Health inspection·March 20, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure 1 of 3 sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach) received care and services from staff who were trained and competent in feeding tube management according to the facility ' s policies and procedures (P&P) titled, Gastrostomy Tube. This failure had the potential for Resident 3 and all residents who received tube feeding to not receive appropriate feeding tube nutrition and feeding tube care. Cross reference F726 Findings: During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems). During a review of Resident 3 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications). During a review of Resident 3 ' s admission Minimum Data Set (MDS – a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition. During a review of Resident 3 ' s physician ' s order (PO), dated 3/11/25, the PO indicated to provide [brand name] tube feeding to Resident 3 to run at 55 milliliters (ml, unit of measure) per hour for 20 hours to provide 1100 ml/1650 calories in 24 hours via feeding pump machine (enteral feeding pump, a medical device used to deliver tube feeding directly to the stomach). Page 1 of 8 056360 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 3/20/25 at 5:20 am inside Resident 3 ' s room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3 ' s tube feeding machine at the bedside read, holding, which indicated Resident 3 ' s tube feeding was on hold and not running or infusing. During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3 ' s room, no other staff went inside Resident 3 ' s room while CNA 3 provided care to Resident 3 inside the room. During a concurrent observation and interview on 3/20/25 at 5:28 am inside Resident 3 ' s room, Resident 3 ' s tube feeding machine at the bedside read, running, which indicated Resident 3 ' s tube feeding was infusing. CNA 3 stated CNA 3 turned Resident 3 ' s tube feeding machine to run after CNA 3 provided care to Resident 3. During a subsequent interview on 3/20/25 at 5:29 am in Station 1 nurses ' station with CNA 3, CNA 3 stated CNAs were not supposed to turn residents ' tube feeding machine on and off. CNA 3 stated licensed nurses were supposed to turn residents ' tube feeding machine on and off for the CNAs. CNA 3 stated CNA 3 turned Resident 3 ' s tube feeding machine to run because CNA 3 did not want the tube feeding machine alarm to wake the residents up. CNA 3 stated an alarm would go off after the tube feeding machine was on hold for some time. During an interview on 3/20/25 at 5:50 am with CNA 4, CNA 4 stated CNAs were allowed to put tube feeding machines on hold, but not allowed to turn tube feeding machines on or off. CNA 4 stated it was common practice for CNA 4 to put residents ' tube feeding machine on hold when CNA 4 provided care to the resident and then put the tube feeding machine to run after CNA 4 provided care to the resident. During an interview on 3/20/25 at 6:24 am Licensed Vocational Nurse (LVN) 5, LVN 5 stated CNAs must not touch tube feeding machines because they could accidentally change the setting on the tube feeding machines. LVN 5 stated only licensed nurses could turn tube feeding machines on, off, on hold, and/or run. During an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs were not allowed to put tube feeding machines on, off, on hold, and/or run. The DSD stated only licensed nurses must turn tube feeding pumps on, off, on hold, and/or run. Before CNAs provided care to the resident, CNAs must notify the licensed nurse assigned to the resident to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. If the licensed nurse assigned to the resident was busy, CNAs must ask another licensed nurse to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. The DSD stated CNAs were not trained on how to operate tube feeding machines and operating tube feeding machines did not fall under the CNAs scope of practice. The DSD stated during new hire orientation and during yearly skills check, CNAs were taught not to disconnect any machines or equipment connected to residents and/or to turn machines or equipment connected to residents on or off. During an interview on 3/20/25 at 9:25 am with the DSD, the CNA Job Description and the most current CNA Comprehensive Clinical Competency Review – Skills Checklist for CNA 3 and CNA 4 were reviewed with the DSD. The DSD stated feeding tubes and tube feeding machines were not included in the competency review and skills check. During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated CNAs 056360 Page 2 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few must not turn tube feeding machines on or off. The DON stated providing tube feeding was considered medication/treatment administration and was not in the CNAs scope of practice. According to the California Health and Safety Code Section (d) (3), Certified nurse assistant means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, and is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision of a registered nurse, as defined in Section 2725 of the Business and Professions Code, or a licensed vocational nurse, as defined in Section 2859 of the Business and Professions Code. During a review of the facility ' s P&P titled, Gastrostomy Tube, dated 2/8/21, the P&P indicated it was part of the facility ' s Licensed Nurse Procedures. The P&P indicated, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube . 056360 Page 3 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate staff provided proper care and maintenance for one of three sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach). This failure had the potential for Resident 3 to not receive appropriate feeding tube nutrition and care by trained and competent staff. Cross reference F693 Findings: During a review of Resident 3's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems). During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube. During a review of Resident 3's admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition. During a review of Resident 3's physician's order (PO), dated 3/7/25, the PO indicated to provide [brand name] tube feeding via feeding pump machine (enteral feeding pump, a medical device used to deliver tube feeding directly to the stomach) to Resident 3 to run at 55 milliliters (ml, unit of measure) per hour to provide 1100 ml in 24 hours. During an observation on 3/20/25 at 5:20 am inside Resident 3's room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3's tube feeding machine at the bedside read, holding, which indicated Resident 3's tube feeding was on hold and not running or infusing. During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3's room, no other staff went inside Resident 3's room while CNA 3 provided care to Resident 3 inside the room. During a concurrent observation and interview on 3/20/25 at 5:28 am inside Resident 3's room, Resident 3's tube feeding machine at the bedside read, running, which indicated Resident 3's tube feeding was infusing. CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run after CNA 3 provided care to Resident 3. 