Health inspection·December 4, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 2 sampled residents (Resident 23 and 101) were provided care in a manner that maintained dignity and respect when: 1.Licensed Vocational Nurse (LVN) 6 left Resident 23 was lying in bed uncovered and exposed without replacing the blanket or gown to maintain the resident's privacy after care was provided. 2.The Treatment Nurse (TN1) was standing next to Resident 101 while assisting the resident to eat during dinner. This failure had potential to negatively affect the residents sense of dignity and respect during the care. Findings: 1. During a review of Patient 101's admission Record (AR), the AR indicated the facility admitted the patient on 8/26/2025 with diagnosis that included but not limited to moderate protein-calorie malnutrition (a condition from not getting enough nutrients) and dysphagia (difficulty or pain during swallowing food or liquids). During a review of Patient 101's MDS (Minimum Data Set-a resident assessment and care screening tool) dated 8/30/2025, the MDS indicated Patient 101's nutritional assessment as malnutrition. The MDS dated [DATE] indicated the resident is alert, oriented and has a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (BIMS score 13 - normal cognitive/brain function). During an observation on 12/1/2025 at 12:24 PM, in facility's dining room, Patient 101 was eating protein ice cream (ice cream with higher protein content than regular ice-cream). TN 1 went to Patient 101 after Patient 101 stopped eating the protein ice and provided feeding assistance to the patient while standing up. Patient 101 had to look up at TN 1 during the feeding since Patient 101 was sitting on the wheelchair during that time. During an interview on 12/01/2025 at 12:34 PM, TN 1 stated all staff must be sitting down at the patient's eye level while providing feeding assistance to the patients. TN 1 stated the Patient 101 must have felt belittled when TN 1 provided feeding assistance to Patient 101 while standing up and not at the Patient 101's eye level. During an interview on 12/01/2025 at 12:34 PM with DON, DON stated if any staff provide feeding assistance to any patient in the facility that is a dignity issue. DON stated if a patient in the facility has a normal cognitive function, the patient will feel really bad if not provided the feed assistance at patient's eye level. Page 1 of 28 055523 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled Assistance with Meals dated 3/2022, the P&P indicated the facility residents will be fed with consideration of safety, comfort and dignity and the facility staff will not provide the assistance while standing over the residents while assisting them with meals. During a review of the facility's Policy and Procedure (P&P) titled Resident Rights dated 2/2021, indicated that the facility residents will be treated with respect, kindness and dignity during the resident's stay in the facility. 2.During a review of Resident 23's admission Record indicated the resident was originally admitted into the facility on [DATE], with diagnosis that included, but not limited to, fracture of of neck of left femur (thigh bone), fracture of greater trochanter ( thigh bone) of left femur (thigh bone) , metabolic encephalopathy (a condition of the brain caused by chemical imbalances) and Alzheimer's disease unspecified(progressive brain disorder that slowly destroys memory and thinking skills, unspecified means details like late or early onset are not specific). During a review of Resident 23's History and physical (H&P), dated 4/15/2025, the H&P indicated, Resident 23 does not have the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 10/20/2025, the MDS indicated Resident 23 had severe cognitive impairment (has significant deficits in memory and thinking, requiring support for safety awareness, decision – making, and reporting needs or changes in condition). The MDS indicated Resident 23 requires maximal assistance with showering needs and moderate assistance for dressing and personal hygiene and sit to stand position. During an observation on 12/1/2025 at 10:45 AM in Resident 23's room, Licensed Vocational Nurse (LVN) 6 was observed performing vital signs check to Resident 23, including blood pressure, heart rate, and respirations. Upon completing the assessment, LVN 6 left Resident 23 uncovered and exposed, without replacing the blanket or gown to maintain the resident's privacy. During a concurrent observation and interview with the Director of Staff Development (DSD) in Resident 23's room, on 12/1/2025 at 10:55AM, the resident was observed lying in bed wearing a hospital gown that was lifted, exposing the resident's brief (adult diaper). Resident 23 did not have a blanket covering his body at the time of the observation. The DSD stated that the resident should not have been left in that condition and stated, the resident is exposed with his brief showing. The DSD acknowledge that this situation was an issue of dignity and privacy. During a review of the facility's policy and procedure (P&P) titled, Dignity dated 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being. Level of satisfaction with life and feeling of self-work and self- esteem. Indicating that staff must promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatments. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity. 055523 Page 2 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents call lights (a device used by residents to signal his or her needs for assistance) were within reach for two of two sampled Residents (Resident 88 and 127) for reasonable accommodation of needs. Resident 88 who was legally blind and Resident 127 were at risk for accident and fall. This deficient practice had the potential for Residents to be unable to call for assistance in an emergency which could lead to a fall and/or injury.Findings: 1. During review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), legal blindness (severe vision loss where you see so poorly that you can't perform normal daily tasks, even with glasses) and absence of left great toe. During a review of Resident 88's History and Physical Examination (H&P), dated 6/19/2025, indicated Resident has fluctuating capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2025, indicated Resident 88 required partial/moderate assistance (helper does less than half the effort) with toileting, bathing, dressing and personal hygiene and substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfer (the ability to transfer to and from a bed to chair). During a review of Resident 88's care plan (CP) for risk for falls with injury with injury related to gait/balance problems, incontinence, poor safety awareness and vision hearing problems, revised 6/17/2025 indicated intervention includes to be sure call light is within reach. During a review of Resident 88's facility document titled Quarterly Risk Data Collection Tool under fall risk assessment dated [DATE], indicated Resident 88 was at risk for fall. During a concurrent observation and interview on 12/1/2025 at 10:14 AM with Certified Nurse Assistant (CNA)1 and Licensed Vocational Nurse (LVN) 2 in Resident 88's room, Resident 88 was observed in bed asleep, with her call light on the floor. CNA 1 stated, Resident 88's call light needs to always be within reach, she cannot reach that call light on the floor, she uses it when she needs assistance. LVN 2 stated, Resident 88 knows how to use the call light, and she uses it for assistance. LVN 2 stated, Resident potentially could fall and/or injure self-trying to reach for the call light on the floor, when she needs assistance. 2. During review of Resident 127's admission Record indicated Resident 127 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included polyneuropathy (multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness), dementia (decline in mental ability that interferes with daily life), muscle wasting and difficulty walking. During a review of Resident 127's MDS, dated [DATE], indicated Resident 127's cognitive skills was intact. The MDS indicated, Resident 127 required partial/moderate assistance with personal hygiene, and dependent with toileting, bathing, dressing and chair/bed-to-chair transfer. During a review of Resident 127's care plan (CP) for risk for falls related to gait/balance problems and limited mobility, revised 4/17/2025 indicated intervention includes to be sure call light is within reach. During a review of Resident 127's facility document titled Quarterly Risk Data Collection Tool under fall risk assessment dated [DATE], indicated Resident 127 was at risk for fall. During a concurrent observation and interview on 12/1/2025 at 10: 56 AM with Resident 127 and Treatment Nurse (TN) 1, Resident 127 was observed in bed awake and alert with her call light was on the floor and out of reach. Resident 127 stated, she did not know why the call light was on the floor and complained that she could not reach it to call for assistance. Resident 127 stated, relies on her call light to get assistance from staff. TN 1 stated that the call light should never be on the floor and must always be within the resident's reach. TN 1 stated that Residents Affected - Few 055523 Page 3 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 127's inability to access her call light could result in staff being unaware of her needs, especially in emergency situations. During an interview on 12/2/2025 at 3:31 PM with the Director of Nurses (DON), DON stated, he expects call lights to be within reach of residents, it is facility policy, especially to those who can use it. DON stated, it is essential for the call light to be within reach so Residents can call for assistance especially for emergency. DON stated, for resident not able to reach for the call light had the potential for fall and/or injury from trying to get up to call for help. A review of the facility's policy and procedure (P&P) titled, Call Light dated 1/2024, indicated; a) each resident is provided with means to call staff directly for assistance from his/her bed , from toileting/bathing facilities and from the floor, b) resident call light shall be within reach, and c) answer the resident call system in a timely manner. 