Health inspection·March 28, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received Restorative Nursing Assistant (RNA) services to increase, maintain, or prevent a decline in range of motion (ROM – the extent of movement of a joint) mobility per physician ' s orders, by failing to: 1. Initiate RNA services until 1/26/2025 (16 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s left upper extremity (UE) elbow extension (a device, like a brace or splint, that helped extend or straighten the elbow joint after an injury, surgery, or to assist with recovery or rehabilitation) and left hand-roll. 2. Initiate RNA services until 1/27/25 (17 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s left UE passive range of motion (PROM, exercises where a physical therapist or equipment moved a patient ' s joint through range of motion [ROM], helping to maintain or regain movement after injury or surgery, without the patient actively using their muscles) 3. Initiate RNA services until 1/29/2025 (19 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s right UE active assisted ROM (AAROM, moving a body part with some help from an outside source [like a person or a machine] but you were still actively trying to move yourself) 4. Ensure the facility ' s staff implemented a care plan for Resident 1 ' s RNA services, in accordance with the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered. These deficient practices resulted in a delay of care and not receiving the needed exercises placing Resident 1 at risk for further ROM decline and contractures (a permanent tightening or shortening of muscles, tendons, skin, and nearby tissues that caused joints to become stiff and limits movement). Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted the resident on 10/29/2024, with diagnoses including cerebral infarction (stroke - a stroke happens when there was a loss of blood flow to part of the brain) hemiplegia and hemiparesis (neurological conditions that caused weakness or paralysis on one side of the body) affecting left non-dominant side, adult failure to thrive (a decline caused by chronic diseases and functional impairments which could Page 1 of 10 055523 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cause weight loss, decreased appetite, poor nutrition, and inactivity), and muscle wasting and atrophy (muscle wasting, also known as muscle atrophy, was the loss of muscle and strength, which could occur due to various factors like inactivity, injury, illness, or aging). During a review of Resident 1 ' s History and Physical (H&P) dated 11/21/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 2/4/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper did all of the effort and the resident did none of the effort to complete the activity) on facility staff for all self-care and mobility. The MDS indicated the resident had the following Restorative Nursing Programs for at least 15 minutes a day in the last seven calendar days: two days of passive range of motion, zero days of active ROM (AROM, you were moving a joint yourself using your own muscles, without any external help, to improve flexibility and strength), and zero days of splint or brace assistance. During a review of Resident 1 ' s Telephone Order dated 1/10/2025 at 9:48 AM, the Telephone Order indicated Restorative Nursing Assistant (RNA, where specialized nursing assistants help residents regain or maintain their ability to perform daily activities and improve their physical function after an illness or injury) program: daily every day (QD) seven times a week as tolerated. Apply left upper extremity (UE) elbow extension and left hand-roll. Wear time: four to six hours every day shift every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday. During a review of Resident 1 ' s Telephone Order dated 1/10/2025 at 9:49 AM, the Telephone Order indicated RNA program: daily QD five times a week as tolerated. Left UE PROM, right UE active assisted ROM every evening shift every Monday, Tuesday, Wednesday, Thursday, Friday. During a review of Resident 1 ' s Telephone Order dated 1/10/2025 at 11:23 AM, the Telephone Order indicated RNA program on both lower extremities (LE) for QD five times a week or as tolerated one time a day. During a review of Resident 1 ' s Documentation Survey Report (DSR) dated January 2025, the DSR indicated the RNA program for left UE elbow extension and left-hand roll, wear time 4-6 hours daily QD seven times a week as tolerated was started on 1/26/2025 and not on 1/10/2025 as ordered by the therapist. The DSR indicated for the month of January 2025 Resident 1 only received treatment for four days: 1/26/2025, 1/27/2025, 1/29/2025, and 1/30/2025. During a review of Resident 1 ' s DSR dated January 2025, the DSR indicated the RNA program for left UE PROM daily QD five times a week as tolerated was started on 1/27/2025 and not on 1/10/2025 as ordered by the therapist. The DSR indicated for the month of January 2025 Resident 1 only received treatment for five days: 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025. During a review of Resident 1 ' s DSR dated January 2025, the DSR indicated the RNA program for right UE AAROM daily QD five times a week as tolerated was started on 1/29/2025 and not on 1/10/2025 as ordered by the therapist. The DSR indicated the for month of January 2025 Resident 1 only received treatment for two days: 1/29/2025 and 1/30/2025. During a review of Resident 1 ' s DSR dated February 2025, the DSR indicated the RNA