Health inspection·November 13, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify the medical doctor (MD 1) of clinical issues for one of two sampled residents (Resident 1) when Registered Nurse (RN) 2 and RN 3 did not inform MD 1 when they were unable to initiate an intravenous (IV) line (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition directly into the bloodstream) and were therefore unable to administer Dextrose (sugar) 5% in Water (D5W - a fluid used to provide hydration through an IV line) ordered by MD 1 on 10/31/2025 for hydration. These failures had the potential to result in serious harm, including cardiac arrhythmias (when the heart beats too fast, too slow, or in an uneven way), worsening of Resident 1's condition, or death due to untreated low potassium levels and delayed fluid therapy. (Cross Reference

F684)During a review of Resident 1's History and Physical (H&P) from the General Acute Care Hospital (GACH), dated 10/9/2025, timed at 11:20 PM, the H&P indicated that Resident 1 presented to the GACH's emergency department (ED) with persistent nausea and vomiting. During a review of Resident 1's Speech-Language Pathology Evaluation (SLP) from GACH, dated 10/17/2025, timed at 12:09 PM, the SLP indicated that Resident 1 exhibited nausea and vomiting while on a diet of clear liquid (a diet that consists of only clear liquids). The SLP indicated that during the evaluation, only a clear liquid diet was attempted due to the resident exhibiting nausea and vomiting. The SLP further indicated that during the cognitive evaluation, the resident had impaired cognitive function with deficits in orientation (a person's awareness of their surroundings), memory, insight, processing speed, and attention. During a review of Resident 1's Nutrition Reassessment (NR) from GACH, dated 10/20/2025, timed at 10:51 AM, the NR indicated a recommendation to start the resident on Glucerna oral nutrition supplement. The NR also indicated a plan to monitor Resident 1's oral intake, weight, labs, gastrointestinal function, and skin integrity. The NR further indicated a plan to monitor Resident 1's tolerance to the resident's diet. The NR indicated an added goal for Resident 1 to achieve and maintain oral intake of more than 75% of meals. The NR further indicated that Resident 1's Nutritional Risk Level was high. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disease characterized by high blood sugar levels), Fatty Liver disease (condition where an excessive amount of fat accumulates in the liver), Acute Kidney Failure (significant decline in kidney function that leads to the body's inability to effectively remove waste products, regulate fluids, and maintain electrolyte balance), hypertension (HTN, a condition where the force of your blood pushing against the walls of your arteries is consistently too high), and Cardiomegaly (an enlarged heart). During a review of Resident 1's History and Physical (H&P) from the facility, dated 10/21/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 10/22/2025, indicated Resident 1 had moderately impaired cognition (the Page 1 of 10 055523 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ability to process thoughts) and was dependent (helper does all of the effort) on activities such as eating, bathing/showering, toileting, and personal hygiene. During a review of Resident 1's doctor Progress Notes (PN), dated 10/30/2025, the Notes indicated that Resident 1 was observed resting in bed, drowsy, and sleepy. The Notes also indicated that Resident 1 had dry, peeling skin, dry mucosa (lining of mucous membranes such as the inside the mouth). The Notes also indicated that Resident 1 had diffuse anasarca (a condition in which a person has swelling all over the body that can be caused by underlying conditions such as the inability of the heart to pump blood effectively throughout the body or heart failure, kidney disease, and conditions related to low protein and albumin) and had +2 edema (swelling) (a +2 swelling indicates that when a healthcare provider presses on the swollen area for a few seconds, the indentation measures up to 4 millimeters in depth and lasts for up to 15 seconds). The Notes also indicated a plan for lab and skin care. During a review of Resident 1's doctor's orders for the month of October 2025, the orders included a Basic Metabolic Panel (BMP- a blood test, which measures glucose, electrolytes such as sodium and potassium, and kidney function), dated 10/30/2025, and confirmed by RN 2. During a review of Resident 1's Lab Results received from the Laboratory Facility (LF), dated 10/31/2025, the LF indicated that a nurse from the facility confirmed the receipt of the critical lab