055523 Page 4 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Resident 59, 72, and 84) could hold the Resident Council meeting (an independent group of nursing home residents that convenes at least once a month to discuss their concerns, offer suggestions, and plan activities) independently, without staff presence. This failure violated the resident's rights from exercising their right to hold Resident Council meetings privately without the presence of the facility staffs, as well as participating in and voicing grievances without fear of retaliation. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted resident on 12/29/2018 with diagnoses that include but not limited to diabetes mellitus (chronic disorder characterized by insulin resistance, difficulty in blood sugar control and poor wound healing) and End Stage Renal Disease (irreversible kidney failure). During a review of Resident 59's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 59 had intact cognition (ability to understand and make decisions). During a review of Resident 72's AR, the AR indicated the facility admitted the resident on 2/17/2023 with diagnoses that included hypertension (HTN-high blood pressure) and dysarthria (difficulty speaking) followed by cerebral infarction (brain damage due to interruption of blood flow in the brain or stroke). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 had intact cognition. During a review of Resident 84's admission Record (AR), the AR indicated the facility admitted resident on 8/29/2024 with diagnoses that include but not limited to hypertension and cerebrovascular accident with no residual effect. During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84 had intact cognition.During a Resident Council meeting on 12/2/2025 at 10:32 am with Resident 59, 72 and 84, Resident 59 stated that the Resident Council member do not want DON (Director of Nursing) or facility Administrator (ADM) or Activity Director (AD - a facility staff in charge of the social, recreational, and therapeutic programs in the facility to increase the resident's physical, mental and emotional health) to be present at the Resident Council meetings. Resident 72 and Resident 84 stated they both agreed with Resident 59. During an interview on 12/2/2025 at 10:32 am, Resident-59, 72 and 84 stated that Resident Council members were not previously made aware by the facility that Resident Council meetings can be conducted without the facility staff being present in the meeting. During an interview on 12/2/2025 at 12:29 pm with Activity Assistant (AA1 - a facility staff that coordinates recreational, and therapeutic programs to the residents). AA1 stated either the DON, facility ADM or AD were always present in Resident Council meetings. AA1 stated she is sometimes asked by the AD to be present in the meeting,. During an interview on 12/3/2025 at 9:25 am with AD, AD stated that there is always a facility staff present during the monthly Resident Council meetings to help resolve any issues residents might have. AD stated she never reviewed with the residents the right to conduct Resident Council meetings that indicated the resident council meetings could be help without the staff being present in the meeting. During an interview on 12/3/2025 at 3:19 pm with DON, DON stated that either DON, ADM or the AD is always present in monthly Resident Council meetings, to help resolve any issues residents might have. During an interview with on 12/4/2025 at 1:30pm, DON stated that DON was not aware of the residents right to conduct Resident Council meetings without any facility staff being present in the meeting. During a review of the facility's Policy and Procedure (P&P) titled, Resident Council, dated 2/2021, the P&P indicated that the staff, visitors, or other guests may attend the Resident Council meetings if invited by respective resident group. Residents Affected - Some 055523 Page 5 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 100 and Resident 42) by ensuring Resident 100 and 42's wall clock in the room displays the accurate time of the day at all times. This deficient practice had the potential to cause disorientation, that could negatively affect Resident 100 and Resident 42's quality of life.Findings: 1.During a review of Resident 100's admission Record indicated the facility admitted Resident 100 on 10/15/2025 with diagnoses that included hemiplegia and hemiparesis (paralysis or severe weakness), hypertension (high blood pressure), and lack of coordination. During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 10/19/2025, indicated Resident 100's cognitive status (ability to think and reason) was severely impaired. Resident 100 was dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. During a concurrent observation and interview on 12/1/2025 at 10:29 AM the wall clock in the shared room of Resident 100 and Resident 42 was noted to display an incorrect time (4:25), while the actual time was 10:29 AM. LVN 1 stated maintaining accurate time on the wall clock supports a homelike environment and prevent disorientation, especially for alert or confused residents. FAM 1 expressed appreciation for the surveyor's attention to the issue, noting that Resident 100 is becoming more alert and benefits from proper orientation. FAM 1 also shared that she became aware of the incorrect time after Resident 42 expressed frustration earlier that morning, asking for the correct time. 2. During a review of Resident 42's admission Record indicated the facility originally admitted Resident 42 on 7/1/2024 and readmitted on [DATE] with diagnoses that included diabetes (blood sugar, is too high), mild cognitive impairment (memory or thinking problems), and anemia (blood lacks enough healthy red blood cells). During a review of Resident 42's MDSdated 10/19/2025, indicated Resident 100's cognitive status was moderately impaired and was dependent with toileting, bathing, dressing and personal hygiene. During a concurrent observation and interview on 12/1/2025 at 10:45 AM with Resident 42, in Resident 100 and Resident 42's room. The rooms wall clock now reads the right time 10:45 (shorthand pointed at #10 and long hand pointed at #9). Resident 42 just gave a thumbs up when asked how he feels about seeing the right time on the wall clock but did not want to be interviewed further. During an interview on 12/2/2025 at 3:25 PM with the Director of Nurses (DON), DON stated, it is the responsibility of the facility's responsibility to provide a homelike environment to all the residents of the facility, which includes ensuring the wall clock in residents rooms to read the right time regardless of the resident's level of alertness. DON stated having the right time on resident's wall clocks helps prevent confusion and disorientation, which could negatively impact residents' quality of life. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, indicated; a) Residents are provided with safe, clean, comfortable, and homelike environment, and b) homelike setting includes: clean, sanitary, and orderly environment. 055523 Page 6 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to ensure that the facility informed one of eight residents (Resident 129) reviewed for resident's rights. Resident 129 and/or the representatives were not informed in writing the facility's policy on bed hold and return ( the facility keeps the resident's bed/room saved for up to 7 days while the resident is temporarily out of the facility) and keeps the document in the resident's clinical record that the resident was placed on bed hold at the time of transfer to the General Acute Care Hospital (GACH) on 9/9/2025 in accordance with the facility's policy and procedure (P&P) titled Bed-Holds and Returns, This deficient practice had the potential for residents' bed not to be appropriately held during hospitalization and to lose their room or their right to return to the same bed. Findings: A review of the admission record indicated Resident 129 was originally admitted to the facility on [DATE] with a diagnosis of pressure ulcer of sacral region (localized skin injury or underlying tissue of the lower spine due to unrelieved pressure, friction and shear), neurocognitive disorder with Lewy bodies( progressive brain disorder that causes problems with thinking, memory, movement , and behavior due to abnormal protein deposits in the brain) and diabetes ( disease in which the amount of sugar in the blood is too high). A review of the Minimum Data Set (MDS - s standardized assessment and care screening tool) dated 6/18/2025, indicated Resident 129 had severely impaired mental status cognition (ability to think and reason) requiring total assistance from staff in activities of daily living. A review of Resident 129's nursing note titled Transfer to Hospital, dated 9/9/2025, indicated Resident 129 was transferred to GACH on 9/9/2025, there was no documented evidence in the nurse's note that the facility notified the responsible party regarding the bed hold option. A review of Resident 129's Order Summary Report, dated 9/9/205, indicated to transfer to Resident 129 to GACH ER for further evaluation due to altered mental status and failure to thrive. The order report did not include a physician's order to put Resident 129's bed on hold for 7 days. A review of Resident 129's Transfer Form dated 9/9/2025, indicated Resident 129 was transferred to GACH on 9/9/2025 for further evaluation due to altered mental status and failure to thrive. A review of Facility Census reports dated 9/8/2025 through 9/18/2025 indicated that on 9/8/2025, Resident 129 was listed as occupying room [ROOM NUMBER]B. For 9/9/2025 to 9/18/2025, the census listed room [ROOM NUMBER]B as empty (no resident occupying the bed) but with no indication that the bed was on behold status for Resident 129. During a concurrent interview and record review of Resident 129's clinical records on 12/3/2025 at 2:51 PM with Director of Nursing (DON), DON stated no documented evidence in the resident's clinical record that the physician ordered to place Resident 129 bed on hold was when the resident was transferred to the hospital. In addition, the DON was unable to provide a bed-hold notification form. DON stated every time a resident is to transfer out a bed hold must be ordered to ensure a bed is available on return. During a review of the Facility's policy and procedure (P&P) titled Bed-Holds and Returns, dated 10/2022, the P&P indicated residents and or representatives are informed (in writing) of the facility and state bed-hold policies. 