 3 was supposed to flush 5 ml of water between every medication.??During an interview with the Director of Nursing (DON) on 6/26/2025 at 10:37 AM, the DON stated thick medications (Pro-Stat) should be mixed with water to make it easier to administer by gravity. The DON stated g-tube medications should be given by gravity and forcing the medications with a plunger could cause the g-tube to become displaced. The DON stated a displaced g-tube could cause infection, delay in medication administration, and hospitalization.During an interview with Dispensing Pharmacy (Pharm 1) on 6/26/2025 at 2:43 PM, Pharm 1 stated Omeprazole DR was designed to [deliver] delayed release of the medication and should not be left to dissolve prior to administration. Pharm 1 stated Omeprazole should be prepared by adding the contents of the capsule to 50 ml of water or apple juice and immediately administered through the g-tube. Pharm 1 stated the g-tube should be flushed with water after administration of each medication to ensure the medications were administered. Pharm 1 stated dissolving Omeprazole for 10-15 minutes prior to administration altered the mechanism of action (specific molecular interaction through which a drug produces its therapeutic effect) of the medication and would affect its efficacy (ability of the medication to produce a desired result).??During review of the undated Pro-Stat administration directions listed on the manufacturer label on 6/25/2025, the Pro-Stat label contained the following directions for tube feeding:1. Flush feeding tube with 30-60 mL of water.2.Pour 30 mL of Pro-Stat in a 4-6 fluid ounce (fl oz- a unit of measurement) container.3.Add 30-60 mL water and mix well with a disposable spoon or tongue blade.4.Administer Pro-Stat via syringe.5.Flush with 30-60 mL of water.During a review of the facility's P&P titled, Feeding Tube - Administration of Medication, undated, dated 11/1/2017, the P&P indicated medications are administered appropriately and safely when the resident has a feeding tube in place and medications are delivered through the feeding tube. ?The P&P indicated do not force any medication or fluid into the tube and allow gravity to work as much as possible.?The P&P indicated medications must be given separately, flushed with 5 mL of warm water in between each medication.?? Event ID: Facility ID: 056118 If continuation sheet Page 15 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 253, 2, and 90) received treatment and care in accordance with professional standards of practice and the facility's policies and procedures (P&P) by failing to ensure:A. Resident 253's peripheral intravenous (IV - into or within a vein) Heplock (Heparin Lock [H/L] - a medical needle or tube catheter device placed in a vein to administer medication, fluid or nutrients directly into the bloodstream) was discontinued.B. Resident 90 received treatment for a self-inflicted scratch on the nose.C. Resident 2 was evaluated for self-administration of medications. On 6/23/2025, an unprescribed and unlabeled tube of hydrocortisone 1% cream was observed on Resident 2's bedside table.This deficient practice could potentially result in complications from an old H/L access including infiltration (when IV fluid leaks into tissue because of improper catheter placement or dislodgement), phlebitis (inflammation of a vein) and bloodstream infection (the invasion and growth of germs in the body) and potentially compromise Resident 41's health. For Resident 2, the failure resulted in Resident 2 independently applying an unprescribed topical medication without licensed nurses' oversight and/or staff (in general) intervention, placing Resident 2 at risk for potential undetected adverse effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication) from unprescribed topical medication and untreated medical conditions. For Resident 90, there was a potential for Resident 90's scratch to worsen or become infected.A. During a review of Resident 253's admission Record (AR), the AR indicated, Resident 253 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM2– adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (a condition resulting from nerve damage that can cause pain, numbness, tingling, and muscle weakness, often in the hands and feet), unspecified and dependence on respirator [ventilator – a medical device to help support or replace breathing] status. Residents Affected - Some During a review of Resident 253's History and Physical (H&P), dated 6/14/2025, the H&P indicated, Resident 253 did not have the capacity to understand and make decisions. During a review of Resident 253's Order Summary Report (OSR), active orders as of 6/23/2025, the OSR did not indicate a physician's order to keep an IV access. During a concurrent observation and interview on 6/23/2025 at 10:56 AM with Registered Nurse Supervisor (RNS) 3, Resident 253 was lying in bed on a ventilator and had a H/L in Resident 253's left forearm. Resident 253's H/L site had an Opsite (brand name) transparent film dressing (sterile covering) that was labeled and dated vaguely. RNS 3 stated, RNS 3 could not figure out or state what the label and date was on the Opsite dressing and the dressing should have been replaced. RNS 3 stated, it was the protocol of the facility to ensure there was an indication for an IV access. RNS 3 stated, IV access was only good for 7 days. RNS 3 stated, Resident 253 was not getting any IV fluids or IV medications and staff should have asked Resident 253's physician to discontinue the H/L since Resident 253 no longer needed the H/L. During a concurrent interview and record review on 6/25/2025 at 8:47 AM with RNS 2, Resident 253's admitting OSR, active orders as of 6/13/2025 was reviewed. RNS 2 stated, RNS 2 could not see any IV fluid or IV antibiotic (medications that treat bacterial infections) physician orders in the OSR. RNS 2 stated, it was important to ensure the label and date was clear so staff would know when the dressing was due to be changed. RNS 2 stated, facility waited 7 days after admission to keep a H/L but should be discontinued if there was no indication or physician order for an IV access to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 16 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 infection. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/27/2025 at 8:48 AM with the Director of Nursing (DON), the DON stated, when a resident was admitted with an IV access, staff would notify the physician if there is a need and facility maintained the IV access as long as there was an order. The DON stated, to discontinue the H/L if there was no indication there's no point of keeping it, since the H/L would be a source of infection and was a risk, for infection control. Residents Affected - Some During a review of the facility's undated policy and procedure (P&P) titled, IV Peripheral I.V. Catheters, undated, the P&P indicated, to label IV site dressing with date, time and initials. The P&P indicated, the physician must order a heparin lock flush. The P&P indicated, IV cannulas should be removed routinely after 72 hours unless otherwise specified by a physician's order. During a review of the facility's P&P titled, Care Standards, date revised, 11/1/2017, the P&P indicated, facility ensured all residents received necessary care and services that were evidence-based and in accordance with accepted professional clinical standards of practice. During a review of the facility's P&P titled, Care and Services, date revised, 11/1/2017, the P&P indicated, the identification of needed care and services began during the pre-admission process. The P&P indicated, once admitted , the resident received an admission assessment where initial care and service needs were identified. B. During a review of Resident 90's AR, the AR indicated Resident 90 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes (condition in which the body cannot properly store or use sugar) hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke) affecting the right dominant side.During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all the effort) for bathing and toileting hygiene. During an observation on 6/25/2025 at 9:30 AM, Resident 90 was observed with a dried scab on the left side of the nose.During an interview on 6/25/2025 at 10:22 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated LVN 4 did not know how or when Resident 90 got the wound on the nose but stated LVN 4 noted it was already present when Resident 90 was transferred to the skilled nursing area from the subacute area on 6/11/2025. During an interview on 6/25/2025 at 12:29 PM with Treatment Nurse (TN) 2, TN 2 stated Resident 90 had right side weakness but was able to scratch with the left hand and Resident 90 tended to scratch Resident 90's own face. TN 2 stated the wound on Resident 90's nose was a self-inflicted scratch. TN 2 stated there was no documentation to indicate when the wound was discovered and no documentation to indicate if Resident 90's physician had been notified. TN 2 stated there were no treatment orders for the scratch on Resident 90's nose. TN 2 stated when the injury was discovered, it should have been documented in the skin observation tool and SBAR to ensure facility staff, physician and Resident 90's family were notified of the changes and to assist in monitoring for healing. TN 2 stated if the wound is not treated it could potentially get worse or infected. During a review of Resident 90's SBAR dated 6/25/2025, the SBAR indicated the scratch on Resident 90's nose measured 0.5 x 0.5 cm with minimal bleeding and redness toward the side. The SBAR indicated a message was left with Resident 90's physician's office. During a review concurrent interview and record review on 6/26/2025 at 4:41 PM with the Assistant Director of Nursing (ADON) Resident 90's Order Summary Report (OSR) dated with active orders as of 6/26/2025 was reviewed. The ADON stated the OSR indicated no active orders for monitoring or treatment orders for Resident 90's self-inflicted scratch. The ADON stated Resident 90's physician should have been followed up with immediately. The ADON stated if it was not treated then the wound could potentially get worse, infected or cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 17 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some other problems. The ADON stated an SBAR should have been initiated when the scratch was initially discovered to communicate the changes to facility staff, Resident 90's family, and physician and to ensure Resident 90 received treatment. During a review of the facility's P&P titled Care Standards dated 11/1/2017, the P&P indicated all residents shall receive necessary care and services to assist them in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care. Care is documented in the medical record according to state and/or federal regulations. C. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 4/18/2025, with diagnoses including metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should ), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and was dependent (helper does all of the effort) with mobility. During an observation on 6/23/2025 at 10:38 AM inside Resident 2's room, an unlabeled tube of hydrocortisone 1% cream was observed on Resident 2's bedside table. During an interview on 6/23/2025 at 10:40 AM with Resident 2, Resident 2 stated she had been applying the cream intermittently to her external vaginal area without staff guidance, and no one had inquired about its use. During a concurrent interview and record review on 6/25/2025 at 10:22 AM, Resident 2's Order Summary Report and Care Plan were reviewed with Registered Nurse Supervisor (RNS) 4. RNS 4 confirmed there was no physician's order for the hydrocortisone 1% cream and no documentation of an assessment or interdisciplinary team (IDT) evaluation for self-administration of medication. RNS 4 stated, There should have been a clinical assessment to determine whether that (hydrocortisone 1%) cream was appropriate and safe for her condition. We didn't have that (clinical assessment). During an interview on 6/26/2025 at 1:08 PM, the Assistant Director of Nursing (ADON) explained that Resident 2 had been using the hydrocortisone 1% cream independently before it was determined if the hydrocortisone 1% cream's use was appropriate and/or medically necessary. The ADON acknowledged that the lack of clinical review could have delayed the identification and treatment of a more serious underlying condition. During a review of the facility's policy and procedure (P&P) titled, Care Standards, dated 11/1/2017, the P&P indicated the facility would ensure all residents receive necessary care and services that are evidence-based and in accordance with accepted professional clinical standards of practice. During a review of the facility's job description titled, Registered Nurse Supervisor Job Description, the job description indicated the responsibilities of the Registered Nurse Supervisor included being accountable for the management and clinical care of residents, ensuring provision of quality nursing care in accordance with Federal, State, and Company requirements based on acuity of residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 18 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 .ensuring the exchange of essential information necessary for the provision of quality resident care. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's job description titled, Licensed Vocational Nurse Job Description, the job description indicated that the responsibilities of the Licensed Vocational Nurse included ensuring the exchange of information necessary for quality resident care, specific to medication administration. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 19 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to,A. implement a care-planned intervention to provide a padded landing mat at bedside for one of three sampled residents (Resident 37), who was identified as a high fall risk.B. Remove an oxygen condenser (a medical device that concentrates oxygen from room air for use in oxygen therapy), from one of three sampled resident's (Resident 87) room.This failure had the potential to result in falls and injuries such as fractures or head trauma for Resident 37 and the potential to result in Resident 87 receiving additional oxygen and leading to hyperoxemia (condition characterized by abnormally high levels of oxygen in the blood). Cross Reference F656Findings: A. During a review of Resident 37's admission Record (AR), the AR indicated the facility admitted Resident 37 on 2/1/2025, and re-admitted the resident on 5/22/2025, with diagnoses including acute respiratory failure (when the lungs suddenly cannot get enough oxygen into the blood and/or cannot remove enough carbon dioxide [a colorless, odorless gas] from the blood), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and severe intellectual disabilities (when a person has certain limitations in mental functioning and in skills such as communicating, taking care of him or herself, and social skills). During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool), dated 5/26/2025, the MDS indicated Resident 37's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 37 was dependent (helper does all of the effort) with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and dependent with mobility. During a review of Resident 37's Fall Risk Assessment, dated 5/22/2025, the fall risk assessment for Resident 37 indicated a total score of 14, which classified the resident as high risk for falls. According to the assessment tool, a score above 10 meant the resident was at high risk for falls. During an observation on 6/23/2025 at 9:10 AM, Resident 37 was observed in bed with both legs dangling off the right side of the bed. The resident appeared restless. No floor mats were observed on either side of the bed. During an interview on 6/26/2025 at 10:09 AM, Respiratory Therapist (RT) 3 stated RT 3 was familiar with Resident 37 and had frequently observed Resident 37 to be restless and often dangling Resident 37's legs off the right side of the bed. RT 3confirmed that Resident 37 was considered at high risk for falls. During a concurrent interview and record review on 6/26/2025 at 10:30 AM, Resident 37's Care Plan Report and Fall Risk Assessment was reviewed with Registered Nurse Supervisor (RNS) 5. RNS 5 stated that Resident 37's Care Plan included an intervention to provide a padded landing mat at bedside to minimize injury in the event of a fall. RNS 5 acknowledged that, based on Resident 37's behavior and high fall risk, floor mats were an appropriate intervention and should have been implemented to reduce the potential for serious injury. During an interview on 6/26/2025 at 1:08 PM, the Assistant Director of Nursing (ADON) stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 20 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when a resident was identified as a high fall risk and care plan interventions such as floor mats were in place, especially when the resident exhibited known behaviors like restlessness and dangling feet off the bed, staff must ensure care plan interventions were consistently implemented. The ADON acknowledged that interventions were developed to reduce the risk of serious injury and should be followed to maintain resident safety. The ADON stated that failure to implement care-planned safety measures compromised the residents' well-being and increased the potential for preventable harm, such as fractures or head trauma. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 11/1/2017, the P&P indicated Based on the information gathered from the history and assessment of the resident, the Nursing Staff and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls .The Nursing Staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk for falls. B. During a review of Resident 87's AR, the AR indicated Resident 87 was originally admitted on [DATE] with a diagnosis of alcoholic liver disease (condition caused by excessive alcohol consumption that damages the liver). During a review of Resident 87's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective and evaluation plan]), titled, Risk of Falls secondary to Generalized Weakness, History of Falls, initiated on 9/30/2024, the CP indicated, two of the interventions, were to keep Resident 87's environment hazard free and provide a safe environment at all times. During a review of Resident 87's Order Summary Report, dated 6/26/2025, the Order Summary Report did not indicate oxygen orders for the resident. During an observation on 6/23/2025, at 9:30 am, in Resident 87's room, an oxygen condenser was at the bedside. During an interview on 6/23/2025, at 12:29 pm, with Resident 87, Resident 87 stated, Oxygen is not mine. During a concurrent observation and interview on 6/25/2025, at 9:51 am, with a Certified Nursing Assistant 7 (CNA 7), in Resident 87's room, an oxygen condenser was at the bedside. CNA 7 stated, I know if they are not using (condenser), it should not be here.During a concurrent observation and interview 6/25/2025, at 10:11 am, with Licensed Vocational Nurse 6 (LVN 6), in Resident 87's room, an oxygen condenser was at the bedside with the date 5/5/2025 labled on the humidifier. LVN 6 stated, Should not be here if there are no orders for oxygen and stated the date 5/5/2025 on the humidifier. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 10/24/2022, the P&P indicated, Ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 21 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure and provide appropriate treatment and sufficient services for one of four sampled residents (Resident 38) who had a clinically-justified indwelling catheter (a medical device that drains urine from your bladder into a bag outside your body) by failing to monitor Resident 38's supra-pubic catheter (a type of indwelling catheter) closely for changes in condition, recognizing, reporting and addressing such changes.This deficient practice could potentially result in Resident 38 to develop a recurrence of a urinary tract infection (UTI - an infection in the bladder/urinary tract) leading to more serious complications.Findings:During a review of Resident 38's admission Record (AR), the AR indicated, Resident 38 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including UTI, site not specified and neuromuscular dysfunction of bladder (loss of bladder control), unspecified.During a review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/3/2025, the MDS indicated, Resident 38's BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was intact. The MDS indicated, Resident 38 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). The MDS indicated, Resident 38 was dependent (helper does all of the effort) for toileting hygiene.During a review of Resident 38's History and Physical Examination (H&P), dated 6/22/25, the H&P indicated, Resident 38 had the capacity to understand and make decisions.During a review of Resident 38's Order Summary Report (OSR), active orders as of 6/24/2025, the OSR indicated an order on 6/20/2025 to irrigate suprapubic catheter with 100 cc (cubic centimeter - a unit of volume) NS (normal saline - a sterile solution of salt and water) as needed for hematuria (blood in the urine), sediments and cloudiness.During a concurrent observation and interview on 6/24/2025 at 9:13 AM with Infection Preventionist (IP) 1, Resident 38 was lying in bed and had a urinary catheter draining to gravity. IP 1 grimaced as IP 1 observed Resident 38's urine drainage. IP 1 stated, Resident 38 had a suprapubic catheter and the urine drainage was milky, beige and custard looking. IP 1 stated, the urine drainage was not normal and staff should have checked, flushed (irrigated), did a COC (change of condition) and notified the physician to prevent Resident 38 from further developing a UTI.During an interview on 6/25/2025 at 8:47 AM with Registered Nurse Supervisor (RNS) 2, RNS 2 stated, urinary catheters were checked every morning, every shift and as needed by staff. RNS 2 stated, staff should have flushed Resident 38's suprapubic catheter until it (drainage) was clear and monitor the drainage. RNS 2 stated, staff was to notify the physician if the drainage was not clear after flushing. During an interview on 6/27/2025 at 8:48 AM with the Director of Nursing (DON), the DON stated, suprapubic catheter was monitored for drainage output daily. The DON stated, Resident 38's suprapubic catheter should have been monitored closely since Resident 38 just recently came back from the hospital, for infection control.During a review of Resident 38's Treatment Administration Record (TAR), dated 6/1/2025 6/24/2025, the TAR did not indicate, any documentation of the order to irrigate Resident 38's suprapubic catheter with 100 cc NS as needed for hematuria, sediments and cloudiness.During a review of Resident 38's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled, [Resident 38] is at risk for urinary tract infection (UTI) r/t (related to) Indwelling Suprapubic Catheter, date initiated 6/24/2025, the CP indicated, interventions included to monitor/document/report to physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 22 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete prn (as needed) for signs and symptoms of UTI and to notify physician for any COC.During a review of the facility's policy and procedure (P&P) titled, Catheter - Care of, date revised 11/1/2017, the P&P indicated, the purpose of the P&P was to prevent catheter-associated UTI while ensuring that residents were not given in-dwelling catheters unless medically necessary. The P&P indicated, a resident, with or without a catheter, received the appropriate care and services to prevent infections to the extent possible.During a review of the facility's P&P titled, Catheter - Suprapubic, Care of, date revised 11/1/2017, the P&P indicated, suprapubic catheter care would be performed daily and as needed. Event ID: Facility ID: 056118 If continuation sheet Page 23 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and date a tube feed water flush bag for one of one sampled resident (Resident 83) who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine). This failure could potentially lead to infections (the invasion and growth of germs in the body) and other complications in Resident 83's digestive system (a group of organs that work together to digest and absorb nutrients from the food you eat).Findings:During a review of Resident 83's admission Record (AR), the AR indicated, Resident 83 was originally admitted to the facility 8/27/2024 and readmitted on [DATE] with multiple diagnoses including encephalopathy (a disturbance of brain function), unspecified and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 83's care plan (CP) for [Resident 83] having a feeding tube, date initiated 2/7/2025, the CP indicated, one of the interventions was to change TF (tube feeding) every 24 hours.During a review of Resident 83's History and Physical Examination (H&P), dated 2/8/2025, the H&P indicated, Resident 83 could make needs known but could not make medical decisions.During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/17/2025, the MDS indicated, Resident 83's cognition was severely impaired. The MDS indicated Resident 83 had a feeding tube (e.g., nasogastric or abdominal [PEG]) for nutrition while a resident [at the facility].During a review of Resident 83's Order Summary Report (OSR), active orders as of 6/26/2025, the OSR indicated, an enteral feed order dated 6/15/2025 for Isosource 1.5 to provide 1949 cal (calories - a measurement of the energy content of food)/(per)1500 cc (cubic centimeter - a unit of volume) per day via g-tube (gastrostomy tube - a tube inserted through the belly that brings nutrition directly to the stomach) and an order dated 6/17/2025 for enteral feed to flush tubing with the minimum of 55 cc's water for 20 hours.During an observation on 6/23/2025 at 9:50 AM, Resident 83 was lying in bed with a tube feed of Isosource 1.5 calories infusing at 75 cc/hr via a tube feed pump. The tube feed pump indicated Total Fed: 1346 ml (millimeters - a measure of volume). The 1500 ml Isosource tube feed bag was labeled and dated 6/22/25 @12 pm and had about 150 ml left in the bag. The 1000 ml water flush bag had no label or date and had about 500 ml left in the bag. During an interview on 6/23/2025 at 9:56 AM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the tube feed water flush bag should also be labeled and dated for infection control [purposes].During an interview on 6/27/2025 at 8:48 AM with the Director of Nursing (DON), the DON stated, the tube feeding and the water flush bag were replaced every 24 hours, the whole set up and should be labeled and dated. The DON stated, it was important to label and date the tube feeding for patient identifier and for staff to know what time the set up was changed and when to replace the bags to prevent GI (gastrointestinal - refers to the organs and system involved in digestion) upset and for infection control [purposes].During a review of the facility's policy and procedure (P&P) titled, Bolus Feeding, date revised 11/1/2017, the P&P indicated, enteral feeding would be provided when a resident was unable to take food and/or fluids orally, through a nasogastric, gastrostomy, or jejunostomy tube according to written physician orders. The P&P indicated, to change equipment every 24 hours. The P&P indicated, to make sure that equipment and products were labeled with the date and time they were first used or opened. Event ID: Facility ID: 056118 If continuation sheet Page 24 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the oxygen humidifier was labeled for two of two sampled residents (Resident 11 and 85).This failure had the potential to result in infection and complications associated with oxygen therapy to Resident 11 and 85. Findings:During a review of Resident 11's admission Record (AR), the AR indicated, Resident 11 was originally admitted to the facility on [DATE] with multiple diagnoses including Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [C02, a colorless, odorless gas that is a waste product made by the body) with hypoxia (low levels of 02 in the body) and Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause ongoing inflammation and narrowing of airways, making it difficult to breathe).During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated that Resident 11's cognitive skills (ability to think and process information) for daily decision making had moderate cognitive impairment.During a review of Resident 11's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective and evaluation plan]), titled .resident has COPD, initiated on 3/3/2025, CP indicated goals for Resident 11 to be free of signs and symptoms of respiratory infections through review date.During a review of Resident 11's CP, titled .presence of wounds, initiated on 4/9/2025, CP indicated goals were to reduce the transmission of S. Aureus (type of bacteria that can cause a variety of infections, ranging from mild skin issues to sever, life-threatening illnesses) and multidrug-resistant organisms (MDROs, bacteria or other microorganisms that have become resistant to multiple antibiotics, making the difficult to treat and can lead to serious infections) and prevent transmission of infectious agents in the facility. CP indicated interventions use hand hygiene, gowns and gloves during morning and evening care, toileting and changing incontinence briefs, caring for devices, giving medical treatments, wound care (any skin opening requiring a dressing), mobility assistance and cleaning environment.During a review of Resident 11's Order Summary Report (OSR), active orders as of 6/26/2025, the OSR indicated, to administer oxygen at 2 L/min (liters per minute) via nasal cannula (small flexible tube that delivers extra O2 into the nose) to keep O2 Sat (oxygen saturation [SpO2], a measurement of how