result on 10/31/2025 at 1:57 pm. The lab results indicated Resident 1's blood sodium (an electrolyte that helps control fluid balance, muscles, and nerves) level was 158 mEq/L (milliequivalents per liter- a unit used to measure the amount of an electrolyte in blood or fluid; normal range 135-145 mEq/L), chloride (an electrolyte that helps keep fluid balance, supports muscles, and digestion) level was 120 mEq/L (normal range: 90-109 mEq/L), magnesium (an electrolyte that helps muscles move, nerves send signals, and the heart to beat steadily) level of 1.7 mg/dL (milligrams per deciliter - a unit of measurement; normal range of 1.8-3.1 mg/dL). During a review of Resident 1's Change in Condition Evaluation Form (CIC) dated 10/31/2025, timed at 5:00 PM, and signed by RN 2, the CIC indicated that Resident 1 had a critical potassium level of 2.7 mEq/L (normal range 3.5-5.2 mEq/L). The CIC indicated that Resident 1's doctor, MD 1, was notified of the change in condition at 5:00 pm and gave orders for Potassium 40 mEq now (in a doctor's order - means the medication or treatment should be administered as soon as possible) then potassium twice a day, D5W [at] 50 [ml per hour] [for a total of 1 liter], Magnesium 400 mg daily, and a BMP for 11/3/2025. During a review of Resident 1's doctor's orders on 10/31/2025 timed at 5:39 PM, confirmed by RN 2, the order indicated to Insert peripheral IV line (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition directly into the bloodstream) for IV hydration and Dextrose Intravenous solution 5% use 50 mL/hr (millliters per hour, a unit of measuring volume to be administered per hour) intravenously every shift for hydration. During a review of Resident 1's care plan for critically low potassium level of 2.7 mEq/L, dated 10/31/2025, the care plan indicated a goal that the resident will maintain a normal potassium level of 3.5 to 5.5 mEq/L, initiated on 10/31/2025. The care plan also indicated that MD 1 gave orders that included for staff to administer Potassium 40 mEq now and D5W 50 ml/hr for 1 liter. During a review of Resident 1's care plan for nutritional problems, dated 10/28/2025, the care plan indicated Resident 1 had a risk of malnutrition related to the need for restrictive/therapeutic and mechanically altered diet, varied/poor oral intake, poor ability to feed self, and abnormal labs. The care plan indicated a goal for Resident 1 to maintain adequate nutritional status. The care plan further indicated interventions for staff to monitor, document, and report signs and symptoms of dehydration; such as dry skin, mucosa membranes, decreased urine output, muscle cramping, edema, ascites, confusion, and skin turgor (the ability of the skin to stretch and then return to its normal shape after being pinched). During another review of Resident 055523 Page 2 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1's PN for the dates 10/30/2025 to 11/1/2025, the PN included an entry dated 10/31/2025, timed at 11:05 PM, indicating that RN 2 attempted to insert an IV line twice but was unsuccessful. The entry further indicated that an IV expert will come the next day at 7:00 AM to attempt to insert the IV. The entry also indicated that RN 3 was notified of the failed attempts of the IV insertion. The PN did not indicate documented evidence that MD 1 was made aware that Resident 1's order for D5W would not be administered to the resident on 10/31/2025 due to failed attempts of IV insertion. During another review of Resident 1's PN dated 10/31/2025 timed at 11:20 PM and another entry dated 11/1/2025, timed at 1:00 AM and 2:00 AM, the resident was documented as resting quietly, without distress, and breathing normally. At 1:00 a.m., the PN indicated that an IV attempt would be made in the morning. The PN did not indicate attempts to inform MD 1 that the D5W hydration could not be started as ordered on 10/31/2025. During an interview with RN 2 on 11/7/2025 at 3:31 pm, RN 2 stated she notified MD 1 of Resident 1's lab results and received telephone orders on 10/31/2025 at 5:00 pm for Potassium 40 mEq by mouth one time to be pulled from the e-kit, Potassium 20 mEq two times a day, Magnesium 400 mg daily, and one liter of D5W IV. During a phone interview on 11/10/2025 at 2:25 pm, RN 3 stated she only observed Resident 1's arms and did not attempt IV insertion, opting to wait for the IV nurse in the morning. RN 3 stated she did not inform the physician of the delay in starting IV fluids. During an interview with TPIV 1 on 11/12/2025 at 11:34 am, TPIV 1 stated she was contracted by the facility to assist with starting IV lines. TPIV 1 stated the facility would call or send a text message requesting an IV and she would