program for 055523 Page 2 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left UE elbow extension and left-hand roll, wear time 4-6 hours daily QD seven times a week as tolerated did not have documentation on 2/1/2025 and 2/6/2025. During a review of Resident 1 ' s DSR dated March 2025, the DSR indicated the RNA program for left UE elbow extension and left-hand roll, wear time 4-6 hours daily QD seven times a week as tolerated did not have documentation on 3/15/2025, 3/16/2025, 3/17/2025, and 3/24/2025. During an interview on 3/26/2025 at 12:40 PM, Resident 1 ' s Responsible Party (RP) indicated the resident was supposed to be getting RNA five times a week for 15 minutes but the facility did not provide treatment since last week Thursday. The RP stated he (Resident 1) receives RNA services maybe twice a week. During an observation and interview with Resident 1 ' s Emergency Contact (EC) in Resident 1 ' s room on 3/27/2025 at 10:25 AM, the EC was at the resident ' s bedside and observed Resident 1 without a left arm elbow extension or a left hand-roll. The EC stated the resident had not declined but he (Resident 1) had not improved. During an interview and record review of Resident 1 ' s DSR for January 2025 on 3/28/2025 at 10:45 AM, the Restorative Nursing Assistant (RNA) 1 stated the treatment should have started on 1/11/2025 and the facility staff were not following the physician ' s orders. The RNA stated if the treatment was not started when ordered Resident 1 could decline and have a contracture. During an interview and record review of Resident 1 ' s DSR for January 2025 on 3/28/2025 at 1:05 PM, the Director of Nursing (DON) stated the facility staff were not following the physician ' s order because the treatment did not start when ordered. The DON stated the physician ' s orders should have been followed and if the physician ' s orders were not followed the resident would decline, could lost physical mobility and have contractures. During a concurrent interview and record review of Resident 1 ' s Comprehensive Care Plan on 3/28/2025 at 1:15 PM, the DON stated there was no care plan for the resident ' s RNA services but there should have been. The DON stated if there was no care plan for the resident, there was nothing for the facility staff to refer to for RNA services and Resident 1 ' s condition could get worse and the resident ' s left hand could have contractures. During a concurrent interview and record review of the facility ' s undatedP&P titled, Care Plans, Comprehensive Person-Centered, the P&P indicated, The comprehensive, person-centered care plan describes the services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The P&P indicated, Assessments of resident ' s were ongoing and care plans were revised as information about the resident ' s and the resident ' s condition change. The DON stated the facility was not following the policy and Resident 1 could decline and have contractures. During a review of the facility ' s undated P&P titled, Restorative Nursing Services, the P&P indicated, Resident would receive restorative nursing care as needed to help promote optimal safety and independence. The P&P indicated, Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident-centered and were outlined in the resident ' s plan of care. The P&P indicated, Restorative goals may include, but were not limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or 055523 Page 3 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0688 strengthening physiological and psychological resources; maintaining dignity, independence, and self-esteem; and participating in the development and implementation of the plan of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055523 Page 4 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent weight loss for one of three sampled residents (Resident 1) who was fed via gastrostomy tube (G-tube, a surgically placed feeding tube that delivers nutrition directly into the stomach through a small opening in the abdomen, used when someone could not eat or swallow safely or adequately) by failing to: Residents Affected - Few 1. Perform weekly weights upon admission and on 1/18/2025 when recommended on Resident 1 ' s Registered Dietician (RD) Nutrition Care Recommendation. 2. Follow RD recommendations from 12/20/2025 and 1/18/2025 for the physician to consider new complete blood count (CBC – a common blood test that provided information about the different components of the blood)/basic metabolic panel (BMP, measures eight different substances in your blood), increase free water (FWF, the amount of water in an enteral formula [tube feeding] that was not part of the nutritional components, but rather was the actual water used as an ingredient) to 300 milliliters (ml, a unit of volume in the metric system) every shift, and add probiotic (supplement containing live bacteria [good bacteria] that was intended to help improve gut health and potentially other aspects of your well-being) tablet every day for 14 days, when recommended on Resident 1 ' s Nutrition Assessment. 3. Ensure the facility ' s staff notified the physician of Resident 1 ' s RD recommendations and weight loss in accordance with the facility ' s policy & procedures (P&P) titled Nutrition (Impaired)/Unplanned Weight Loss – Clinical Protocol. 4. Ensure the facility ' s staff implemented a Situation, Background, Assessment, and Recommendation (SBAR, communication tool that helped provide essential, concise information, usually during crucial situations) for Resident 1 ' s weight loss, in accordance with the facility ' s P&P titled, Change in a Resident ' s Condition or Status. 