Health inspection·November 21, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to reduce the risk of a fall and injury hazard for Resident 1 (who had a fall with a skin tear at the facility on 7/17/24), by not providing Resident 1 with bilateral floor mats as indicated in Resdient 1's care plan and physician order. This deficient practice had the potential to placed Resident 1 at risk for recurrent falls and injury. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/7/24 with diagnoses including metabolic encephalopathy (a group of conditions that cause brain dysfunction), muscle weakness (a lack of muscle strength), multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left knees, and abnormal posture (a chronic, involuntary, or rigid body position or movement that can indicate a severe brain or spinal cord injury). During a review of Resident 1's History & Physical (H&P) dated 4/10/24, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan, initiated on 7/17/24 indicated Resident 1 had a fall on 7/17/24. The care plan indicated, the goal was for Resident 1's skin tear to resolve without complication. The interventions were to place Resident 1's bed in lowest position, provide bilateral floor mats, continue interventions on the at-risk plan, and conduct requent visual checks. During a review of Resident 1's Fall Risk Assessments, dated 7/17/24, the assessments indicated the resient had a fall risk score of 13 (high risk). During a review of Resident 1's Physician Order Summary Report, dated 7/19/24, the report indicated, an active physician order for bilateral floor mats. During a review of Resident 1's Fall Risk Assessments, dated 10/10/24, the assessments indicated the resient had a fall risk score of 14 (high risk). During a review of Resident 1's Fall Risk Assessments, dated 10/30/24, the assessments indicated the resient had a fall risk score of 12 (high risk). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056360 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 056360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Glen Care Center 1033 E. Arrow Highway 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)