055523 Page 7 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for two of seven residents (Resident 55 and 35) reviewed for comprehensive care plan by failing to: 1. Develop a CP to ensure Resident 55 received necessary care and interventions while receiving Ambien (a medication used to treat insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep). 2. Develop a CP to ensure Resident 35 received necessary care and intervention while on hospice care (an end-of-life care).?? These deficient practices placed Resident 55 at risk of not receiving appropriate interventions to prevent the unnecessary use of psychoactive medications, which could result in adverse side effects (undesired effects). Additionally, these practices had the potential to compromise individualized care and negatively impact the quality of services provided to Resident 35. 2.During a review of Resident 35's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia (your lungs had a long-term problem where they could not get enough oxygen in your blood, causing tissues and organs to not get the oxygen they need), heart failure (the heart could not pump enough blood and oxygen to meet the body's needs), chronic obstructive pulmonary disease (COPD, a progressive lung disease that locked airflow, making breathing hard to do). During a review of Resident 35's History & Physical (H&P) dated 6.26.25, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/17/2025, 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 receiving oxygen therapy (extra oxygen when you could not get enough from the air) and Hospice care (compassionate, comfort-based care for people with a serious illness when a cure was not possible, shifting the goal from curing the disease to ensuring the best quality of life for the time remaining). During a review of Resident 35's Order Summary Report dated 7/11/2025, the Order Summary Report indicated the resident was admitted to hospice care due to chronic respiratory failure with hypoxia. During a review of Resident 35's Comprehensive (complete) Care Plan, dated 7/11/2025, the Care Plan did not include information regarding hospice care. During an interview on 12/4/2025 at 10:49 AM, the Registered Nurse Supervisor (RNS) stated the facility staff who received the order from the physician to admit the resident to hospice would be the person to create the care plan. The RNS stated there should have been a care plan for hospice for Resident 35 for the safety of the resident. The RNS stated if there was no care plan for hospice, the facility staff would not know who to contact and what to do for the resident. During an interview with the Registered Nurse Supervisor (RNS), it was stated that the facility staff member who received the physician's order to admit a resident to hospice would be responsible for initiating the hospice care plan. The RNS emphasized that a hospice care plan should have been developed for Resident 35 to ensure the resident's safety. The RNS further explained that in the 055523 Page 8 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few absence of a hospice care plan, facility staff would lack critical guidance on who to contact and what actions to take to appropriately care for the resident. During a concurrent interview and record review on 2/4/2025 at 10:36 AM, the Director of Nursing (DON) stated a care plan was the plan of care for the resident of what the facility would do for any problems the resident would have including their diagnoses and how the facility would care for the resident. The DON stated Resident 35 should have had a Hospice Care Plan because if the facility did not have a hospice care plan the facility staff would not know how to care for the resident in different circumstances. The DON stated the facility was not following the policy but should have been otherwise the facility staff would not know how to care for the resident because nothing would be there. During a review of the facilities policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered revised March 2022, the P&P indicated, The facility will develop a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and assessments of residents are ongoing. The care plans are revised as information about the residents' and the resident's conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and at least quarterly, in conjunction with the required quarterly MDS assessment. Findings: 1.During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included panic disorder (sudden periods of intense fear) and type II diabetes mellites (a condition that happens when your blood sugar is too high). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 55 had intact cognition (ability to understand and make decisions) and memory that required setup or clean-up assistance with eating, and supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and shower/bathe self. During a review of Resident 55's Order Summary Report, dated 12/3/2025, the report indicated on 11/28/2025 the physician renewed the order of Ambien Oral Tablet five milligram (MG, a measurement unit) one tablet to be administered by mouth every 24 hours as needed for insomnia. During a review of Resident 55's Medication Administration Record (MAR), dated 11/2025 and 12/2025, the MARs indicated Resident 55 was administered Ambien five MG one tablet as needed for 25 days from 11/1/2025 to 12/2/2025. During a concurrent interview and record review on 12/3/2025 at 1:12 PM Licensed Vocational Nurse (LVN) 4 stated, Resident 55 had been taking Ambien at bedtime as needed for sleep but there was no CP in place to indicate the care and interventions to implement while Resident 55 had been taking Ambien. LVN 4 stated the nurse who received the initial order of Ambien was responsible to initiate the CP. LVN 4 stated it was important to develop a CP for the use of Ambien because Ambien was a psychotropic medication (medication that affects mood and disorder), and it required close monitoring of the adverse reaction, side effects and effectiveness or ineffectiveness of the medication to treat the 055523 Page 9 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0656 insomnia and to ensure consistent and safe care to the residents. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident 55's CP on 12/4/2025 at 10:59 AM, the DON stated the assigned nurse did not develop a CP for Resident 55 for the use of Ambien. The DON stated that the nurse should have initiated the care plan to ensure safe and appropriate care for the resident, especially considering that Ambien is a psychotropic medication requiring monitoring for effectiveness and potential side effects. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan is developed for each resident within seven days of completion of required MDS assessment, and no more than 21 days after admission. 