much oxygen one's blood is carrying) at/above 90% for COPD.During a review of Resident 85's admission Record (AR), the AR indicated, Resident 85 was originally admitted to the facility on [DATE] with diagnoses of Hypertensive Heart (long-term condition that develops from chronic high blood pressure) and Chronic Kidney Disease (a condition where the kidneys are damaged and cannot filter blood effectively) with Heart Failure (a condition where the heart cannot pump enough blood to meet the body's need) and with Stage 5 Chronic Kidney Disease or End Stage Renal Disease (most severe stage of chronic kidney disease-unable to adequately filter waste and excess fluid from blood).During a review of Resident 85's CP, titled .indwelling medical devices (Dialysis Subclavian Tunneled Catheter, tubing inserted into chest area to provide dialysis treatment [medical procedure that filters and cleanses the blood when the kidneys are unable to perform these functions due to kidney failure]) initiated on 10/28/2024, CP indicated goals were to reduce the transmission of S. Aureus (type of bacteria that can cause a variety of infections, ranging from mild skin issues to sever, life-threatening illnesses) and multidrug-resistant organisms (MDROs, bacteria or other microorganisms that have become resistant to multiple antibiotics, making the difficult to treat and can lead to serious infections), prevent transmission of infectious agents in the facility and be free from signs and symptoms of infection. CP indicated interventions use Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 25 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete hand hygiene, gowns and gloves during morning and evening care, toileting and changing incontinence briefs, caring for devices, giving medical treatments, wound care (any skin opening requiring a dressing), mobility assistance and cleaning environment.During a review of Resident 85's Order Summary Report (OSR), active orders as of 6/26/2025, the OSR indicated, to administer oxygen at 2 L/min (liters per minute) via nasal cannula (small flexible tube that delivers extra O2 into the nose) to keep O2 Sat (oxygen saturation [SpO2], a measurement of how much oxygen one's blood is carrying) at/above 90% for respiratory failure.During an observation on 6/23/2025, at 10:21 am, in Resident 11and 85's room, the oxygen humidifier (a device that adds moisture to oxygen gas before it is inhaled by a patient) was not labeled.During a concurrent observation and interview on 06/24/2025, at 3:15 pm, with Licensed Vocational Nurse (LVN) 1, Resident 11's and 85's room, their oxygen humidifier was not labeled on 6/23/2025. LVN 1 stated it is important to date oxygen tubing and humidifier so we can change every Sunday and when it is complete.During an interview on 6/26/2025, at 10:16am, with Respiratory Therapist (RT) 2, RT 2 stated oxygen tubing/humidifier needs to be dated. We change them out every week and as needed. Always change on Sunday. It is important to date, so we are aware when it was the last time changed and it is important to change it to make sure that they are not filthy, infection control, that it is not kinked, keep the integrity of the tubing to work properly.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/24/2022, indicated, .Infection Control All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: Are for single resident use only. Will be changed weekly and when visibly soiled.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 10/24/2022, the P&P indicated, .The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.Prevent, detect, investigate, and control infection in the Facility.Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Event ID: Facility ID: 056118 If continuation sheet Page 26 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%, unit of measurement). The facility had 12 medication errors out of 27 opportunities which resulted in an overall medication error rate of 44.44%, affecting three of three residents (Residents 40, 51, and 10) observed during medication administration (pass). The medication errors noted were as follows:A.For Resident 40, compatibility (the ability to combine two medicines without interfering with the action of either) was not checked before tablets of Escitalopram (Lexapro, a medication used to treat depression [serious illness that negatively affects how one feels, thinks, and acts]), Senna (a laxative), Multivitamins with Minerals (a naturally occurring element, a supplement used to treat vitamin and mineral deficiency), Vitamin D3 (type of vitamin D that is naturally produced in the body when the skin is exposed to sunlight), and Docusate Sodium (stool softener) were crushed and mixed with other medications.?Additionally, an incorrect form of Docusate Sodium was administered to Resident 40.B.For Resident 51, the facility failed to: administer Acetaminophen (a pain reliever) 30 minutes before wound care as ordered by Medical Doctor (MD 1, Resident 51's physician) 1 for Resident 51, administer Xarelto (a blood thinner), Glimepiride (medication used to treat high blood sugar levels), and Potassium (vital mineral) Chloride (medication used to treat low potassium) with food as ordered by MD 1. The facility failed to ensure attempts were not made to crush Potassium Chloride extended release (ER- medication is slowly released over time) and follow MD 1's order not to crush the medication. Additionally, the facility failed to administer Zinc Sulfate (supplement used for wound healing) and Ascorbic Acid (supplement used for wound healing) according to MD 1's orders, the medications were omitted for 21 days (6/4/2025 to 6/25/2025). C. For Resident 10, the facility failed to administer Omeprazole (a medication that reduces stomach acid) via gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach) by mixing the medication with water instead of apple juice as ordered and failure to not allow the medication to dissolve in water, and not push the medication down with a syringe plunger instead of allowing the medication to travel down the tube by gravity per standard practice and the facility policy.These failures to administer medications in accordance with manufacturer's specifications and standards of practice placed Residents 40, 51, and 10 at risk to experience significant medical complications including pain, delayed wound healing, abnormal heart rhythm (when the heart beats too fast, too slow, or irregularly from a normal rhythm), g-tube obstruction or dislodgement, and hospitalization.Cross Referenced: F760 and F658Findings:A. During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility 12/27/2018 with diagnoses that included dysphagia (difficulty swallowing), hemiplegia (severe or complete loss of strength or paralysis on one side of the body), hemiparesis (a mild or partial weakness or loss of strength on one side of the body).During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 6/12/2024, the MDS indicated Resident 40's cognitive skills (thought process and ability to reason or make decisions) was severely impaired.During a review of Resident 40's Order Summary Report (OSR) for the month of June 2025, the OSR indicated active medication orders for:?1. Lexapro (Escitalopram) 10 milligrams (mg, unit of measurement), give one tablet by mouth one time a day for depression manifested by verbalization of being sad/depressed, dated 5/4/2025.2. Docusate Sodium tablet 100 mg, give one tablet by mouth two times a day for bowel management, hold for loose stool, dated 9/3/2023.3. Senokot (Senna) tablet 8.6 mg, give one tablet by mouth one time a day for bowel management, hold if loose stools, order date 8/21/2023?4. Multivitamin-Minerals tablet, give one tablet by mouth one time a day for supplement, dated 10/20/2023.5. Vitamin D3 Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 27 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Cholecalciferol) tablet 25 micrograms (mcg - a unit of measurement), give one tablet by mouth one time a day for supplement, dated 7/18/2023.6. Divalproex Sodium Delayed Release (DR, delayed release, medication released after a delayed time) Sprinkle 125 mg, give four (4) capsules (500 mg) by mouth two times a day for seizure disorder (also known as epilepsy, a neurological condition characterized by sudden, abnormal electrical disturbances in the brain), dated 7/18/2023.During a medication administration (pass) observation in Station 2, at Medication Cart (Med Cart) 2 on 6/24/2025 at 8:37 AM with LVN 1, LVN 1 prepared the following medications for Resident 40 and placed them into a medicine cup:? 