5. Ensure the facility ' s staff implemented a care plan for Resident 1 ' s weight loss, in accordance with the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered. These deficient practices resulted in Resident 1 losing 10 pounds (lbs.) in five months and potentially placing the resident at risk for further weight loss that could result in harm. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted the resident on 10/29/2024, with diagnoses including cerebral infarction (stroke - a stroke happens when there was a loss of blood flow to part of the brain) hemiplegia and hemiparesis (neurological conditions that caused weakness or paralysis on one side of the body) affecting left non-dominant side, adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1 ' s Telephone Physician ' s Order dated 10/29/2024 at 8 PM,the Physician ' s Order indicated hydrochlorothiazide (a thiazide diuretic [water pill] used to help reduce 055523 Page 5 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the amount of water in the body by increasing the flow of urine, also used to treat high blood pressure) oral tablet 25 milligram (mg, unit of mass), give one tablet via G-tube one time a day for hypertension (HTN [high blood pressure], a condition where the force of blood against the walls of the blood vessels was consistently too high). During a review of Resident 1 ' s Telephone Physician ' s Order dated 10/29/2024 at 8 PM, the Physician ' s Order indicated enteral feed (tube feeding, delivers nutrients directly into the digestive system through a tube, by passing the mouth and throat, when someone could not eat normally) order every eight hours flush feeding tube (gently pushing water through the tube to keep the tube clean and prevent blockages, especially after feedings or medications) with 240 cubic centimeter (cm³, a unit of volume that corresponds to a volume of one ml) of water every eight hours. During a review of Resident 1 ' s Telephone Physician ' s Order dated 10/29/2024 at 8 PM, the Physician ' s Order indicated enteral feed order every shift (formula) Isosource 1.5 (a food for special medical purposes specifically formulated for the dietary management of malnutrition and other medical conditions with increased nutritional needs that could not be met through diet modification alone) via G-tube for a total of 1300 cc/1950 kilocalorie (kcal, a unit of measurement for energy, specifically the energy content of food) at a rate of 65 cc/hour for 20 hours or until dose met. During a review of Resident 1 ' s Telephone Physician ' s Order dated 10/29/2024 at 11 PM, the Physician ' s Order indicated enteral feed order every shift (formula) Isosource 1.5 via G-tube for a total of 1200 cc/1800 kcal at a rate of 60 cc/hour for 20 hours or until dose met. During a review of Resident 1 ' s History and Physical (H&P) dated 11/21/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Weights Summary since admission, the Weights Summary indicated: 1. 10/30/2024 – 209 pounds (lbs.) 2. 11/4/2024 – 206 lbs. 3. 11/25/2024 – 203 lbs. 4. 12/3/2024 – 203 lbs. 5. 1/3/2025 – 193 lbs. 6. 2/5/2025 – 188 lbs. 7. 3/5/2025 – 188 lbs. During a review of Resident 1 ' s Nutrition assessment dated [DATE] at 11:55 AM, the Nutrition Assessment indicated the resident ' s most recent weight was 203 lbs., and the resident ' s body mass index (BMI, a simple calculation that estimated a person ' s body fat percentage based on their height and weight) was 26.8 (Overweight BMI 25-29.9) indicating the resident was overweight. The Nutrition Assessment indicated the resident ' s tube feeding was Isosource 1.5 at 60 ml/hour for 20 hours, free water (FWF, the amount of water in an enteral formula [tube feeding] that was not part of the nutritional components, but rather was the actual water used as an ingredient) was at 240 ml every 055523 Page 6 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eight hours, and Resident 1 presented with diarrhea (a condition characterized by frequent, loose, and watery bowel movements). The Nutrition Assessment indicated recommendations for the physician to consider new CBC/BMP, increase FWF to 300 milliliters (ml, a unit of volume in the metric system) every shift, and add probiotic tablet every day for 14 days. During a review of Resident 1 ' s Registered Dietician (RD) Nutrition Care Recommendation dated 12/20/2024,the RD Recommendation indicated for the physician to consider new CBC/BMP, increase free water to 300 ml every shift, and add probiotic tablet every day for 14 days. The RD Recommendation indicated the responsibility of the RD recommendations was Nursing and Dietary. During a review of Resident 1 ' s Nutrition assessment dated [DATE] at 12:40 AM, the Nutrition Assessment indicated the resident ' s most recent weight was 193 lbs., the resident ' s ideal body weight range was 184 =/- 10%, and no new labs were available. The Nutrition Assessment indicated the resident ' s tube feeding was Isosource 1.5 at 60 ml/hour for 20 hours and FWF was at 240 ml every eight hours. The Nutrition Assessment indicated Resident 1 was noted with a 10 lbs., 4.9 % weight loss with possible causative factors to include fluid shifts related to loose stools last month and diuretic (medications that increased urine output by promoting the excretion of water and electrolytes (such as sodium, potassium, and