055523 Page 10 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain the low air loss (LAL - specialized air mattress with tiny holes that constantly released air, creating a gentle airflow to keep skin dry, manage moisture, and prevent painful pressure ulcers (a skin injury due to prolonged unrelieved pressure and friction]) for people who could not move much) mattress at the proper inflation, weight, and therapy settings, and did not follow the care plan for Resident 40, one of two sampled residents identified as high risk for developing pressure ulcers and reviewed for pressure ulcer prevention. The facility failed to: Ensure the LAL mattress was correctly set at an inflation level consistent with Resident 40's weight and clinical needs. Implement Resident 40's care plan interventions to adjust the LAL mattress according to the resident's weight and comfort level. These deficient practices had the potential to compromise effective pressure redistribution and increase the risk of developing or worsening pressure injuries for Resident 40. Findings: During a concurrent observation and interview, on 12/1/2025 at 11:21 AM, in Resident 40's room, the LAL mattress was observed to be set to alternating therapy mode, with a normal pressure system status and a comfort level of two. According to manufacturer specifications, comfort level one supports residents up to 120 pounds, while levels two through five supports up to 500 pounds. Comfort level one is considered softer, and level five firmer. Resident 40 expressed discomfort with the mattress, stating it felt different from previously used LAL mattresses and that she never felt the air moving around as expected. Resident 40 further stated that she had informed facility staff 100 times but they don't listen. During a review of Resident 40's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included pressure ulcer of sacral region (a wound that developed on the tailbone area from constant pressure, like sitting or lying in one spot too long cutting off blood flow, killing skin cells, and causing the skin and tissue to break down into painful, open sores that could get infected) irritable bowel syndrome (a common gut problem that caused stomach pain, cramping, bloating, gas, and changes in bowel habits), and paraplegia (paralysis of the legs and lower body). During a review of Resident 40's History & Physical (H&P) dated 4/21/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 40's Braden Scale for Predicting Pressure Sore Risk (a simple, six part checklist used by healthcare providers to spot resident's at high risk for bedsores by rating their sensory perception, moisture, activity, mobility, nutrition, and friction/shear) dated 7/23/2025 at 9:12 AM, the Braden Scale indicated the resident's perception was slightly limited, was occasionally moist, bedfast, very limited in mobility, had adequate nutrition and had a problem with friction and shear. The Braden Scale resulted in a score of 13, indicating the resident was at moderate risk for pressure sores. During a review of Resident 40's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/23/2025, the MDS indicated the resident's Cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident had occasional pain and had a pressure ulcer/injury. The MDS indicated the resident was at risk for developing pressure ulcers/injuries and had three stage four pressure ulcers. The MDS indicated the resident's skin and ulcer/injury treatment consisted of a pressure reducing device for chair, a pressure reducing device for bed, and pressure ulcer/injury care. During a review of Resident 40's Nutrition assessment dated [DATE] at 3:11 AM, the Nutrition Assessment indicated the resident's most recent weight was 87 pounds. The Nutrition Assessment indicated identification of risk factors included underweight body mass index (BMI, a simple number calculated from your weight and height to estimate body fat). The Nutrition Assessment indicated Residents Affected - Some 055523 Page 11 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident was on a fortified/high protein diet (boosting your regular meals with extra protein and calories by adding protein-rich ingredients to foods you already eat without making the portion size much bigger, to help with muscle, healing, or weight management when you need more nutrition.) and was receiving Pro-Stat (concentrated, fast-absorbing liquid protein supplement for people needing extra protein due to wounds, poor appetite, or muscle loss, helping with healing and preserving body mass). During a review of Resident 40's LAL Mattress Care Plan dated 11/8/2025, the Care Plan indicated a goal for the resident's skin to remain intact. The Care Plan interventions included setting the LAL Mattress according to the residents' weight or comfort and providing education regarding the risks and benefits of LAL Mattress use. During a review of Resident 40's Physician's Wound Care Orders and Visit dated 12/1/2025, the Orders indicated for the resident, facility pressure injury prevention and relief protocol. The Treatment Goals indicated healing was exapted to be delayed due to identified barriers to healing such as impaired mobility (difficulty moving freely and easily impacting daily life and independence), incontinence (the involuntary loss of bladder control [urine] and bowel control [stool]), and non-adherence/lifestyle choices. During an interview on 12/4/2025 at 9:33 AM, the Treatment Nurse (TN) 1 stated Resident 40 was under 100 pounds and pressure ulcer prevention interventions included repositioning the resident, high protein meals and snacks, and a low air loss mattress. TN 1 stated the treatment nurses were the ones who check the LAL mattress settings to ensure the resident was comfortable. During a concurrent observation and interview on 12/4/2025 at 9:44 AM, TN 1 stated the LAL mattress setting should have been set at level one because of Resident 40's weight and also based on the verbalized comfort of the resident. TN 1 stated the purpose of the LAL mattress was to distribute the resident's weight to improve her wounds and that incorrect settings could result in worsening of pressure injuries and increased pain and suffering for the resident. During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines revised 2/7/2024, the P&P indicated The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated General Guidelines included Redistributing support surfaces are to promote comfort for all bed or chairbound residents, promote circulation and provide pressure relief or reduction. The P&P indicated Guidelines for Selecting Appropriate Pressure-Relieving Devices included Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. During a review of the facility's P&P titled Prevent of Pressure Injuries revised February 2024, the P&P indicated The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The P&P indicated Support Surfaces and Pressure Redistribution included Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice and Device-Related Pressure Injuries included Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device and monitor regularly for comfort and signs of pressure-related injury. 055523 Page 12 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and accident-free environment for three of 3 sampled residents (Resident 23, 135 and Resident 10) by failing to: 1. Post the required No Smoking/Oxygen in Use signage in the resident's doorway in the presence of supplemental oxygen for Residents 23 and 101 in accordance with the facility's policy and procedure (P&P) titled Oxygen Administration. 2. Supervise and implement safety measures for Resident 10 during a smoking break. These deficient practices had the potential to result in a significant fire hazard and compromise the safety and life of the residents, staffs and visitors in the facility. Findings: 1.A Review of Resident 23's admission Record indicated the resident was originally admitted into the facility on 3/5/2025, with diagnosis that included, fracture (broken bone) of neck of left femur (thigh bone) , fracture of greater trochanter ( thigh bone) of left femur ( thigh bone) , metabolic encephalopathy (a condition of the brain caused by chemical imbalances ) and Alzheimer's disease unspecified(progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 23's History and physical (H&P), dated 4/15/2025, the H&P indicated, Resident 23 does not have the capacity to understand and make decisions. A review of Resident 23's Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 10/20/2025, indicated Resident 23 has severe cognitive impairment (has significant deficits in memory and thinking, requiring support for safety awareness, decision – making, and reporting needs or changes in condition). The MDS indicated Resident 23 requires maximal assistance with showering needs and moderate assistance for dressing and personal hygiene and sit to stand position. A review of Resident 23's Fall Risk Assessment – V3, dated 10/22/2025, indicated based on answers to questions on fall Risk assessment Resident 23 was a high risk for fall. A review of Resident 23's Care plans indicated Resident 23 has had 1-2 falls in the past 2-6 months and had chronic Nasal bone fracture ( from CT scan result done 2/23/2025) prior to admission, The Care Plan interventions included to assist the Resident to bathroom or toilet as necessary and do frequent visual checks to ensure and assist to maintain proper body positioning while in bed and wheelchair. A review of Resident 23's Care plan (CP) dated 6/10/2025 and revised on 10/29/2025 indicated Resident 23 was at high risk for falls related to behavioral problems, impaired balance, cognitive impairment, and recent femur fracture The CP goal indicated for Resident 23 to be free from falls and demonstrate safe participation in care and mobility routines through review date of 1/18/2026. A review of Resident 23's CP, initiated on 11/07/2025 indicated Resident 23 has spontaneous behavior of getting out of bed/chair, and the CP goal for the resident to be free from injury, target date 1/18/2026. The interventions included, for the facility to provide frequent visual checks and activity participation, implement fall precautions including bed/chair alarms, low bed position, and call light withing reach at all times and to ensure supervised mobility with assistive devices during all transfers and ambulation. 