send an IV Nurse to the facility to place the IV within two hours. TPIV 1 stated that she reiterated to the facility multiple times that urgency was not part of the company's services. TPIV 1 stated if an IV Nurse was unable to come to the facility to start an IV and a resident was in need of one, the facility was responsible for notifying their doctor for next interventions; potentially to send the resident out to the hospital or request a peripherally inserted central catheter (PICC- a long, thin tube that is placed into a vein in the upper arm that ends in a large vein near the heart, used for medication, fluids, or nutrition) or a midline catheter (a soft tube also placed in a vein in the arm but does not extend as far as a PICC line, used for medication or fluids). TPIV 1 restated that her IV Nurses had no obligation to respond to the facility's request to start an IV and only responded to the request if an IV Nurse was available to assist the facility. TPIV 1 stated that she received a phone call from RN 2 on 10/31/2025 around 5:30 pm requesting an IV for Resident 1, she did not receive information on the status of Resident 1's condition or why Resident 1 required an IV. TPIV 1 responded that none of her IV Nurses could come to the facility until 7 am. During a phone interview with MD 1 on 11/12/2025 at 1:00 pm, MD 1 stated that she assessed Resident 1 on 10/30/2025 and found the resident to be debilitated (in a very weakened or feeble state), unresponsive, and edematous (swollen with an abnormal accumulation of fluid in the tissues). MD 1 further stated Resident 1 was drowsy and ordered labs to be drawn after that assessment. During a phone interview on 11/10/2025 at 1:41 pm, RN 2 stated she was unable to start an IV for Resident 1 and contacted the third-party IV provider at 6:00 pm on 10/31/2025. However, an IV nurse was not available until 7:00 a.m. the next day. RN 2 did not notify the physician about the delay and instead endorsed the information to RN 3. During a phone interview with the Director of nursing (DON) on 11/13/2025 at 4:22 pm, the DON stated that if a resident required an IV line and the RN supervisor or the IV Nurse is unable to place one, the RN supervisor is responsible for notifying the doctor for further orders with options to send the resident to the hospital if they are unstable or placing an order for a PICC line/midline. The DON stated RN 3 should have attempted to establish an IV for Resident 1 at least two to three times to start the D5W IV fluids. The DON further stated Resident 1 055523 Page 3 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0580 Level of Harm - Minimal harm or potential for actual harm had elevated sodium levels of 158 and high sodium levels have the potential to cause seizures, dehydration, and kidney issues if left untreated. During a review of the facility's undated P&P titled, Intravenous Administration of Fluids and Electrolyte, the P&P indicated to Notify physician, supervisor, and on coming shift of complications. of treatment and report other information in accordance with. professional standards of practice. Residents Affected - Few 055523 Page 4 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide care in accordance with professional standards of practice for one of two residents sampled for quality of care (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 did not notify Resident 1's medical doctor (Medical Doctor [MD] 1) or assess Resident 1 for a change in condition when LVN 1 was informed of Resident 1's low blood potassium (an electrolyte that is essential to the normal functioning of muscles such as the heart) level of 2.7 mEq/L (milliequivalent per liter- a unit of measure; normal levels between 3.5 to 5.2 mEq/L) on [DATE] from 1:57 pm to 5:00 pm.2. LVN 2 and Registered Nurse (RN) 2 did not administer Resident 1's Potassium 40 mEq (milliequivalent- a measure of chemical concentration used in medicine) that was ordered by MD 1 in response to the resident's low blood potassium level on [DATE], as soon as the medication was made available in the facility's emergency drug kit (e-kit- a kit that contains essential medications that may be needed urgently before a pharmacy can deliver them).3. The facility did not administer Resident 1's Dextrose (sugar) 5% in Water ([D5W]- a fluid that is used to provide hydration to patients intravenously [IV- in the vein]) as ordered by MD 1 on [DATE] for hydration.4. The facility failed to increase Resident 1's assessments for possible complications of low potassium levels (hypokalemia) from [DATE] at 5:00 pm to [DATE] at 4:50 am.This deficient practice had the potential to result in serious harm, including cardiac arrhythmias (when the heart beats too fast, too slow, or in an uneven way) or death, due to failing to promptly address Resident 1's low potassium level and dehydration.During a review of Resident 1's History and Physical (H&P) from the General Acute Care Hospital (GACH), dated [DATE], timed at 11:20 PM, the H&P indicated that Resident 1 presented to the GACH's emergency department (ED) with persistent nausea and vomiting. The H&P also indicated that Resident 1's heart rate was 117 beats per minute which is above the normal range of 60 to 100 bpm. The H&P indicated abnormal laboratory results including creatinine (a waste product produced by muscle metabolism and marker for kidney disease, with normal ranges of 0.5 to 1.1) level of 1.29, a potassium (an electrolyte that is essential to the normal functioning of muscles such as the heart, with normal levels between 3.5 to 5.2 mEq/L) level of 3.3 mEq/L, and an alkaline phosphatase (a blood test that is used by clinicians to identify diseases, with normal levels between 35 to 104) level of 281. The H&P indicated Resident 1 had a potassium level of 3.3 mEq/L on [DATE] and a potassium level of 3.0 on [DATE]. The H&P further indicated that Resident 1 had a diagnosis of hypokalemia and the treatment plan included potassium replacement as needed. During a review of Resident 1's History and Physical (H&P) from General Acute Care Hospital (GACH), dated [DATE], timed at 2:31 PM, the H&P indicated that the resident possibly had a thrombus (a blood clot) in the left intrahepatic (in the liver) branches of the portal vein (a blood vessel that connects to the liver) that was noted on the resident's CT Scan (computed tomography scan- a medical imagining technique used to create images of the body) from [DATE]. The H&P included a suggestion by the doctor for either a CT scan or MRI Scan (magnetic resonance imaging- a medical imagining technique that uses strong magnetic field to create detailed images of the organs and soft tissues). The H&P also indicated that a follow-up colonoscopy (a procedure in which a camera is used to visually inspect the colon) should be considered for Resident 1. During a review of Resident 1's Speech-Language Pathology Evaluation (SLP) from GACH, dated [DATE], timed at 12:09 PM, the SLP indicated that Resident 1 exhibited nausea and vomiting while on a diet of clear liquid (a diet that consists of only clear liquids). The SLP indicated that during the evaluation, only a clear liquid diet was attempted due to the resident exhibiting nausea and vomiting. The SLP further indicated that during the cognitive evaluation, the resident had impaired cognitive function Residents Affected - Few 055523 Page 5 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with deficits in orientation (a person's awareness of their surroundings), memory, insight, processing speed, and attention. During a review of Resident 1's Nutrition Reassessment (NR) from GACH, dated [DATE], timed at 10:51 AM, the NR indicated a recommendation to start the resident on Glucerna oral nutrition supplement. The NR also indicated a plan to monitor Resident 1's oral intake, weight, labs, gastrointestinal function, and skin integrity. The NR further indicated a plan to monitor Resident 1's tolerance to the resident's diet. The NR also included lab values for Resident 1's potassium on [DATE] at 3.9 mEq/L and on [DATE] at 3.5 mEq/L. The NR indicated an added goal for Resident 1 to achieve and maintain oral intake of more than 75% of meals. The NR further indicated that Resident 1's Nutritional Risk Level was high. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disease characterized by high blood sugar levels), Fatty Liver disease (condition where an excessive amount of fat accumulates in the liver), Acute Kidney Failure (significant decline in kidney function that leads to the body's inability to effectively remove waste products, regulate fluids, and maintain electrolyte balance), hypertension (HTN, a condition where the force of your blood pushing against the walls of your arteries is consistently too high), and Cardiomegaly (an enlarged heart). During a review of Resident 1's History and Physical (H&P) from the facility, dated [DATE], the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. The H&P indicated that Resident 1 did not have heart murmurs (a recurring sound heard in the heart through a stethoscope that is usually a sign of disease or damage), heart [NAME] (an abnormal heart sound), and jugular vein distention (bulging vein in the neck when the blood is unable to flow normally). The H&P indicated that Resident 1's rehabilitation potential was fair (the resident had some compacity to improve with therapy, but progress may be limited or slower due to factors such as medical complexity, cognitive impairment, low motivation, or limited support systems). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], indicated Resident 1's code status as Full Code (attempt CPR [cardiopulmonary resuscitation- an emergency way to help someone whose heart or breathing has stopped by pushing on their chest and giving breaths] if the heart stops). The MDS also indicated Resident 1 had moderately impaired cognition (the ability to process thoughts) and was dependent (helper does all of the effort) on activities such as eating, bathing/showering, toileting, and personal hygiene. During a review of Resident 1's doctor Progress Notes (PN), dated [DATE], the Notes indicated that Resident 1 was observed resting in bed, drowsy, and sleepy. The Notes also indicated that Resident 1 had dry, peeling skin, dry mucosa (lining of mucous membranes such as the inside the mouth). The Notes also indicated that Resident 1 had diffuse anasarca (a condition in which a person has swelling all over the body that can be caused by underlying conditions such as the inability of the heart to pump blood effectively throughout the body or heart failure, kidney disease, and conditions related to low protein and albumin) and had +2 edema (swelling) (a +2 swelling indicates that when a healthcare provider presses on the swollen area for a few seconds, the indentation measures up to 4 millimeters in depth and lasts for up to 15 seconds). The Notes also indicated a plan for lab and skin care. During a review of Resident 1's doctor's orders for the month of [DATE], the orders included a Basic Metabolic Panel (BMP- a blood test, which measures glucose, electrolytes such as sodium and potassium, and kidney function), dated [DATE], and confirmed by RN 2. During a review of Resident 1's Lab Results received from the Laboratory Facility (LF), dated [DATE], the LF indicated that a nurse from the facility confirmed the receipt of the critical lab result on [DATE] at 1:57 PM. The Lab Results indicated that Resident 1's blood potassium level was 2.7 mEq/L and was flagged as CL or critically low. During a review of Resident 1's Lab Results while in the facility, 055523 Page 6 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated [DATE], the results indicated that Resident 1's potassium level was at 2.7 mEq/L. The results also indicated a received date of [DATE] at 12:05 PM and a reported date of [DATE] at 1:24 PM. The results also indicated that the document was reviewed by RN 2 on [DATE] at 6:52 PM. During a review of the facility's document titled Counseling/Disciplinary Notice dated [DATE], the notice indicated that Resident 1's lab results was called to LVN 1 at 1:57 pm per the LF and the lab result for potassium was critically low. The Notice added that LVN 1 did not inform her supervisor and did not notify MD 1. The Notice further stated that LVN 1 did not do a Change of Condition (Also referred to as Change in Condition Evaluation Form [CIC]- a communication tool used by healthcare staff when a resident experiences a change in their condition) and no documentation was seen on Resident 1's chart. During a review of Resident 1's Change in Condition Evaluation Form (CIC) dated [DATE], timed at 5:00 PM, and signed by RN 2, the CIC indicated that Resident 1 had a critical potassium level of 2.7 mEq/L. The CIC indicated that Resident 1's doctor, MD 1, was notified of the change in condition at 5:00 pm and gave orders for Potassium 40 mEq now (in a doctor's order - means the medication or treatment should be administered as soon as possible) then potassium twice a day, D5W [at] 50 [ml per hour] [for a total of 1 liter], Magnesium 400 mg daily, and a BMP for [DATE]. However, during a review of Resident 1's doctor's orders for the month of [DATE], the physician orders for [DATE], included the following: a) Klor-Con (a brand name for potassium chloride - to treat low blood potassium levels) oral tablet extended release, give 40 mEq by mouth one time only for hypokalemia with additional instructions for dose will be taken from E-kit dated [DATE], timed at 5:11 PM, and confirmed by RN 2. The doctor's order did not include the word now as indicated in Resident 1's CIC note.b) Potassium oral tablet, give 20 mEq by mouth two times a day for hypokalemia, dated [DATE], timed at 5:15 PM, and confirmed by RN 2. c) Dextrose Intravenous solution 5% use 50 ml/hr (milliliters per hour, a unit of measuring volume to be administered per hour) intravenously every shift for hydration, dated [DATE], timed at 5:04 PM, and confirmed by RN 2. d) Magnesium (an oral supplement to treat low blood magnesium level) oral