chloride) through the kidneys) treatment. The Nutrition Assessment indicated recommendations for the physician to consider new CBC/BMP, increase FWF to 300 milliliters every shift, and add probiotic tablet every day for 14 days. During a review of Resident 1 ' s RD Nutrition Care Recommendation dated 1/18/2025, the RD Recommendation indicated for the physician to consider new CBC/BMP, increase free water to 300 milliliters every shift, add probiotic tablet every day for 14 days, and weekly weights times four. The RD Recommendation indicated the responsibility of the RD recommendations was Nursing. During a review of the facility ' s Weekly Weights Form for January 2025, the Weekly Weights Form did not have any documentation that Resident 1 ' s weight was taken. During a review of Resident 1 ' s Medication Administration Record (MAR) dated January 2025, the MAR indicated the resident received hydrochlorothiazide oral tablet 25 mg, one tablet via G-tube one time a day for HTN. During a review of Resident 1 ' s Medication Administration Record (MAR) dated February 2025, the MAR indicated the resident received hydrochlorothiazide oral tablet 25 mg, one tablet via G-tube one time a day for HTN. During a review of Resident 1 ' s Nutrition assessment dated [DATE] at 3:47 PM, the Nutrition Assessment indicated the resident ' s most recent weight was 193 lbs., the resident ' s BMI was 25.5 indicating the resident was overweight, and no new labs were available. The Nutrition Assessment indicated the resident ' s tube feeding was Isosource 1.5 at 60 ml/hour for 20 hours and FWF was at 240 ml every eight hours. The Nutrition Assessment indicated the resident presented with weight loss in one month but Resident 1 ' s BMI was overweight which was acceptable for age and condition and would monitor the resident ' s next weight for indication to increase tube feeding as needed. The Nutrition Assessment indicated weight fluctuations were expected due to diuretic treatment. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 2/4/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS 055523 Page 7 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the resident was dependent (helper did all of the effort and the resident did none of the effort to complete the activity) on facility staff for all self-care and mobility. The MDS indicated the resident did not have weight loss of 5% or more in the last month or loss of 10% or more in the last six months. During a review of Resident 1 ' s Weight Note dated 2/13/2025 at 11:10 AM, the Weight Note indicated the resident had weight loss in one month and continued weight loss since admission. The Weight Note indicated the resident ' s BMI classified as WNL (within normal limits) due to tall stature but recommended increasing tube feeding to Isosource 1.5 at 65 ml/hour for 20 hours and changing FWF to 175 ml every four hours. During a review of Resident 1 ' s Telephone Physician ' s Order dated 2/14/2025 at 1:23 PM, the Physician ' s Order indicated enteral feed order every shift (formula) Isosource 1.5 via G-tube for a total of 1300 cc/1950 kcal at a rate of 65 cc/hour for 20 hours or until dose met. During a review of Resident 1 ' s Telephone Physician ' s Order dated 2/14/2025 at 1:35 PM, the Physician ' s Order indicated enteral feed order every eight hours flush feeding tube with 350 cm³ of water every eight hours for a total of 1050 ml/day. During a concurrent interview and record review with the Weights Summary on 3/28/2025 at 11 AM, the Restorative Nursing Assistant (RNA) 1 stated weekly weights were not done for Resident 1 upon admission but should have been. RNA 1 stated for new admissions the RNA checks the resident ' s weight for four weeks and then monthly. The RNA stated if weights were not being done the resident could lose weight without the facility staff knowing about the weight loss and could affect him (Resident 1) especially because the resident was on tube feedings. During an interview on 3/28/2025 at 11:23 AM, the RD stated if recommendations from the RD were not implemented, the resident could have been at risk for further weight loss and malnutrition (a state of poor nutrition that occurred when the body did not receive enough essential nutrients, such as calories, protein, vitamins, and minerals) which could make the resident sick and have to go to the hospital. The RD stated she was not an employee of the facility when the resident was identified with weight loss and was unaware if the physician was notified. The RD stated the physician should have been notified to communicate the recommendations made because the RD was unable to make that order, the RD was only able to provide recommendations and the physician must approve. During a concurrent interview and record review of Resident 1 ' s Comprehensive Care Plan on 3/28/2025 at 11:45 AM, the RD stated there was not a weight loss care plan for Resident 1 but there should have been one. The RD stated the reason to initiate a care plan was to make everyone know what the goals and interventions were and if there was not a weight loss care plan the facility staff would not know that the weight loss even happened. The RD stated if a weight loss care plan was not the facility staff would not be aware the resident needed special focus and to monitor for signs or symptoms of malnutrition. During a concurrent interview and record review of all of Resident 1 ' s Change of Condition (COC), the Registered Nurse Supervisor (RNS) 1 stated there