055523 Page 13 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Nursing Staffing Assignment and sign in sheet for 12/01/2025 7AM – 3PM, indicated Certified Nursing Assistant (CNA5) was assigned to room [ROOM NUMBER]A at start of shift ( 7AM – 11AM) then removed from assignment. During a concurrent observation and interview on 12/1/2025 at 10:20AM with Licensed Vocational Nurse (LVN5), Resident 23's room, was dark upon entry with the,privacy curtain drawn completely around the bed, preventing visual observation of the resident. Upon exiting room Resident 23's feet were observed protruding under the curtain. LVN 5 entered the room and was asked to pull back the curtain, revealing Resident 23 on the floor with his back against the bed. No bed alarm was present. LVN5 stated not being sure if the resident is supposed to have a bed alarm but that this is his usual behavior to fall out of bed. LVN 5 stated the resident should have been monitored and placed in the activity room for safety. When asked why the curtain was drawn around the resident and who had pulled it closed, LVN 5 stated he did not know and stated the curtain was not to be drawn around the resident due to the fact he requires supervision. During a Concurrent observation and interview on 12/1/2025 at 10:41AM with Director of Nursing (DON) in Resident 23's room, resident observed lying in bed. DON stated that Resident 23 reported he had been sitting on the side of the bed and slipped, sliding from the bed to the floor, and confirmed this was an unwitnessed fall. The DON stated Resident 23's privacy curtain should not have been shut and that the curtain should only be closed when staff are providing care for privacy, adding that staff are not able to properly monitor the resident if the privacy curtain is drawn. The DON further stated that current interventions for Resident 23 are to include having the resident located closer to the nursing station, frequent monitoring and or up in the activity room for safety. The DON also stated it was his opinion that resident 23 does not have the capacity to draw the curtains himself. During an interview , on 12/2/2025 at 2:56PM Certified Nursing assistant ( CNA5) stated she was a new CNA and had been assigned to care for Resident 22A. CNA 5 stated she was providing activities of daily living ( ADLs), including diaper changes, feeding , vital signs, and breakfast, to residents on her assignment. CNA 5 stated that prior to providing care to Resident 23, Licensed Vocational Nurse (LVN 6) told her not to worry about providing care for resident 23 and that he would have an alternate CNA to monitor this resident while she completed her other care. CNA 5 stated that when she entered the room, LVN6 told her to leave. CNA5 stated that before leaving the room, she noted or believed Resident 23 was in his bed and observed privacy curtain drawn completely around him. CNA 5 stated, I did look prior to leaving room, the resident was still in his bed and stated she did not know who had drawn the curtain around the resident or why. CNA5 stated the LVN did not want her to provide care for this resident. CNA 5 further stated that later, while she was showering her assigned resident, another CNA (unknown) came to her, informing her that resident 23 had fallen on the floor and that she would be in trouble. Unknown CNA stated, how could she leave this resident knowing they were a high risk for falls. CNA 5 stated that afterward she was brought into the Administrators office and was required to sign a corrective action form. 2. During a review of Resident 135's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a long-term problem where they could not get enough oxygen into your blood causing tissues and organs to not get the oxygen they need), interstitial pulmonary disease (a group of disorders where lung tissue around the air sacs [alveoli] get inflamed, scarred, and thickened, making oxygen hard to get into the blood, leading to shortness of breath, a dry cough, and fatigue). During a review of Resident 135's History and Physical (H&P) dated 11/29/2025, the H&P indicated 055523 Page 14 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 the resident had capacity to understand and make medical decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen NC to be change every week on Monday and PRN (with name and date label) in the morning every Monday. Residents Affected - Some During an observation of Resident 135's room on 12/1/2025 at 11:36 AM, the resident's room did not have a No Smoking/Oxygen in Use sign posted. During a concurrent observation and interview on 12/1/2025 at 1:05 PM, LVN 1 confirmed Resident 135's room did not have a No Smoking/Oxygen in use sign posted outside while the resident was receiving supplemental oxygen. LVN 1 stated the sign was important for alerting facility staff and visitors the presence of oxygen in use, which required avoiding open flames due to the risk of fire or explosion. LVN 1 further stated that not having the sign posted was a safety concern and could negatively impact the resident's quality of care if staff were unaware that oxygen was in use. LVN 1 stated that such signage should have been posted in accordance with the facility's protocols. During a concurrent observation and interview on 12/3/2025 at 10:03 AM, the DON stated there should have been a No Smoking/Oxygen in Use sign posted as a safety protocol to make sure everyone knew the resident was using supplemental oxygen and no one should make a fire or light a cigarette. The DON stated the facility staff were not following the physician's orders and without a sign posted, there was potential for an explosion. During a concurrent interview and record review of the facility's P&P titled Oxygen Administration revised February 2024, the P&P indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated Place a no smoking sign on the outside of the room entrance door. And place an Oxygen in Use sign in a designated place on or over the resident's bed. The DON stated they were not following the policy because the facility did not place a sign over the resident's bed and for Resident 135 did not have a sign posted at all. The DON stated the facility should have been following the policy so everyone would know the resident was on oxygen and there would not be an explosion. 3. During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 4/11/2024 with diagnoses that include but not limited to major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 feeling down, depressed, or hopeless 2-6 days in the previous 2 weeks of the assessment. Resident 10 is wheelchair dependent. Resident 10 need assistance with setting up or clean-up for eating. Resident 10 need assistance with oral hygiene, upper body dressing and personal hygiene. Resident 10 need substantial/maximum assistance with toileting hygiene, shower/bathe self, lower body dressing pulling on/taking off footwear. During an observation on 12/2/2025 at 8:50 am in facility's designated smoking area (at the corner of facility parking lot), Resident 10 was smoking. No staff or other residents were present in facility's designated smoking area. 055523 Page 15 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/2/2025 at 11:07 am with Resident 10, Resident 10 stated that Resident 10 is allowed to smoke outside the designated smoke break times. Resident 10 stated the facility staff is only present in the facility's designated smoking area during the smoking break times. During an interview on 12/3/2025 at 10:19 am with MDS nurse, MDS nurse stated that Resident 10's smoking assessment was done on 6/30/2025 and was not completed after that. MDS nurse stated that the Resident 10's medical condition could have changed and without a complete smoking assessment (facility tool to evaluate resident's smoking habit, physical and cognitive ability to smoke with supervision or without supervision and fire safety risks), Resident 10 was not safe to smoke without supervision. MDS nurse stated that the resident was at risk of an accident, fire and burns. During an interview on 12/3/2025 at 3:19 pm with DON, DON stated that if a resident missed a quarterly smoking assessment and still going for smoking without supervision, there is risk of fire and resident safety since resident's medical condition can be changed from last quarterly smoking assessment. During a review of the facility's Policy and Procedure (P&P) titled, Smoking Policy - Residents, dated 1/2024, the P&P indicated that a resident's capability to smoke safely is re – evaluated every quarter to smoke safely and without supervision. A review of the facility's policy and procedure ( P&P) titled, Falls and Fall Risk, managing dated 2/7/2024, indicated staff, based on previous evaluations and current data, to identify resident – specific risk factors and causes and implement interventions to help prevent residents from falling and minimize complications from falls. The Policy identified environmental risk factors for falls, that included poor lighting and required a resident – centered approach to managing falls and fall risk. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/2023, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility – wide priorities. The policy also indicates individualized, Resident – centered approach to safety to include addressing safety and accident hazards for individual residents by using a system approach of supervision at its core component. The type and frequency of resident supervision is determined by the individual resident's assessed for needs. 