056360 Page 4 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a subsequent interview on 3/20/25 at 5:29 am in Station 1 nurses' station with CNA 3, CNA 3 stated CNAs were not supposed to turn residents' tube feeding machine on and off. CNA 3 stated licensed nurses were supposed to turn residents' tube feeding machine on and off for the CNAs. CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run because CNA 3 did not want the tube feeding machine alarm to wake the residents up. CNA 3 stated an alarm would go off after the tube feeding machine was on hold for some time. During an interview on 3/20/25 at 5:50 am with CNA 4, CNA 4 stated CNAs were allowed to put tube feeding machines on hold, but not allowed to turn tube feeding machines on or off. CNA 4 stated it was common practice for CNA 4 to put residents' tube feeding machine on hold when CNA 4 provided care to the resident and then put the tube feeding machine to run after CNA 4 provided care to the resident. During an interview on 3/20/25 at 6:24 am Licensed Vocational Nurse (LVN) 5, LVN 5 stated CNAs must not touch tube feeding machines because they could accidentally change the setting on the tube feeding machines. LVN 5 stated only licensed nurses could turn tube feeding machines on, off, on hold, and/or run. During an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs were not allowed to put tube feeding machines on, off, on hold, and/or run. The DSD stated only licensed nurses must turn tube feeding pumps on, off, on hold, and/or run. Before CNAs provided care to the resident, CNAs must notify the licensed nurse assigned to the resident to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. If the licensed nurse assigned to the resident was busy, CNAs must ask another licensed nurse to put the tube feeding machine on hold or to disconnect the resident from the tube feeding machine. The DSD stated CNAs were not trained on how to operate tube feeding machines and operating tube feeding machines did not fall under the CNAs scope of practice. The DSD stated during new hire orientation and during yearly skills check, CNAs were taught not to disconnect any machines or equipment connected to residents and/or to turn machines or equipment connected to residents on or off. During an interview on 3/20/25 at 9:25 am with the DSD, the CNA Job Description and the CNA Comprehensive Clinical Competency Review - Skills Checklist for CNA 3 and CNA 4 were reviewed with the DSD. The DSD stated feeding tubes and tube feeding machines were not included in the competency review and skills check. During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated CNAs must not turn tube feeding machines on or off. The DON stated providing tube feeding was considered medication/treatment administration and was not in the CNAs scope of practice. According to the California Health and Safety Code Section (d) (3), Certified nurse assistant means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, and is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision of a registered nurse, as defined in Section 2725 of the Business and Professions Code, or a licensed vocational nurse, as defined in Section 2859 of the Business and Professions Code. During a review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube, dated 056360 Page 5 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0726 2/8/21, the P&P indicated it was part of the facility's Licensed Nurse Procedures. The P&P indicated, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056360 Page 6 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

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 implement Enhanced Barrier Precautions (EBP- an infection control strategy in nursing homes that expands the use of personal protective equipment [PPE], specifically gowns and gloves, during high-contact resident care to prevent the spread of infection) for one of 13 sampled residents (Resident 3). Residents Affected - Few This failure had the potential to spread infections to the residents, staff, and visitors that could lead to hospitalization and/or death. Findings: During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach commonly for people with swallowing problems). During a review of Resident 3 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. The H&P also indicated Resident 3 had a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications). During a review of Resident 3 ' s admission Minimum Data Set (MDS – a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility. The MDS indicated Resident 3 received tube feeding for nutrition. During an observation on 3/20/25 at 5:20 am inside Resident 3 ' s room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3 ' s tube feeding machine at the bedside read, holding, which indicated Resident 3 ' s tube feeding was on hold and not running or infusing. CNA 3 did not have an isolation gown on. During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3 ' s room, there was a sign posted on the outside wall next to the doorway to Resident 3 ' s room which indicated Resident 3 was on EBP. During an interview on 3/20/25 at 5:29 am with CNA 3, CNA 3 stated EBP must be observed when providing care to residents with G-tubes because residents who have G-tubes were more at risk for infection. CNA 3 stated staff must wear an isolation gown when providing care to Resident 3. CNA 3 stated CNA 3 forgot to put on an isolation gown when CNA 3 walked inside Resident 3 ' s room. During an interview on 3/20/25 at 8:49 am with the Director of Staff Development (DSD), the DSD stated CNAs must follow EBP when providing care to residents with tubes, ports, or wounds because residents with tubes, ports, or wounds were more at risk for getting an infection. 056360 Page 7 of 8 056360 03/20/2025 Arbor Glen Care Center 1033 E. Arrow Highway Glendora, CA 91740

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/20/25 at 9:06 am with the Infection Prevention Nurse (IPN), the IPN stated staff needed to follow EBP when providing care to residents with tubes, wounds, catheters and with any type of device which required protection from infection. Staff must put on mask, gown, and gloves when providing care to residents on EBP. The IPN stated it was important for staff (general) to follow EBP so that residents do not get infections. Residents Affected - Few During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated it was important for all staff to put on masks, gown, and gloves when providing care to residents on EBP to protect the residents from infection. During a review of the facility ' s policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 1/2025, the P&P indicated, Enhanced Barrier Protection (EBP) is used in conjunction with standard precautions and expand use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization of MDROs) .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting . 056360 Page 8 of 8