tablet, give 400 mg (milligram, a unit of measuring weight), dated [DATE], timed at 5:09 pm, and confirmed by RN 2.e) Insert peripheral IV line (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition directly into the bloodstream) for IV hydration, ordered on [DATE], timed at 5:39 PM, and confirmed by RN 2. During a review of Resident 1's care plan for critically low potassium level of 2.7 mEq/L, dated [DATE], the care plan indicated a goal that the resident will maintain a normal potassium level of 3.5 to 5.5 mEq/L, initiated on [DATE]. The care plan also indicated that MD 1 gave orders that included for staff to administer Potassium 40 mEq now and D5W 50 ml/hr for 1 liter. During a review of the facility's undated Emergency Kit Pharmacy Log, the log indicated that on [DATE] at 10:23 PM, four (4) pieces of the medication potassium ER 10 mEq was taken from the E-kit. The log indicated that the medication was ordered by MD 1 for Resident 1. The log indicated under directions to give 40 mEq [one time] now. The log further indicated that the time the medication was given was at 10:25 PM. During a review of Resident 1's Medication Administration Record (MAR) for [DATE], the MAR indicated that Resident 1's Klor-Con oral tablet 40 mEq was administered on [DATE] at 10:32 PM by LVN 2. During a review of Resident 1's Progress Notes (PN) for the dates [DATE] to [DATE], the PN indicated that MD 1 saw and examined Resident 1, dated [DATE], timed at 5:06 PM. The PN indicated MD 1 ordered lab tests, including CBC and BMP. A review of the PN also included an entry on [DATE] at 5:00 PM, that indicated Resident 1 had a critically low potassium of 2.7 mEq/L. The PN entry indicated that Resident 1's doctor, MD 1, gave orders of D5W at 50 mL/hr, BMP to be drawn on [DATE], Magnesium 400 mg daily, Potassium 40 mEq now then Potassium 20mEq twice a day. During another review of Resident 1's PN for the dates [DATE] to [DATE], the 055523 Page 7 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PN included an entry dated [DATE], timed at 10:30 PM, indicating that Potassium 40 mEq was retrieved from the E-kit and was administered to Resident 1. Another entry in the PN, dated [DATE], timed at 11:05 PM, indicated that the nurse attempted to insert an IV line (an intravenous line, a small plastic tube that is inserted into the vein that is used to deliver medication or fluids into the person's circulatory system) twice but was unsuccessful. The entry further indicated that an IV expert will come the next day at 7:00 AM to attempt to insert the IV. The entry also indicated that RN 3 was notified of the failed attempts of the IV insertion. The PN did not indicate documented evidence that MD 1 was made aware that Resident 1's order for D5W would not be administered to the resident on [DATE] due to failed attempts of IV insertion. During another review of Resident 1's PN for the dates [DATE] to [DATE], the PN indicated that on [DATE] at 11:20 PM and another entry dated [DATE], timed at 1:00 AM and 2:00 AM, the resident was documented as resting quietly, without distress, and breathing normally. At 1:00 a.m., the PN indicated that an IV attempt would be made in the morning. During a review of Resident 1's PN for the dates [DATE] to [DATE], documentation showed that on [DATE] at 4:50 AM, Resident 1 was found unresponsive with no vital signs. The PN indicated facility staff initiated a code blue (a medical emergency indicating a patient's heart or breathing has stopped), CPR, and called 911. At 4:56 am EMS (emergency medical services) arrived and took over the CPR for 20 minutes. At 5:16 am, CPR on Resident 1 was stopped and Resident 1 expired. The medical doctor was notified at 5:30 a.m. of Resident 1's death. During a review of Resident 1's PN for the dates [DATE] to [DATE], the PN did not indicate documented evidence that Resident 1's nurses attempted to administer Klor-con 40 mEq earlier than 10:30 PM on [DATE]. The PN did not include documented evidence that Resident 1 was monitored and assessed by the licensed nurses for signs and symptoms of low potassium level such as muscle weakness, numbness, tingling, palpitations, constipation and cramps as indicated in the resident's care plan for critically low potassium level of 2.7 mEq/L from [DATE] at 5:00 pm to [DATE] at 4:50 am. During a review of the facility's undated P&P titled Administering Medications, the P&P stated, Medications are administered in a safe and timely manner, and as prescribed The P&P further stated, Medications are administered in accordance with prescriber orders. Medication administration times are determined by resident need and benefit, not staff convenience. During a review of the facility's