055523 Page 16 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the peripheral Intravenous (IV-small catheters inserted into a vein used to administer fluids, blood and medications) sites for one of eight (Resident 52) on the right and left arms peripheral IV dressings were dated and initialed by the staff who changed the dressing in accordance with the facility's policy and procedure titled Peripheral and Midline intravenous and the physician's order. This deficient practice had the potential to increase the risk for result IV infection, IV site skin breakdown, IV infiltration (IV fluid leaking out from the veins and into the tissues causing swollenness, pain and tissue damage) Findings: A review of the admission records indicated Resident 52 was admitted originally on 11/04/2025, with a diagnosis of acute embolism ( a blockage in the blood vessel caused by something that has traveled there through the bloodstream such as a blood clot) and thrombosis (a blood clot ) of left femoral vein (a large vein in the upper leg/groin area) , respiratory failure (when lungs cannot get enough oxygen into the blood that result in difficulty breathing) A review of Resident 52's Minimum Data Set ( MDS- standardized comprehensive assessment tool) dated 10/01/2025, indicated Resident shows moderate impairment in memory and thinking abilities, and may need repetition, cues, and assistance for making decisions and recalling information and is dependent on staff to complete most activities such as dressing , personal hygiene, showering and toileting hygiene as well. A review of an Order Summary Report with an order date of 12/1/2025 indicated to change Resident 52's peripheral IV dressing every 7 days and with site change as needed and every Sunday. During an observation on 12/1/2025 at 10:09 AM in Resident 52's room, the resident's right and left peripheral IV dressing site was observed without the date the IV dressing was changed and the initial of the staff that changed the dressing. During a concurrent observation and interview on 12/1/2025 at 10:15AM with Registered Nurse Supervisor (RN) 2 in Resident 52's room,the resident's right and left peripheral IV dressing sites were observed without the date the IV dressing was changed and the initial of the staff that changed the dressing. RN2 stated, IV dressing should be changed every Sunday and the peripheral IV site must be dated so staff can monitor when the dressing need to be changed and to assess for signs of infection. During a concurrent observation and interview on 12/1/2025 at 10:18 AM, in Resident 52's room with Director of Nursing (DON), stated it was important to have a date of when the IV was inserted and when the IV dressing was changed to know when the dressing will be changed again as indicated in the facility's policy and procedure. During a review of the facility's policy and procedure ( P&P) titled, Peripheral and Midline IV Dressing Changes dated 3/2022, the policy indicated purpose of procedure is to prevent complications associated with intravenous therapy including catheter related infections associated with contaminated, loosened or solid catheter-site dressings and to include in steps in the procedure labeling of dressing with the date and time of dressing change, and initials. Residents Affected - Few 055523 Page 17 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure Resident 102 was free from significant medication error by failing to administer the correct dose of Retacrit ( a stimulating agent used to increase red blood cell production used to treat anemia (not enough healthy red blood cells that carry oxygenated blood to the tissues) reducing the need for blood transfusions) as ordered by the physician. This deficient practice had the potential to further worsened Resident 102's anemia and compromise resident's well-being and that may lead to the need for urgent blood transfusion and hospitalization. Findings: A review of the admission record indicated Resident 102 was admitted to the facility originally on 11/05/2025, with a diagnosis that included hemiplegia(paralysis affecting one side of the body) and hemiparesis (weakness or inability to move on one side of body) , anemia, and diabetes (Chronically high blood glucose ( sugar) levels). A review of resident 102's History and Physical (H&P), dated 11/06/2025, indicated Resident 102 had the capacity to understand and make decisions. A review of resident 102's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 11/21/2025, indicated Resident 102 was cognitively (though process or ability to reason and remember) intact. A review of Resident 102's Order Summary Report indicated the physician ordered on ordered on 11/18/2025 to start 11/19/2025 to administer Retacrit injection solution) inject 6000 unit subcutaneously (injected into the skin on the fatty tissue) one time a day every Monday, Wednesday and Friday for anemia. A review of Resident 102's Medication Administration Record (MAR), dated 12/3/2025 at 9AM indicated, LVN 4 administered Retacrit Injection solution 6000 units subcutaneously to Resident 21's upper left arm for anemia. During an observation and interview of a medication pass on 12/3/2025 at 7:46 AM with LVN4 was observed drawing up medication and administering Retacrit 3000units (1ml) subcutaneously to Resident 102. When asked if she had administered the correct dose as ordered by the physician, LVN 4 looked at the vial label and checked the physician's order that indicated to administer Retacrit 6000units subcutaneously. LVN 4 stated she had made a medication error and needed to administer another dose. During an observation and interview on 12/3/2025 at 08:41AM with Director of Nursing (DON) and LVN 4, the physician's order and the medication vial for Retacrit for Resident 102 were reviewed and compared. The DON stated that the LVN 4 had administered 3,000units, and therefore made a medication error and needed to administer one more vial to total the ordered amount of 6,000 units. The DON further stated that an underdose of Retacrit for Resident 102, who had anemia, could result in adverse (unwanted or harmful result) signs and symptoms related to low hemoglobin such as shortness of breath, need for blood transfusion and worsening fatigue. A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 4, 2023, indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method(route) of administration before giving the medication. Residents Affected - Few 055523 Page 18 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview and record review, the facility failed to label a used by date for the following food items in accordance with the facility's policy and procedure Food Receiving and Storage and with the professional standards for food service safety by failing to: 1. Indicate the used by date of an opened box with five pieces of pie shell 2. Indicate the used by date of an opened plastic container of dill pickle relish 3. Indicate the used by date of an opened bag of brownie powder and the facility staff failed to perform hand hygiene after engaging in activities that contaminate the hands and prior to dispensing meal trays to residents for three of ten sampled residents (Resident 64, Resident 119, and Resident 134) in accordance with the facility's policy and procedure (P&P) titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it and result in a widespread infection in the facility. 2. During a review of Resident 64's admission Record (AR), the AR indicated the facility admitted Resident 64 on 5/10/2024 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hyperlipidemia (high level of fat in the blood). During a review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/13/2025, the MDS indicated Resident 64 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making that required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, and was dependent on toileting hygiene, chair/bed-to-chair transfer, and shower/bathe self. During a review of Resident 119's AR, the AR indicated the facility originally admitted Resident 119 on 5/14/2022 and readmitted her on 1/12/2023 with diagnoses that included unspecified dementia and hypertension (high blood pressure). During a review of Resident 119's MDS, dated [DATE], the MDS indicated Resident 119 had severely impaired cognition and memory. The MDS indicated Resident 119 required setup or clean-up assistance with eating, and substantial/maximal assistance with oral hygiene, personal hygiene, toileting hygiene, chair/bed-to-chair transfer and shower/bathe self. During a review of Resident 134's AR, the AR indicated the facility admitted Resident 134 on 11/28/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension. During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134 had moderately impaired cognition and memory. The MDS indicated Resident 134 was independent with eating, and required supervision or touching assistance with oral hygiene, personal hygiene, toileting hygiene, chair/bed-to-chair transfer and shower/bathe self. During a dining observation on 12/1/2025 at 12:13 PM in the dining room, Certified Nursing 055523 Page 19 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assistant (CNA) 4 did not perform hand hygiene between multiple task when she picked up four soiled cups from four different residents and put the cups on top of a meal tray cart, then, she removed the newspaper from a resident's hands and threw it in a trash bin. Next, CNA 4 picked up Resident 64's meal tray from the meal cart and set up the food and utensils on the table for Resident 64. Then, CNA 4 picked up Resident 119's meal tray from the meal cart and set up the food and utensils on the table for Resident 119. Afterwards, CNA 4 picked up Resident 134's meal tray from meal cart and set up the food and utensils on the table for Resident 134. During an interview on 12/1/2025 at 12:29 PM?with CNA 4, CNA 4 stated she did not perform hygiene after collecting soiled cups from the residents and after discarding the newspaper into the trash bin. CNA 4 stated she did not perform hand hygiene before passing meal trays to residents and between residents. CNA 4 stated she should perform hand hygiene after each task that could contaminate her hands and before handling food to prevent spread of infection. During an interview on 12/4/202 at 10:55 AM with the Director of Nursing (DON), the DON stated the CNAs are expected to perform hand hygiene both