1. One tablet of Escitalopram 10 mg.?2. One tablet of Multivitamin with Minerals?3. One tablet of Senna 8.6 mg.4. One tablet of Vitamin D3 25 mcg.5. One capsule of Docusate Sodium 100 mg.?6. Four capsules of Divalproex Sodium DR. The four capsules were opened and the contents placed in a medication cup and mixed with less than a teaspoonful of applesauce.LVN 1 crushed all tablets together and mixed all 5 medications with apple sauce. LVN 1 was stopped by the surveyor before LVN 1 administered the medications to Resident 40.During a concurrent medication pass observation and interview on 6/24/2025 at 8:56 AM, LVN 1 stated six morning medications were prepared for Resident 40. LVN 1 entered Resident 40's room, administered the Divalproex Sodium DR Sprinkles mixed with applesauce followed by administration of Docusate Sodium capsule to Resident 40. Resident 40 spit the capsule out into a cup of water and requested for all the remaining medications to be crushed and mixed with apple sauce.During a concurrent observation and interview on 6/24/2025 at 8:58 AM, LVN 1 was observed disposing the Docusate Sodium capsule. LVN 1 stated there was a tablet form of Docusate Sodium 100 mg that would be crushed and given to Resident 40. LVN 1 placed one tablet of Docusate Sodium 100 mg into the medication cup with the remaining four medications that included one tablet of, Escitalopram 10 mg, Multivitamins with Minerals, Senna 8.6 mg, and Vitamin D3 25 mcg. LVN 1 was observed crushing all of the tablets together and mixing the medications with apple sauce. LVN 1 was stopped by the surveyor before LVN 1 administered the medications to Resident 40. During an interview with LVN 1 on 6/24/2025 at 9:06 AM, LVN 1 stated Resident 40 sometimes took medications whole and other times requested the medications to be crushed. LVN 1 stated LVN 1 did not talk to MD 3 to request [an order for] crushing of medications and mixing with apple sauce. LVN 1 stated LVN 1 was unaware if there was a current order for Resident 40's medications to be crushed. LVN 1 stated LVN 1 did not speak to a pharmacist to determine if the medications could be crushed, mixed, and administered together to Resident 40.?? During a concurrent interview and record review on 6/24/2025 at 9:14 AM, of Resident 40's OSR with a Registered Nurse Supervisor (RNS) 1, RNS 1 stated there was an order placed for Resident 40 dated 10/30/2023 indicating, May crush medications and administer with apple sauce. RNS 1 stated nurses should check for, or obtain, orders to crush medications prior to crushing oral medications. RNS 1 stated crushed oral medications should be given one by one to keep track of what medication was administered and to prevent aspiration (inhalation of foreign material into the airway) or choking if the resident could not tolerate taking the medications all at once. RNS 1 stated the form of the medication should not be changed without a doctor's order and LVN 1 should have called MD 3 prior to administering Docusate Sodium capsule instead of a tablet. RNS 1 stated following physicians' orders ensured patient safety and prevented harm from incompatibility (refers to the undesirable reactions that occur when two or more drugs are mixed, leading to reduced efficacy [ability of the medication to produce a desired result or effect] or safety).During an interview on 6/24/2025 at 9:22 AM, with RNS 1, stated that LVN 1 should have discarded the crushed medications and prepared them again. RNS 1 stated LVN 1 should prepare Resident 40's medications by crushing them one at a time and mix each medication with applesauce and administer the medications to Resident 40 one medication at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 28 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a time.During a concurrent interview and record review on 6/24/2025 at 9:37 AM, Resident 40's June 2025 Medication Administration Record (MAR, a legal record of medication administration) was reviewed. Resident 40's MAR indicated an order for Docusate Sodium 100 mg tablet. LVN 1 stated LVN 1 should not have administered the capsule form of Docusate Sodium because the correct order indicated a tablet form.During an interview on 6/26/2025 at 10:37 AM, Director of Nursing (DON) stated licensed nurses cannot crush different medications together because medications may have interactions. The DON stated physicians did not authorize nurses to crush multiple medications together and licensed nurses must crush the medications separately. B. During a review of Resident 51's AR, the AR stated Resident 51 was admitted to the facility 4/24/2021 and readmitted [DATE] with diagnoses that included, stage 4 pressure ulcer [PU, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction, the wound extends to the muscle, bone, or tendon) of sacral (a triangular bone located at the base of the spine) region, hypokalemia (low potassium [vital mineral]), protein-calorie malnutrition (lacking in protein and calories).During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognition was moderately impaired. The MDS indicated Resident 51 required supervision for eating, moderate assistance for oral hygiene, and substantial/dependent upon staff assistance for bed mobility, transferring, dressing, toileting, and showering/bathing.?During a review of Resident 51's CP, dated 4/21/2025, the CP indicated Resident 51 had stage 4 (four) PU on the sacro coccyx (the area where the base of the spine connects to the very end of the spine) area that extended to left and right buttocks. The CP indicated Resident 51 had the potential for further PU development related to incontinence (lack of voluntary control over urination or defecation [discharge of feces from the body]) and impaired mobility. The CP's interventions indicated to Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort.? During a review of Resident 51's OSR, dated active as of 6/24/2025, the OSR indicated Resident 51 had active medication orders for the following morning medications:??? a. Acetaminophen tablet 325 mg, give two tablets by mouth every day shift for pain management. The order indicated to give 30 minutes before treatment, order date 3/31/2025? b. Xarelto oral tablet 15 mg, give one tablet by mouth one time a day for atrial fibrillation (a-fib, an irregular heart rate that causes poor blood flow), dated 3/13/2025.?? c. Glimepiride oral tablet 1 mg, give one tablet by mouth one time a day for diabetes mellitus (DM- a disease that results in high blood sugar), order date 3/13/2025.?? d. Potassium Chloride ER oral tablet 10 milliequivalents (meq- a unit of measurement), give one tablet by mouth one time a day for supplement. The order indicated to administer with or after meals with 4-8 ounces (oz, unit of measurement by volume) of water, dated 4/7/2025. e. Digoxin (medication used to treat heart failure) oral tablet 125 mcg, give one tablet by mouth one time a day for heart failure. Hold if heart rate (HR) is less than 60 beats per minute (normal HR is between 60 and 100 beats per minute [bpm]), dated 3/13/2025.? f. Docusate Sodium oral capsule 250 mg, give one capsule by mouth one time a day for bowel management. Hold for loose stool, dated 5/7/2025.?? g. Furosemide (medication used to lower blood pressure) oral tablet 40 mg, give one tablet by mouth one time a day for congestive heart failure (CHF, long term condition in which the heart doesn't pump as well as it should). Hold for systolic blood pressure (the blood pressure when the heart squeezes) less than 110 millimeters of mercury (mmHg, a unit of measurement), dated 5/25/2025. h. Multivitamins with Minerals oral tablet, give one tablet by mouth one time a day for wound healing support, dated 3/18/2025.? i. Polyethylene Glycol 3350 (laxative) oral powder 17 grams (g-unit of measurement by weight)/scoop, give one scoop by mouth one time a day for bowel management, give with 8 oz of water, dated 4/7/2025.??? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 29 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some j. Spironolactone (medication used to treat heart failure) oral tablet 50 mg, give one tablet by mouth one time a day for CHF, dated 3/13/2025.?? k. Insulin Glargine (medication used to lower blood sugar) 15 units (u- a unit of measurement) subcutaneously (SQ- injected into the tissue just below the skin) Solution 100 u/ milliliter (mL, unit of measurement), Inject 15 units SQ one time a day for DM. Hold if blood sugar (BS) is less than 100 (normal BS range is between 72 and 99 milligrams per deciliter [mg/dl, unit of measurement] when fasting and below 140 mg/dL two hours after eating), dated 4/9/2025.??? l. Ascorbic Acid oral tablet 500 mg, give one tablet by mouth one time a day for supplement, dated 6/4/2025.? m. Zinc Sulfate oral tablet 220 mg, give one tablet by mouth one time a day for supplement for one month, dated 6/4/2025.??? During a concurrent medication pass observation and interview on 6/24/2025 at 9:55 AM, with LVN 2, in Station 3, Med Cart 3, LVN 2 prepared the following medications for Resident 51:? a. Two tablets of Acetaminophen 325 mg. b. One tablet of Xarelto 15 mg.? c. One tablet of Glimepiride 1 mg.? d. One tablet of Potassium Chloride ER 10 meq.? e. One tablet of Digoxin 125 mcg.? f. One capsule of Docusate Sodium 250 mg.? g. One tablet of Furosemide 40 mg.? h. One tablet of Multivitamins with Minerals.? i. One scoop of Polyethylene Glycol Oral Powder 17 g? j. One tablet of Spironolactone 50 mg.? k. Insulin Glargine 15 units SQ.?? LVN 2 stated the medications listed above were the only medications to administer to Resident 51 scheduled at 9 AM.During a medication pass observation on 6/24/2025 at 10:42 AM, Resident 51 requested oral medications to be crushed. LVN 2 was observed asking the Assistant DON (ADON) to get an order from the physician to crush the medications and mix with apple sauce. At 10:59 AM, the ADON was observed returning to LVN 2 and stated The order is in.??? During a concurrent medication pass observation and interview with LVN 2 on 6/24/2025 at 11:04 AM, LVN 2 stated it should be okay to crush all the medications because the doctor had placed the order. LVN 2 was observed crushing the medications individually and placing each medication into separate medicine cups with half a teaspoon of apple sauce. LVN 2 attempted to crush Potassium Chloride ER and was stopped by the surveyor. LVN 2 stated LVN 2 intended to crush Potassium Chloride ER tablet, mix with apple sauce, and administer it to Resident 51.? During an interview with the ADON on 6/24/2025 at 11:06 AM, the ADON stated Potassium Chloride ER tablets should not be crushed, as indicated on the medication card (also known as bubble/blister pack, packaging that organizes and dispenses medications in individual doses). The ADON stated LVN 2 should have double checked the medication card to made sure the medication was crushable; the nurse should have contacted the physician to get an order for a liquid form. The ADON stated crushing Potassium Chloride ER could cause the medication to be released immediately and lead to high levels of potassium in the blood which could cause an irregular heart rhythm.??? During a review of the DailyMed (the official provider of Food and Drug Administration [FDA] label information [package inserts]), for Potassium Chloride ER, updated 10/2014, the DailyMed indicated, physicians should consider reminding the patient of the following: To