document titled Counseling/Disciplinary Notice, dated [DATE], the notice indicated that Licensed Vocational Nurse (LVN) 1 was working at the facility on [DATE] when the laboratory results were made available to the facility on [DATE] at 1:57 PM. The Notice added that RN 2 was the one that contacted the resident's doctor, MD 1, and received orders from MD 1 at 5:00 PM. During a concurrent record review and interview with RN 1 on [DATE] at 2:29 pm, Resident 1's nurses Progress Notes dated [DATE] was reviewed. RN 1 stated there was no documentation that LVN 1 spoke to lab personnel or notified the doctor about Resident 1's abnormal lab results. RN 1 stated she was not aware of Resident 1's abnormal lab results because LVN 1 did not notify her of the results. RN 1 stated that the lab calls the facility to report critical results and the licensed nurse (LVN or RN) that receives the result is responsible for notifying the doctor and initiating a CIC. RN 1 further stated LVN's are responsible for notifying the RN supervisor of abnormal lab results so the RN can assess the resident for symptomatic changes in the resident. RN 1 stated the CIC should be initiated immediately so interventions for the resident's change in condition can be implemented right away. RN 1 stated low potassium levels can cause heart problems like chest pain, painful muscles, and myocardial infarction (heart attack) if left untreated. During an interview with RN 2 on [DATE] at 3:31 pm, RN 2 stated she reviewed Resident 1's lab values and noted no interventions or documentation had been completed regarding potassium level of 2.7 mEq/L. RN 2 stated she notified MD 1 of Resident 1's lab 055523 Page 8 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few results and received telephone orders on [DATE] at 5:00 pm for Potassium 40 mEq by mouth one time to be pulled from the e-kit, Potassium 20 mEq two times a day, Magnesium 400 mg daily, and one liter of D5W IV. RN 2 stated she verbally notified LVN 2 to administer the Klor-Con (Potassium) from the e-kit after placing the orders in Resident 1's EHR on [DATE] at around 5:15 pm. RN 2 verified the Klor-Con was available in the facility's e-kit at that time. RN 2 stated she followed up with LVN 2 on [DATE] around 10:20 pm, five (5) hours after the order was placed, and was informed by LVN 2 that the Klor-Con had not been pulled from the e-kit and not administered to Resident 1 yet. During a phone interview on [DATE] at 11:27 AM with the Lab Manager (LM), the LM stated when a resident's lab result is critical, the laboratory staff will call the facility to confirm that the facility received the lab result containing the critical lab value. During a follow-up phone interview at 12:12 PM with the LM, the LM stated that the laboratory staff contacted the facility on [DATE] at 1:57 PM. The LM stated that the laboratory staff spoke with a nurse, who confirmed that the facility received Resident 1's critical lab result of potassium 2.7 mEq/L. During a phone interview on [DATE] at 2:25 p.m., RN 3 stated she only observed Resident 1's arms and did not attempt IV insertion, opting to wait for the IV nurse in the morning. RN 3 stated she did not inform the physician of the delay in starting IV fluids. During an interview with TPIV 1 on [DATE] at 11:34 am, TPIV 1 stated she was contracted by the facility to assist with starting IV lines. TPIV 1 stated the facility would call or send a text message requesting an IV and she would send an IV Nurse to the facility to place the IV within two hours. TPIV 1 stated that she reiterated to the facility multiple times that urgency was not part of the company's services. TPIV 1 stated if an IV Nurse was unable to come to the facility to start an IV and a resident was in need of one, the facility was responsible for notifying their doctor for next interventions; potentially to send the resident out to the hospital or request a peripherally inserted central catheter (PICC- a long, thin tube that is placed into a vein in the upper arm that ends in a large vein near the heart, used for medication, fluids, or nutrition) or a midline catheter (a soft tube also placed in a vein in the arm but does not extend as far as a PICC line, used for medication or fluids). TPIV 1 restated that her IV Nurses had no obligation to respond to the facility's request to start an IV and only responded to the request if an IV Nurse was available to assist the facility. TPIV 1 stated that she received a phone call from RN 2 on [DATE] around 5:30 pm requesting an IV for Resident 1, she did not receive information on the status of Resident 1's condition or why Resident 1 required an IV. TPIV 1 responded that none of her IV Nurses