Health inspection·July 16, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure adequate respiratory supply in the facility for 14 of 14 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14) who had a tracheostomy tube (a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing) and on a mechanical ventilator (a form of life support that helps a person breathe (ventilate) when they can't breathe on their own) in accordance with the facility's policy and procedure (P&P) titled, Heat and Moisture Exchange (HME-a device that helps maintain the temperature and humidity of exhaled air, preventing it from becoming too dry and irritating to the airways) when there were 8 HMEs left in the facility for 14 residents on 6/29/2025 and the HME supply was not replenished until 7/2/2025.This failure resulted in Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14 not having their HME changed every 24 hours per policy and procedure and had the potential for the residents to develop respiratory complications. During a review of Resident 1's, Resident 2's, Resident 3's, Resident 4's, Resident 5's, Resident 6's, Resident 7's, Resident 8's, Resident 9's, Resident 10's, Resident 11's, Resident 12's, Resident 13's, and Resident 14's admission Record (AR), the AR indicated the facility admitted the residents with diagnoses which included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood). The AR indicated Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14 had a tracheostomy tube and were on a mechanical ventilator.During a review of Resident 1's, Resident 2's, Resident 3's, Resident 4's, Resident 5's, Resident 6's, Resident 7's, Resident 8's, Resident 9's, Resident 10's, Resident 11's, Resident 12's, Resident 13's, and Resident 14's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated the residents were dependent (helper does all the effort) on others for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the residents were dependent on oxygen therapy, suctioning, tracheostomy care, and were ventilator dependent.During a concurrent interview and record review on 7/16/2025 at 10:28 am with the Respiratory Therapist Lead (RTL), the RTL reviewed the June 2025 and July 2025 invoices (lists of supplies sent) of respiratory supplies sent to the facility by the respiratory supply vendor. RTL stated the invoice indicated HMEs were delivered to the facility on 6/4/2025 and on 6/24/2025, and RTL picked up a shipment of 2 boxes of HMEs on 7/1/2025 which RTL delivered to the facility on 7/2/2025. The invoices also indicated there were only 8 HME's left in the facility for 14 residents on 6/29/2025, 6/30/2025, and 7/1/2025. The RTL stated, I do not believe the eight (8) HME's were enough for our 14 residents from 6/29/2025, 6/30/2025, and 7/1/2025. RTL stated RTL found out that there were only 8 HMEs left in the facility through text message from Respiratory Therapist Residents Affected - Some Page 1 of 2 056118 056118 07/16/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (RT) 1 and RTL picked up HME supplies. RTL stated RTL ordered the respiratory supplies timely from the vendor, but the vendor did not deliver. RTL reviewed the facility P&P titled, Heat and Moisture Exchange (HME), dated 5/1/2024, and stated the purpose of the HME according to the P&P was To provide a source of humidity to the inspired gas on a mechanical ventilator dependent resident. The P&P indicated, A Licensed Nurse or Respiratory Therapist may apply heat and moisture exchange (HME) to tracheostomy tubes for activities of daily living and external transports on mechanically ventilated residents.HME should be discarded twenty-four hours after opening packaging or when excessively soiled with secretions and shall be changed each day shift.During a concurrent interview and record review on 7/16/2025 at 3:52 pm with Assistant Director of Nursing (ADON), ADON stated 8 HME's were not enough for fourteen ventilator dependent residents. ADON reviewed the facility P&P titled, Heat and Moisture Exchange (HME), dated 5/1/2024, and stated the purpose of the HME according to the P&P was To provide a source of humidity to the inspired gas on a mechanical ventilator dependent resident. The P&P indicated, A Licensed Nurse or Respiratory Therapist may apply heat and moisture exchange (HME) to tracheostomy tubes for activities of daily living and external transports on mechanically ventilated residents.HME should be discarded twenty-four hours after opening packaging or when excessively soiled with secretions and shall be changed each day shift. 056118 Page 2 of 2