Health inspection·December 13, 2024

F 0694 Provide for the safe, appropriate administration of IV fluids 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 1 of 13 sampled residents (Resident 2) was provided peripherally inserted central catheter (PICC - a thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart. It is used to administer intravenous (IV) fluids, blood transfusions, chemotherapy, and other drugs, and to draw blood samples) care according to the physician's order and the facility's policy and procedure. Residents Affected - Few This failure had the potential for Resident 2 to develop an infection on Resident 2's PICC site and/or develop sepsis (a life-threatening blood infection). Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses which included cellulitis (a skin infection that causes swelling and redness) of the right lower limb and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's Physician's Order (PO), dated 12/1/24, the PO indicated to monitor Resident 2's PICC site for complications every 8 hours. The PO, dated 12/2/24, indicated to administer levofloxacin (antibiotic-medication used to prevent and treat infections) 500 milligrams (mg-unit of measure) IV solution to Resident 2 one time a day for diabetic infection of the lower limb. The PO, dated 12/3/24, indicated to administer daptomycin (antibiotic) 500 mg IV solution to Resident 2 every evening for diabetic infection of the lower limb. During a review of Resident 2's IV Medication Administration Record (IV MAR), dated 12/1/24-12/31/24, the IV MAR indicated Registered Nurse 1 (RN 1) administered levofloxacin 500 mg IV to Resident 2 and checked Resident 2's IV site at 9 am on 12/12/24 and on 12/13/24. The IV MAR indicated RN 2 administered daptomycin 500 mg IV to Resident 2 and checked Resident 2's IV site at 5 pm on 12/12/24. The IV MAR indicated Resident 2's PICC site had not been cleaned and the dressing had not been changed until 12/13/24 at 3 pm. During a review of Resident 2's History and Physical (H&P-physician's clinical evaluation and examination of the resident), dated 12/4/24, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a concurrent interview and observation on 12/12/13 at 4:44 pm with Resident 2, Resident 2's left upper arm PICC site had dried blood on it and the transparent dressing which was supposed to cover the PICC site had dried blood on it, was falling off, and did not completely cover the PICC (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 3 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 12/13/2024 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)