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.
Based on observation, interview, and record review the facility failed to maintain a safe and comfortable
room temperature in 2 of 2 resident shower rooms observed.This deficient practice had the potential to
cause discomfort and unsafe conditions for residents who used the shower rooms.During a concurrent
observation and interview on 8/26/25 at 11:27 AM, with Certified Nurse Assistant 1 (CNA 1) the thermostat
of the third-floor shower room showed 82 F. CNA 1 stated, It is hot and stuffy, not usually like this.During a
concurrent observation and interview on 8/26/25 at 11:31 AM with Licensed Vocational Nurse 1 (LVN 1) the
thermostat of the second-floor shower room, showed 85 F. LVN 1 stated the room feels hot and stuffy.
During an interview on 8/26/25 at 12:40 PM, with Maintenance Supervisor (MS), MS stated, Yes, the AC
(air conditioner) has been acting up and it is scheduled to be repaired. MS stated that the temperatures are
high in the shower rooms.A review of the facility's policy titled Homelike Environment, revised February
2021, indicated staff are to provide a safe, clean, comfortable, and homelike environment for residents. The
policy indicated comfortable and safe temperatures (71 F - 81 F) must be maintained in resident areas,
including bathing and shower rooms.
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:
555416
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
555416
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Canyon Transitional Care Unit
401 W. Ada Ave.
Glendora, CA 91741
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
Based on observation, interview, and record review, the facility failed to implement their policy and
procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Resident 1's
responsible party (RP, a person who is responsible for guiding, informing, assisting, and advocating for
residents in the healthcare system) was informed when Resident 1's blood sugar level was 480 and
Resident 1 had to be given additional dose of insulin (a hormone that removes excess sugar from the
blood, can be produced by the body or given artificially via medication) on 5/17/2025 at 12:23 pm.2.
Resident 1's blood sugar level of 480 on 5/17/2025 was documented in Resident 1's medical record.3. An
SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare
workers when there is a change of condition among the residents) Communication Form was filled out on
5/17/2025 at 12:23 pm when Resident 1's blood sugar level was 480 and Resident 1 had to be given an
additional dose of insulin.These failures resulted in Resident 1's RP not being informed of Resident 1's
change in condition and had the potential for Resident 1 to receive inadequate monitoring, care, and
treatment of Resident 1's high blood sugar.Findings:During a review of Resident 1's admission Record
(AR), the AR indicated the facility admitted Resident 1 on 12/04/2024, and readmitted Resident 1 on
6/20/2025 with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in
blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P,
physician's clinical evaluation and examination of the resident), dated 6/21/2025, indicated Resident 1 did
not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set
(MDS-a resident assessment tool), dated 6/26/2025, the MDS indicated Resident 1's cognitive skills (the
ability to think and process information) for daily decision making was severely impaired, and Resident 1
was dependent on staff for most activities of daily living (ADLs- activities such as bathing, dressing and
toileting a person performs daily).During a review of Resident 1's Order Summary Report (OSR), dated
9/3/2025, the OSR indicated there was a physician's order, dated 5/17/2025, to give Resident 1 one dose of
an injection of 3 units of insulin lispro (fast-acting insulin) for blood sugar of 480.During a review of Resident
1's Medication Administration Record (MAR) for the month of May 2025, the MAR indicated on 5/17/2025 at
12:23 pm, Resident 1 was given an injection of 3 units of insulin lispro (fast-acting insulin) due to blood
sugar of 480.During a concurrent interview and record review on 9/3/2025 at 3:50 p.m. with the Director of
Nursing (DON), the DON stated any blood sugar level above 401 required a Change of Condition (COC)
note or an SBAR Communication Form, a physician notification, and a family or RP notification. The DON
reviewed Resident 1's medical record and was unable to find a COC note, a progress note, and or an
SBAR Communication Form regarding Resident 1's blood sugar level of 480 on 5/17/2025. The DON was
unable to find family or RP notification regardingDuring a review of the facility's P&P titled, Change in a
Resident's Condition or Status, revised on February 2021, the P&P indicated, Prior to notifying the
physician or healthcare provider, the nurse will make detailed observations and gather relevant and
pertinent information for the provider, including (for example) information prompted by the Interact SBAR
Communication Form.a nurse will notify the resident's representative when there is a significant change in
the resident's physical, mental, or psychosocial status.The nurse will record in the resident's medical record
information relative to changes in the resident's medical/mental condition or status.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555416
If continuation sheet
Page 2 of 2