take each dose with meals and with a full glass of water or other liquid. To take each dose without crushing, chewing, or sucking the tablets . The DailyMed indicated the most common adverse reactions to oral potassium salts are nausea, vomiting, flatulence, abdominal pain/discomfort, and diarrhea. The DailyMed indicated these symptoms are due to irritation of the gastrointestinal tract and are best managed by diluting the preparation further, taking the dose with meals or reducing the amount taken at one time. During observation of LVN 2's medication administration for Resident 51 on 6/24/2025 at 11:12 a.m., Resident 51 only accepted two oral medications that were mixed with half a teaspoon of apple sauce and were taken with water: one tablet of Acetaminophen 325 mg. one tablet of Furosemide 40 mg.Resident 51 refused the remaining oral medications. During an interview with Resident 51 on 6/24/2025 at 11:27 AM, Resident 51 stated Resident 51 did not want to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 30 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some take the rest of the medications because taking so many pills on an empty stomach hurt Resident 51's stomach. Resident 51 stated Resident 51 had not been offered food with Resident 51's morning medications.During an interview with the ADON on 6/24/2025 at 11:48 AM, the ADON stated breakfast trays were served at 7 AM.?? During a review of DailyMed, revised 8/2024, the DailyMed indicated Glimepiride tablets should be administered with breakfast or the first main meal of the day . common adverse reactions included .hypoglycemia (low blood sugar), headache, nausea, and dizziness.During a review of the DailyMed, updated 6/24/2025, the DailyMed indicated Xarelto is indicated to reduce the risk of stroke and systemic embolism (blockage in a blood vessel) in adult patients with nonvalvular atrial fibrillation (irregular heartbeat) . to increase absorption, all doses should be taken with feeding or with food.During an interview with Resident 51 on 6/24/2025 at 11:27 AM, Resident 51 stated Resident 51 received wound care treatments every morning and the nurses were supposed to offer pain medication before treatment. Resident 51 stated Resident 51 did not receive pain medication in the morning prior to the treatment and the wound care treatment was very painful.?? During an interview with Treatment Nurse (TN) 2 on 6/25/2025 at 11:05 AM, TN 2 stated the wound care treatment for Resident 51 was completed between 5 AM and 6 AM on 6/24/2025. TN 2 stated TN 2 was unaware if Resident 51 received pain medication prior to the wound care treatment. TN 2 stated treatment nurses were supposed to coordinate with the charge nurse to ensure Resident 51 received the scheduled pain medication prior to the treatments to prevent the resident from having pain.? During record review of Resident 51's OSR dated 6/24/2025, the OSR indicated Resident 51 physician orders included orders for:a. Ascorbic Acid oral tablet 500 mg: give one tablet by mouth one time a day for supplement. Ordered 6/4/2025b. Zinc Sulfate oral tablet 220 mg: Give one tablet by mouth one time a day for supplement for one month. Ordered 6/4/2025.During an interview with RNS 1 on 6/25/2025 at 11:23 AM, RNS 1 stated that it was important to keep the MAR updated because residents could get worse if they missed their medications for 21 days.During an interview with LVN 2 on 6/25/2025 at 12:07 PM and concurrent record review of Resident 51's OSR, LVN 2 stated the orders for Ascorbic Acid and Zinc Sulfate were placed on 6/4/2025 but were not on Resident 51's MAR. LVN 2 stated Resident 51 did not receive these medications for 21 days. LVN 2 stated these medications were supplements that helped promote healthy tissue growth and are important for healing Resident 51's pressure ulcer. LVN 2 stated the RN Supervisors were responsible for adding new orders in the MAR, but LVN 2 should check the MAR [and compare] with the online orders to ensure accuracy.During an interview with the DON on 6/26/2025 at 10:37 AM, the DON stated when a physician placed an order to crush medications, nurses (in general) were responsible for determining if the medications could be crushed by consulting the pharmacy.??The DON stated nurses could give residents milk, crackers, or apple sauce with medications that required to be given with food and half a teaspoon of apple sauce was not considered enough food to give with these medications. The DON stated it was important to administer medications with food when it was ordered [or indicated on the medication card] to minimize adverse effects of the medicine like nausea and upset stomach, because the residents (in general) would begin refusing their medications in the future and this could delay healing.?The DON stated when a physician placed an order to crush medications, the nurse is responsible for determining if the medications could be crushed by consulting the pharmacy.During a concurrent review of Resident 51's medication cards and interview on 6/26/2025 at 2:43 PM, with the Dispensing Pharmacy (Pharm 1), the following medications contained instructions to take with food:? Glimepiride: Take with food. Potassium Chloride ER: give with or after meals with 4-8 ounces of water.? Xarelto: Take with food.? Pharm 1 stated Potassium Chloride ER could not be crushed and Xarelto had to be taken with food. Pharm 1 stated if Xarelto was taken with food, Resident 51 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 31 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some could experience a higher medication absorption. Pharm 1 stated Glimepiride should be given with a big meal, usually breakfast, because the medication could cause a drop in blood sugar and cause adverse effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication) that included headache, nausea, and/or dizziness. Pharm 1 stated Xarelto should be administered with food due to higher absorption of the medication.C. During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility 4/12/2025 with diagnoses that included, GERD, Dysphagia, aphasia (condition that makes it hard to use and understand language), Quadriplegia (paralysis affecting all four limbs, both arms and both legs), and gastrostomy tube. During a review of Resident 10's CPs, the CP indicated Resident 10 had GERD, dated 4/14/2025, the CP indicated Resident 10 would remain free of discomfort, complications or signs and symptoms related to diagnosis of GERD. The CP's interventions indicated to give medications as ordered and monitor/document side effects and the effectiveness [of the medications].? During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 was totally dependent upon assistance of two or more staff for all activities of daily living (ADL, skills needed to live independently, such as eating, bathing, dressing, toilet use, personal hygiene, bed mobility, and transfer).??? During a review of Resident 10's OSR, active orders as of 6/25/2025, the OSR included the following orders:? a. Omeprazole oral capsule DR 20 mg, via g-tube one time a day for GERD. The order indicated, may open capsule, mix with apple juice. Do not crush granules, order date 4/12/2025.? b. Enteral feed order, every day shift, may flush tube with 5 ml of water between each medication, order date 4/12/2025.? c. Basaglar (a medication that lowers blood sugar) Subcutaneous (SQ, injection into tissue just under the skin) Solution 100 units (unit, of measurement) per mL, instructions indicated, inject 30 units SQ one time a day for DM (Diabetes Mellitus, disease characterized by high blood sugar (glucose) levels). Hold if blood sugar (BS) is less than 100 mg per deciliter (dL, unit of measurement by volume) (normal BS is between 72 and 99 mg/dL when fasting and up to 140 mg/dL two hours after eating), order date 4/12/2025.d. Folic Acid (a vitamin) 400 mcg, give via g-tube one time a day for supplement, order date 4/12/2025.e. Sodium Chloride (a salt supplement) 1 gram (g, unit of measure by weight), give one tablet via g-tube one time a day for supplement, order date 4/12/2025.f. Thiamin HCl (a supplement) 100 mg, give one tablet via g-tube one time a day for supplement, order date 4/12/2025. g. Valproate Sodium oral solution 250 mg/ 5mL, give 30 ml (1500 mg) via g-tube one time a day for seizure disorder.During a concurrent medication pass observation and interview on 6/25/2025 at 8:41 AM, with LVN 3 prepared the following medications for Resident 10: a. 30 units of Basaglar KwikPen a. One tablet of Folic Acid 400 mcgb. One capsule of Omeprazole DR 20 mgc. One tablet of Sodium Chloride 1 gd. One tablet of Thiamin HCl 100 mge. 30 mL of Valproate Sodium oral solution 250 mg/ 5mLLVN 3 stated Resident 10 had a g-tube, and Resident 10's medications must be crushed or be in liquid form to be administered.LVN 3 sprinkled the contents of the Omeprazole capsule into a medicine cup filled with 30 mL of water. LVN 3 was observed crushing the Folic Acid, Sodium Chloride, and Thiamin HCl tablets separately and placed the medications in individual medicine cups with 15 mL of water each. During observation on 6/25/2025 at 09:08 AM, before administering medications individually, LVN 3 flushed the g-tube with 30 mL of water by pushing on a syringe plunger (a device consisting of a rubber cup on a long handle, used to clear blocked pipes by means of water pressure). LVN 3 administered Omeprazole DR mixture by pushing on the syringe plunger in the same manner. LVN 3 administered a second crushed medication (Folic Acid) via gravity, without flushing water between the medications.During a review of Resident 10's OSR, active orders as of 6/25/2025, the OSR included the following orders:? a. Omeprazole oral capsule DR 20 mg, via g-tube one time a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 32 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some day for gastro-esophageal reflux disease (GERD; digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]). The order indicated, may open