could come to the facility until 7 am. During a phone interview on [DATE] at 11:44 am with LVN 1, LVN 1 stated she received a phone call regarding a critical lab result on [DATE] around 2:00 pm [FC1] for Resident 1 from the lab but was too busy. LVN 1 stated she did not initiate a Change in Condition Evaluation Form (CIC), notify RN 1 or MD 1, nor conduct an assessment of Resident 1 regarding the critical lab. LVN 1 stated she did not open Resident 1's electronic health record (EHR) to review the rest of Resident 1's abnormal lab results and stated, the critical lab slipped [her] mind. LVN 1 stated she should have documented the critical result in a progress note and initiated a CIC in Resident 1's EHR to receive orders from MD 1 and initiate nursing interventions for Resident 1's abnormal lab results. LVN 1 further stated she should have assessed Resident 1 for cardiac symptoms such as chest pain in relation to her low potassium levels but did not. During a phone interview with LVN 2 on [DATE] at 12:21 pm, LVN 2 stated she was aware that RN 2 placed an order for Resident 1 to receive Klor-Con but did not see the order on Resident 1's MAR. LVN 2 stated she did not administer Resident 1's Klor-Con until 10:30 pm on [DATE] after RN 2 reminded her to pull the medication from the e-kit. LVN 2 stated, the Klor-Con should have been given immediately considering Resident 1's critically low potassium 055523 Page 9 of 10 055523 11/13/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few level of 2.7 mEq/L. LVN 2 stated, It would be considered a delay in care that the potassium was ordered at 5:11 pm and given at 10:32 pm. During a phone interview with MD 1 on [DATE] at 1:00 pm, MD 1 stated that she assessed Resident 1 on [DATE] and found the resident to be debilitated (in a very weakened or feeble state), unresponsive, and edematous (swollen with an abnormal accumulation of fluid in the tissues). MD 1 further stated Resident 1 was drowsy and ordered labs to be drawn after that assessment. During a phone interview on [DATE] at 1:41 p.m, RN 2 stated she was unable to start an IV for Resident 1 and contacted the third-party IV provider at 6:00 p.m. on [DATE]. However, an IV nurse was not available until 7:00 a.m. the next day. RN 2 did not notify the physician about the delay and instead endorsed the information to RN 3. During a concurrent record review and interview with RN 4 on [DATE][FC2] at 4:02 pm, Resident 1's Progress Notes from [DATE] to [DATE] were reviewed. RN 4 stated that a resident with a CIC for low potassium should be monitored for abnormal heartbeat by palpating (feeling) the resident's pulse and auscultating (listening to) cardiac sounds with a stethoscope. RN 4 further stated that the progress notes did not show documentation of licensed nurses monitoring Resident 1 for abnormal heartbeat. During a phone interview with the Director of nursing (DON) on [DATE] at 4:22 pm, the DON stated that if a resident required an IV line and the RN supervisor or the IV Nurse is unable to place one, the RN supervisor is responsible for notifying the doctor for further orders with options to send the resident to the hospital if they are unstable or placing an order for a PICC line/midline. The DON stated RN 3 should have attempted to establish an IV for Resident 1 at least two to three times to start the D5W IV fluids. The DON further stated Resident 1 had elevated sodium levels of 158 and high sodium levels have the potential to cause seizures, dehydration, and kidney issues if left untreated. During a phone interview with the Director of nursing (DON) on [DATE] at 4:22 pm, licensed nurses are expected to notify the physician and initiate a CIC for critical labs. The DON stated it was a delay in care when LVN 1 failed to act right away on Resident 1's low potassium. The DON further stated that residents with low potassium can experience cardiac complications. The DON further stated the licensed nurses should have notified the doctor promptly for low potassium and other abnormal labs to provide interventions as soon as possible. During a concurrent record review and interview with the DON on [DATE] at 4:25 pm, Resident 1's PN for the dates [DATE] to [DATE] were reviewed. The DON stated that RN 3 did not document that she tried to start an IV for Resident 1 when she should have instead of waiting for the IV Nurse to come in the morning. During a review of the facility's Job Description titled Registered Nurse Supervisor, the job description indicated the RN will make sound independent decisions when circumstances warrant such action and their essential duties and responsibilities included passing out medications when needed. 055523 Page 10 of 10