was no documented evidence that a COC was done for Resident 1 ' s weight loss but there should have been. The RNS 1 stated without a COC the resident could have further weight loss and could cause dehydration which could affect the resident. During a concurrent interview and record review of Resident 1 ' s RD Nutrition Care Recommendation 055523 Page 8 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Level of Harm - Minimal harm or potential for actual harm dated 1/18/2025 at 12:18 PM, the RNS stated upon admission residents were weighed weekly for four weeks and then monthly. The RNS stated because the RD recommended weekly weights for four weeks the facility should have followed those recommendations. The RNS stated if the RD recommendations were not followed the facility staff would not know if the recommendations were working or if Resident 1 was losing more weight especially since the resident was having diarrhea. Residents Affected - Few During an interview on 3/28/2025 at 12:48 PM, the Director of Nursing (DON) stated when there was weight loss, the expectation of the facility staff was to do a SBAR and carry out recommendations. The DON stated he remembers the resident had weight loss and started an Interdisciplinary Team (IDT, a group of healthcare professionals from different fields working together) but never completed the task. The DON stated if recommendations were not implemented the resident could lose more weight and could ultimately harm the resident ' s wellbeing and nutrition. During a concurrent interview and record review of Resident 1 ' s Comprehensive Care Plan on 3/28/2025 at 1:10 PM, the DON stated there was no care plan for weight loss but there should have been. The DON stated the care plan was the Nurses Bible on how to care for the resident and if there was not a care plan there could be a negative impact on the resident and could harm them. During a concurrent interview and record review on 3/28/2025 at 11:45 AMwith the RD of the facility ' s undated policy and procedure (P&P) titled, Nutritional Assessment, the P&P indicated As part of the comprehensive assessment, the nutritional assessment with be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The P&P indicated Once current conditions and risk factors for impaired nutrition were assessed and analyzed, individual care plans would be developed that addressed or minimized to the extent possible the resident ' s risks for nutritional complications. The RD stated the facility was not following the P&P because the resident did not have a care plan for the weight loss but the facility should have been. The RD stated if the P&P was not followed the resident could be at risk for significant weight changes or malnutrition which could be detrimental to the resident ' s health and overall wellbeing. During a concurrent interview and record review on 3/28/2025 at 11:51 AMwith the RD of the facility ' s undated P&P titled, Nutrition (Impaired)/Unplanned Weight Loss – Clinical Protocol, the P&P indicated The staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician would review for medical causes of weight gain, anorexia, and weight loss before ordering interventions. The Physician would help identify medical conditions and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight. The P&P indicated The staff and physician would identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. The physician would authorize appropriate interventions, as indicated. The RD stated the facility was not following the P&P because the physician was not notified. The RD stated if the P&P was not followed the resident could be at risk for significant weight changes or malnutrition which could be detrimental to the resident ' s health and overall wellbeing. During a concurrent interview and record review on 3/28/2025 at 12:36 PMwith the RNS 1 of the facility ' s undated P&P titled, Change in a Resident ' s Condition or Status, the P&P indicated, The nurse would notify the resident ' s attending physician when there had been a significant change in the resident ' s physical, emotional, mental, condition. The P&P indicated Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR 055523 Page 9 of 10 055523 03/28/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Communication Form. The P&P indicated The nurse would record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. The RNS 1 stated the P&P provides guidance on what to do in case something happens and the facility was not following the P&P but should have. The RNS 1 stated if the facility did not follow the policy the resident would not be monitored and could continue losing weight which was a safety concern for the resident and could physically affect Resident 1 because of the weight loss. The RNS 1 stated the physician was not notified because nothing was done. During a concurrent interview and record review on 3/28/2025 at 1:20 PM with the DON of the facility ' s undated P&P titled, Care Plans, Comprehensive Person-Centered, the P&P indicated, The comprehensive, person-centered care plan describes the services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The P&P indicated, Assessments of resident ' s were ongoing and care plans were revised as information about the resident ' s and the resident ' s condition change. The DON stated the facility was not following the policy which could harm the resident and Resident 1 could continue losing weight and affect him physically and mentally. 055523 Page 10 of 10