capsule, mix with apple juice. Do not crush granules, order date 4/12/2025.? b. Enteral feed order, every day shift, may flush tube with 5 ml of water between each medication, order date 4/12/2025.? During an interview with RNS 2 on 6/25/2025 at 9:27 AM, RNS 2 stated medications given through a g-tube should be given by gravity and never be forced down with a plunger because the g-tube could clog or burst and it would have to be replaced. RNS 2 stated this could affect Resident 10 because Resident 10 would not be able to receive medications or feeding while waiting for the g-tube to be replaced.? During an interview with LVN 3 on 6/25/2025 at 09:45 AM, LVN 3 stated, I was nervous. LVN 3 stated LVN 3 should not have pushed any of the medications with the plunger because doing that could cause Resident 10 harm. LVN 3 stated LVN 3 was supposed to flush 5 mL of water between every medication.??LVN 3 stated LVN 3 was supposed to flush with 5 mL of water between every medication.During an interview with Pharm 1 on 6/26/2025 at 2:43 PM, Pharm 1 stated Omeprazole DR was designed to [deliver] delayed release of the medication and should not be left to dissolve prior to administration. Pharm 1 stated Omeprazole should be prepared by adding the contents of the capsule to 50 mL of water or apple juice and immediately administered through the g-tube. Pharm 1 stated the g-tube should be flushed with water after administration of each medication to ensure the medications were administered. Pharm 1 stated dissolving Omeprazole for 10-15 minutes prior to administration altered the mechanism of action (specific molecular interaction through which a drug produces its therapeutic effect) of the medication and would affect its efficacy (ability of the medication to produce a desired result).?? During a review of the facility's Policy and Procedures (P&P) titled, Medication - Administration, dated 11/1/2017, the P&P indicated to provide safe administration of medications for residents in the facility. The P&P indicated if the resident has difficulty swallowing pills, the licensed nurse will notify the attending physician to discuss the possibility of a different form of the medication (i.e., crushed, liquid, or suspension). The P&P indicated if the medication is to be crushed, a physician order is required. The P&P indicated nursing staff will keep in mind the seven rights of medication when administering medication .The right medication. The P&P indicated the resident's MAR will be reviewed for allergies and/or special considerations for administration including .accepted professional standards and principles. The P&P indicated the licensed nurse must know the following information about any medication they are administering: Any precautions and special considerations, the drug's side effects and adverse effects.During a review of the facility's P&P titled, Feeding Tube - Administration of Medication, dated 11/1/2017, the P&P indicated medications are administered appropriately and safely when the resident has a feeding tube in place and medications are delivered through the feeding tube.?The P&P indicated do not force any medication or fluid into the tube and allow gravity to work as much as possible.?The P&P indicated medications must be given separately, flushed with 5 mL of warm water in between each medication.??During a review of the facility's P&P titled Pain Management, dated 11/1/2017, the P&P's purpose indicated to ensure accurate assessment and management of the resident's pain.?The P&P indicated the licensed nurse will administer pain medication as ordered and document all medications administered on the Medication Administration Record (MAR, a legal record of medication administration).?The P&P indicated nursing staff will implement timely interventions to reduce the increase in severity of pain.??? During a review of the facility's P&P titled Physician Orders dated 5/1/2019, the P&P's purpose indicated this will ensure that all physician orders are complete and accurate.? The P&P indicated whenever possible, the licensed nurse receiving the order will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 33 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0759 be responsible for documenting and implementing the order.?? Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 34 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to:A. Ensure opened food containers in one (1) of two (2) refrigerators were labeled with a ‘best by' or ‘use by' date. B. Ensure 1 of four (4) chemical sanitizing buckets maintained the regulated concentration range for 24 of 25 days in June 2025. These deficient practices placed all the residents in the facility at risk for foodborne illnesses (caused by the ingestion of contaminated food or beverages). Findings:A. During an observation on 6/23/2025 at 8:23 AM in the kitchen, three (3) opened containers that were not labeled with a best by or use by date was found inside Refrigerator 1. One (1) of the containers contained tapioca pudding, one contained vanilla pudding, and one contained apple sauce. cDuring an interview on 6/23/2025 at 8:23 AM with the Director of Dietary Services (DDS), the DDS stated that opened containers must be labeled with a best by or use by date to ensure residents received good quality food and to maintain proper food rotation. The DDS added that without date labels, staff would not be able to determine how long the food had been opened, increasing the risk of serving expired food items.During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.B. During a concurrent interview and record review on 6/25/2025 at 11:41 AM, the Dishwasher Station Sanitizer Solution/Quaternary Ammonium Compounds (QAC) Quality Review (QR) Test log was reviewed with the DDS. The log indicated that the quaternary sanitizing solution concentration was consistently recorded at 100 PPM (parts per million) from 6/1/2025 at 5:30 AM to 6/24/2025 at 4:00 PM, across all meal periods. According to the facility's policy, the acceptable concentration range for quaternary sanitizer is 150-400 PPM. Out of 25 days reviewed, 24 days had readings below the facility's acceptable range. The DDS stated that the QAC test results should have been within the facility's acceptable range of 150 to 400 PPM to ensure surfaces were properly sanitized. The DDS explained that if the sanitizing solution concentration was too low, it may not have effectively killed bacteria, and if it was too high, it could have been hazardous to staff or residents.During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, undated, the P&P indicated, staff will check for appropriate quaternary levels by inserting a quaternary test strip into the bucket of sanitizing solution. The P&P indicated, Test strips can range between 150-400 PPM, or per manufacturer's guidelines. Event ID: Facility ID: 056118 If continuation sheet Page 35 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document one of one sampled residents (Resident 91) diagnosis of anxiety in Resident 91's admission Record (AR).This failure had the potential to result in Resident 91 not receiving medication and services related to anxiety.Findings:During a review of Resident 91's admission Record (AR), the AR indicated Resident 91 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (condition where the inability of the lungs to oxygenate the blood leads to dangerously low oxygen levels in the body) and dependence on ventilator (when one cannot breathe on their own and relies on a machine to support their respiratory function).During a review of Resident 91's Medical Professional Progress Note (MPPN) dated 2/27/2025, the MPPN indicated a plan from Resident 91's psychiatrist to begin lorazepam for anxiety manifested by restlessness for 14 days.During a review of Resident 91's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/21/2025, the MDS indicated Resident 91 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) for toileting and personal hygiene. The MDS did not indicate a diagnosis of anxiety.During a review of Resident 91's Order Summary Report (OSR) with active orders as of 6/26/2025, the OSR indicated Resident 91 had a physician order dated 6/21/2025 to give lorazepam (medication used to treat anxiety) 0.5 milligrams (mg - unit of weight) via gastrostomy tube (GT - tube inserted through the abdomen into the stomach for nutrition, fluids, and medications) every six (6) hours as needed for anxiety for 14 days manifested by restlessness.During a concurrent interview and record review on 6/26/2025 at 1:57 PM with Registered Nurse Supervisor (RNS) 5, Resident 91's admission Record (AR) was reviewed. RNS 5 stated RNS 5 did not see a diagnosis of anxiety on Resident 91's list of diagnosis on the AR.During an interview on 6/26/2025 at 4:20 PM with the Assistant Director of Nursing (ADON), the ADON stated Resident 91's anxiety diagnosis needed to be included in the AR to give accurate resident history and to ensure the medication and care given to Resident 91 was specific to their needs.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 5/17/2024, the P&P indicated residents should not receive psychotropic drugs pursuant to an as needed (PRN) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. Event ID: Facility ID: 056118 If continuation sheet Page 36 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an arbitration agreement that provided for a selection of a neutral arbitrator and a venue with both parties agreed upon for three of three sampled residents (Resident 28, 48, and 54.)This deficient practice had the potential to infringe on residents' rights.Findings:a. During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes (condition in which the body cannot properly store or use sugar, the body's main source of energy) and dementia (a gradual decline in mental ability usually caused by brain disease.)During a review of Resident 28's History and Physical (H&P) dated 5/25/2025, the H&P indicated Resident 28 had the capacity to understand and make decisions.b. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including respiratory failure (the failure of the body to exchange gases properly, which leads to a buildup of carbon dioxide and a lack of oxygen in the blood) and heart failure (inability of the heart to efficiently pump blood through the body, causing buildup of blood in the veins and of other body fluids in tissue.)During a review of Resident 48's History and Physical (H&P) dated 2/19/2025, the H&P indicated Resident 48 had the capacity to understand and make decisions.c. During a review of Resident 54's admission Record (AR), the AR indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including dementia (a gradual decline in mental ability usually caused by a brain disease) and osteoarthritis (the breakdown of cartilage lining the bones in joints, usually weight-bearing joints; causes stiffness and pain.)During a review of Resident 54's History and Physical (H&P) dated 6/11/2022, the H&P indicated Resident 54 had the capacity to understand and make decisions.During a concurrent interview and record review on 6/27/2025 at 8:54 AM with the Admissions Coordinator (AC), Resident 28, 48 and 54's Resident-Facility Arbitration Agreement (RFAA) was reviewed. The AC stated the AC did not see where the RFAA indicated to provide fora selection of a neutral arbitrator and a venue to which both parties agree upon. The AC stated it is important to disclose the arbitrator and place to meet because it is part of the residents' rights.During a review of the facility's policy and procedures (P&P), titled, Arbitration Agreement, dated 10/24/2022, the P&P indicated the facility is expected to make a reasonable attempt to provide a fair process and come to agreement with the resident/responsible party on the selection of a neutral arbitrator and location. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 37 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to ensure the facility/QAA (Quality Assessment and Assurance) committee measured the success of actions implemented and tracked performance to ensure improvements were realized and sustained.This deficient practice could potentially result in the facility to miss opportunities to identify and address weaknesses in resident care processes, leading to a higher chance of medical errors, resident harm, and negative outcomes and hinder the improvement of resident safety measures, leaving residents vulnerable to preventable risks.Findings:During an interview on 6/27/2025 at 5:15 PM with the Administrator (ADM) in the presence of the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADM stated, the facility did not have a tracking system in place. The ADM stated, the facility had binders of data collections but not tracking analysis. The ADM stated, it was important to have a tracking system in place so facility could identify where the facility's strengths and weaknesses were.During a review of the facility's policy and procedure (P&P) titled, QAPI Program, date revised 10/24/2022, the P&P indicated, the facility implemented and maintained an ongoing, Facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. Event ID: Facility ID: 056118 If continuation sheet Page 38 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain and implement its Infection (the invasion and growth of germs in the body) Control Program by failing to ensure:a. A personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) for two of four sampled residents (Resident 47 and Resident 51.)b. Enhanced barrier precautions ((EBP, an approach to use Personal Protective Equipment [PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection or illness] to reduce transmission of multidrug-resistant organism) were in place by failing to post a sign in front of one of four sampled resident's (Resident 5) rooms who was on EBP due to having a suprapubic catheter (tube inserted through a small incision in the abdomen to drain urine directly from the bladder.)These deficient practices had the potential to result in transmission of disease and infections to Resident 47, Resident 51, and Resident 5. Findings: Residents Affected - Few a. During a review of Resident 47's admission Record (AR), the AR indicated, Resident 47 was admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with mood disturbance and down syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays). During a review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/12/2024, the MDS indicated, Resident 47's cognitive skills (ability to think and process information) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 47 was dependent (helper does all of the effort) for all activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 47's History and Physical (H&P), dated 10/17/2024, the H&P indicated, Resident 47 did not have the capacity to understand and make decisions. During a review of Resident 51's 'AR, the AR indicated, Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including local infection of the skin and subcutaneous tissue, unspecified and pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of sacral (the triangular bone at the base of the spine) region, stage 4 (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 51's H&P, dated 3/10/2025, the H&P indicated, Resident 51 was alert and oriented times three (describes a patient's level of awareness to person, place and time but not what is happening to them). During a review of Resident 51's MDS, dated 3/16/2025, the MDS indicated, Resident 51's BIMS (Brief Interview for Mental Status – an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was moderately impaired. The MDS indicated, Resident 51 was dependent to requiring supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for ADLs. During an observation on 6/23/2025 at 9:40 AM, Resident 47 and 51were roommates. Resident 47 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 39 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 51's room had an Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) signage posted and a PPE (personal protective equipment – clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart outside of the room. During a concurrent observation and interview on 6/23/2025 at 9:43 AM with Certified Nursing Assistant (CNA) 1, inside the [NAME] and [NAME] restroom shared by Resident 47 and Resident 51, an opened, unlabeled 7.5 fl. oz. (fluid ounce, a unit of volume) of Total Bath Skin & Hair Cleanser (brand name) was stored on the ledge mirror (bathroom mirror shelf). CNA 1 stated, an EBP signage was posted if a resident had a wound and Resident 51 had a wound. CNA 1 stated, the skin and hair cleanser was a personal toiletry and should be labeled and kept inside the resident's drawer at the bedside to prevent transfer of microbes (bacteria), for infection control. During an interview on 6/25/2025 at 9:47 AM with the Infection Preventionist (IP) 1, IP 1 stated, personal toiletries should be labeled with resident's name and room number and stored in resident's drawer where all the hygiene care for personal use were kept for infection control and prevent others from using. b. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including obstructive and reflux uropathy (obstructive refers to a blockage in the urinary tract, preventing normal urine flow while reflux is the abnormal backflow of urine from the bladder into the ureters and potentially the kidneys) and hypospadias (a birth defect in which the opening of the urethra [the tube that carries urine from the bladder] is not located at the tip of the penis) During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had intact cognitions (ability to understand and process information) and was dependent (helper does all of the effort) on staff for bathing and toilet hygiene. During a review of Resident 5's Order Summary Report (OSR) with active orders as of 6/24/2025, the OSR indicated Resident 5 had a physician order dated 4/3/2025 to observe enhanced barrier precautions (EBP) per CDC guidelines. During a review of Resident 5's Care Plan Report (CP - a form where one can summarize a person's health conditions, specific care need, and current treatments) the CP indicated Resident 5 is on enhanced standard precautions for the duration of Resident 5's stay at the facility. The CP indicated all staff will observe appropriate precautions during high-contact resident care activities requiring gown and glove use among residents that trigger EBP use. During a concurrent observation and interview on 6/23/2025 at 10:18 AM with Licensed Vocational Nurse (LVN) 4, the front doorway of Resident 5's room was observed. LVN 4 stated there was no signage indicating EBP or isolation caddy storing personal protective equipment (PPE) for Resident 5. LVN 4 stated Resident 5 should be under EBP because Resident 5 had a suprapubic catheter, and the facility wants to protect the residents from potentially spreading bacteria between staff and residents. During an interview on 6/24/2025 at 10:12 AM with the Infection Preventionist (IP) 1, IP 1 stated residents that needed EBP included residents with catheter and are susceptible to infection and it is very important to protect residents from infection. IP 1 further stated if there is no signage there is a higher chance for residents to get infections and not be protected. An EBP signage would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 40 of 41 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St 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 0880 by the door to inform staff which PPE they will need to wear. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Standard and Enhanced Precautions, dated 4/1/2024, the P&P indicated the purpose of standard and enhanced precautions is to ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents. The P&P further indicated EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g. urinary catheters). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056118 If continuation sheet Page 41 of 41