before and after handling and passing meal trays to each resident. The DON stated, this practice is important to prevent the potential spread of foodborne illness and to ensure the safety and well-being of residents. During a review of the facility's P&P titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 11/2022, the P&P indicated employees must wash their hands after handling soiled equipment or utensils and after engaging in other activities that contaminate the hands. During a review of the facility's P&P titled Handwashing/ Hand Hygiene, dated 10/2023, the P&P indicated hand hygiene is indicated immediately before touching a resident, after touching a resident, and after touching the resident's environment, to help prevent the spread of infections to other personnel, residents, and visitors. Findings: 1.During an initial kitchen tour and interview with the Dietary Supervisor (DS) on 12/1/2025 at 8:45 AM the following were observed without a label with a used by date. In the freezer: -an open box with five pieces of pie shell In the refrigerator: -an open plastic container of dill pickle relish In the food dry storage area: -an open bag of brownie powder During a concurrent interview on 12/1/2025 at 8:45 AM DS stated, the pie shells are used to make residents pies, the pickle relish are used to add with residents' food, and the brownie powder is used to make residents brownie. The open food items should have a used by date label to ensure it was still fresh for consumption, because it potentially could be old and contaminated that could get 055523 Page 20 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0812 residents sick when consumed. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/2025 at 3:15 PM, the Director of Nursing (DON) stated that, per facility policy, food in the kitchen should be labeled with a use by date. The DON explained having the used by date ensures food freshness, helps kitchen staff know when to discard expired items, and prevents serving unsafe food to residents. The DON stated that failure to follow the policy could lead to food contamination and the growth of microorganisms, potentially causing foodborne illnesses that may negatively impact residents' health and quality of life. Residents Affected - Some A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/2022 indicated, a) dry food removed from packaging dated with used by date, b) all foods stored in the refrigerator or freezer are labeled and dated with a used by date. A review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Indicated READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES. 055523 Page 21 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly dispose garbage and refuse (food waste, scraps) by having the lids of two of three metal dumpsters (large trash container designed to be emptied into a truck) to closed completely and did not contain excess garbage bags, the garbage area was clear of litters, used opened boxes on the ground and used wooden pallet in accordance with the facility's policy and procedure titled, Food- Related Garbage and Refuse Disposal. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents, visitors and staffs in the facility.Findings: During a concurrent observation and interview on 12/1/2025 at 9AM with the Dietary Supervisor (DS) in the facility's' garbage area, observed the lids of two of three metal dumpsters was unable to close completely due to much garbage bags, also the garbage area had opened boxes on the ground and a wooden pallet. DS stated, the dumpsters cannot completely close because of too much trash bags, and the garbage area should always be clean without those opened boxes and the wood pallet. DS stated, the garbage area had the potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents, visitors and staffs in the facility. During an interview on 12/2/2025 at 3:15 PM with Director of Nurses (DON), DON stated, it was important to ensure the dumpsters lids are completely closed and the garbage surrounding are clean and free of litter, such as opened boxes and a wooden pallet, because it potentially can attract birds, flies, insects, pest, and rodents. DON stated, it could cause the spread of diseases and/or infections that could affect the life and safety of residents, visitors and staffs. A review of the facility's policies and procedures (P&P) titled Food- Related Garbage and Refuse Disposal, (10/2017), indicated: a) garbage and food wastes will be stored in a manner that is inaccessible to pests, and b) outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter. Residents Affected - Some 055523 Page 22 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

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 infection prevention and control practices in accordance with facility policy and procedures and professional standards for two of four sampled residents (Resident 3 and Resident 135) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 2 wore an isolation gown when providing care one of one sampled residents (Resident 3) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having gastrostomy tube (GT-tube inserted through the abdominal wall directly into the stomach used to deliver nutritional formula, fluid and medications). 2. Label Resident 135's nasal cannula (NC, a small, flexible plastic tube with two prongs that fit into your nostrils to deliver extra oxygen from a tank or concentrator) and humidifier (a fluid in the bottle attached to the oxygen to keep the air moist when inhaled by the residents through the NC to prevent dryness in the nose) in accordance with the physician's order and the facility's policy and procedure (P&P). These deficient practices had the potential to result in Resident 3 acquiring MDROs and/or spreading MDROs to other residents in the facility and Resident 135 to be at risk from misidentification of equipment and increased infection control concerns related to unlabeled respiratory equipment that could compromise the quality of care and quality of lifeFindings: Residents Affected - Some 1.During a review of Resident 3's admission Record (AR), dated 4/11/2024, indicated Resident 3 was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included respiratory failure (don't have enough oxygen in the tissues in your body), end stage renal disease (kidneys have failed to get rid of extra fluid and toxins) and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS) -a resident assessment tool dated 11/7/2025, indicated Resident 3's cognitive status (ability to process and comprehend information) was severely impaired. The MDS indicated Resident 3 was dependent (helper does all the effort) with all ADLs (Activities of Daily Living). During an observation on 12/1/2025 at 11 AM Resident 3's door had a signage indicating Enhanced Barrier Precautions, also observed Resident in bed with head of bed elevated receiving feeding formula via G-tube. During a review of Resident 3's Order Summary Report (OSR) [GG1] dated 12/3/2025, the OSR indicated Resident 3 was placed on: a) on Enhanced Barrier Precautions due to G-tube status, b) Enteral Feed Order (Novasource Renal (feeding formula) via G-tube. During an observation on 12/3/2025 at 8 AM by Resident 3's doorway had a signage EBP indicating staff must wear gloves and isolation gown during high contact resident care activities and Certified Nurse Assistant (CNA) 2 was observed caring for and providing care to Resident 3. During a concurrent observation and interview on 12/3/2025 at 8:10 AM with CNA 2 who was standing by Resident 3's doorway, CNA 2 came out of the privacy curtain of Resident 3's bedside without wearing a Personal Protective Equipment (PPE) such as isolation gown. CNA 2 stated, she washed the face, cleaned the mouth and changed the brief of Resident 3. CNA 2 stated she did not use isolation gown because she forgot. CNA 2, stated, she could spread infection for not wearing isolation gown. During an interview on 12/3/2025 at 8:15 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, 055523 Page 23 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm Resident 3 was on EPB because she has a G-Tube. LVN 3 stated, close contact care requires the staff to wear PPE's which includes wearing isolation gown. LVN 3 stated, performing personal hygiene and changing briefs is considered close contact care, so CNA 2 should have worn the isolation gown. LVN 3 stated, not wearing isolation gown during close contact care had the potential to result in Resident 3 acquiring MDROs and/or spread MDRO's in the facility. Residents Affected - Some During an interview on 12/3/2025 at 8:41 AM with Infection Preventionist Nurse (IPN), IPN stated, Resident 3 was on EBP because of her G-Tube, which creates a direct access to the body, which makes Resident 3 more vulnerable to acquire/spread MDROs. IPN stated, wearing PPEs which includes the isolation gown during close contact care was essential to prevent Resident 3 from acquiring MDROs, as well as preventing the spread of MDROs in the facility. During an interview on 12/3/2025 at 4:15 PM with the Director of Nurses (DON), DON stated, He expects for Resident on EBP, staff should wear PPEs which includes the isolation gown. DON stated, not wearing an isolation gown during a close contact care of a Resident on EBP had the potential to result in introduction MDROs to the Resident and/or spread of MDROs to other residents in the facility which could negatively affect their health and quality of life. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2024, the P&P indicated: a) enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents, b) EBPs employ isolation gown use during high contact resident care activities, and c) examples of high contact resident care activities requiring the use of isolation gown for EBPs include: providing hygiene and changing briefs. A review of the facility's policy and procedure (P&P) titled, Policies and Practices – Infection Control, revised 4/2025, the P&P indicated, the facility infection control policies and practices are intended to facilitate a safe and sanitary environment to help prevent and manage transmission of diseases and infection. 2. During a review of Resident 135's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a long-term problem where they could not get enough oxygen into your blood causing tissues and organs to not get the oxygen they need), interstitial pulmonary disease (a group of disorders where lung tissue around the air sacs [alveoli] get inflamed, scarred, and thickened, making oxygen hard to get into the blood, leading to shortness of breath, a dry cough, and fatigue). During a review of Resident 135's History and Physical (H&P) dated 11/29/2025, the H&P indicated the resident had capacity to understand and make medical decisions. During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen humidifier to be changed every week on Monday and as needed (PRN) when consumed (with name and date label) in the morning. During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen NC to be change every week on Monday and PRN (with name and date label) in the morning every Monday. During an observation in Resident 135's room on 12/1/2025 at 11:33 AM, the resident's NC did not have a label with the date or resident's name. The resident's NC humidifier had the date but did not 055523 Page 24 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0880 have the resident's name. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/1/2025 at 1:02 PM, Licensed Vocational Nurse (LVN) 1 stated the facility staff should have changed the resident's NC's once a week and they should have been labeled. LVN 1 stated if the nasal cannula was not labeled the resident could be at risk for infection because the facility staff would not know how long the NC was used for and the resident could have a respiratory infection or may not be getting the correct amount of oxygen if the NC was damaged. Residents Affected - Some During a concurrent observation and interview on 12/3/2025 at 9:58 AM, the DON stated the nasal cannula should have had a date and a name to know when the NC was changed to make sure the facility staff was following physician's orders. The DON stated if the NC was not labeled the facility staff would not know when the NC was changed and that was an infection control issue. The DON stated dirt could get in or something could accumulate during breathing treatments and the facility staff needed to keep the NC clean. During a concurrent interview and record review of the facility's P&P titled Oxygen Administration revised February 2024, the P&P indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. The DON stated the facility was not following the policy but should have been. 055523 Page 25 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide the required minimum of 80 square feet (sq. ft., unit of measurement) per resident in 34 out of 45 resident bedrooms. Specifically, Resident Bedrooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47 were measured and found to provide less than 80 square feet per resident. These rooms consisted of 31 three-bed capacity bedrooms and three two-bed capacity bedrooms. This deficient practice had the potential to negatively impact residents by limiting adequate space for safe nursing care, reducing privacy, and potentially increasing the risk of accidents or compromised care delivery due to overcrowded conditions. Findings: During a review of the Client Accommodation Analysis (CAA, a form used to identify the room sizes and number of beds in the room) form completed by the facility on 12/1/2025, the Client Accommodation Analysis indicated the facility had 34 bedrooms in the facility that measured less than 80 sq. ft. per resident care area as listed below: room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. During a review of the facility's request for additional room waiver dated 12/1/2025, the request indicated the licensee contends this waiver was necessary to avoid an unreasonable financial hardship and would be able to provide care and services without adversely affecting the health and safety of the facility's residents. The request indicated the following residents' bedrooms: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47. During an interview on 12/4/2025 at 8:45 AM, Certified Nursing Assistant (CNA) 1 stated there was enough space to transfer and care for the residents. CNA 1 stated that sometimes the facility staff would 055523 Page 26 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some need to move the resident's bedside table or bed to make space but doing so did not affect resident care. During an interview on 12/4/2025 at 8:52 AM, Licensed Vocational Nurse (LVN) 2 stated there was enough space to care for the residents and CNAs could move stuff around to transfer and care for the residents as needed. LVN 2 stated the limited space did not affect the residents care or safety. During an interview on 12/4/2025 at 9 AM, LVN 7 stated CNAs would move the bedside table, bed, or wheelchair to make space when using a Hoyer lift (a mechanical device like a mobile crane for people, that used a sling to safely lift and move someone who could not move themselves) to transfer a resident. LVN 7 stated the facility staff were able to work around and make sure there was enough space to transfer residents from the bed to the chair, from the chair to the bed, and in and out of the room safely. During an interview on 12/4/2025 at 9:01 AM, Resident 136 and the Responsible Party (RP) stated they felt there was enough living space in the bedroom. The RP stated the overall space was okay but sometimes the resident or the facility staff needed to move things around but that was not an issue. During an interview on 12/4/2025 at 9:04 AM, Resident 34 stated there was enough space in the bedroom and was glad for the open area near the window. Resident 34 stated the facility staff have never had an issue getting around the room to assist the resident. During an interview on 12/4/2025 at 9:09 AM, Resident 56 stated there was enough living space to do the things the resident wanted to do in the bedroom. Resident 56 stated there have not been issues with space when staff assist and the staff have never complained there was not enough room when providing care. During an interview on 12/4/2025 at 9:31 AM, CNA 6 stated there was enough space to tend to the resident's care and needs and the residents have not complained about the space. CNA 6 stated for the most part, the bedroom was spacious but looked small because of the curtains in all of the bedrooms. During the course of the re-certification survey between 12/1/2025 to 12/4/2025, the above listed bedrooms had sufficient space for the residents' freedom of movement. The bedrooms had adequate space to provide nursing care, privacy during care, and the ability to maneuver resident care equipment with the room. The room size did not have any adverse effect on the residents' personal space, nursing care, and comfort. During an interview on 12/4/2025 at 2:40 PM, the Administrator (ADM) stated the facility would like to request a room waiver for this year. The ADM stated residents, families, and staff have not complained about the space being too small or being unable to care for the residents due to the space. 055523 Page 27 of 28 055523 12/04/2025 Glendale Post Acute Center 250 N. Verdugo Road Glendale, CA 91206

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of four sampled residents (Resident 55) as evidenced by having dust with white debris, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and old dry liquid stains on the floor under the resident's bed. This deficient practice had the potential to result in Residents 55's non homelike environment that affects the resident's quality of life and self-image. During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension (high blood pressure). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 55 had intact cognition (ability to understand and make decisions) and memory that required setup or clean-up assistance with eating, and supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and shower/bathe self. During an observation on 12/1/2025 at 9:06 AM in Resident 55's room, the floor under Resident 55's bed was dusty with small debris particles, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and some old dry liquid stains. During a concurrent observation and interview on 12/2/2025 at 11:45 AM with Resident 55, the floor in Resident 55 remained dirty as observed on the previous day 12/1/2025. Resident 55 stated the floor was very dirty and no one came to clean and mop the floor. Resident 55 stated the staff came to his room to pick up his trash and they had not cleaned the floor for three to four weeks. Resident 55 stated the dirty floor made him uncomfortable and he would like a clean space. During a concurrent observation and interview on 12/2/2025 at 11:56 AM with the Maintenance Supervisor (MS), the MS stated floor in Resident 55's room was dirty, and the housekeeping staff did not clean and mop the floor every day. The MS stated he did not know for how long the floor was not cleaned and there was no document indicating when this room was last cleaned. The MS stated the housekeeping staff should clean and mop every resident's floor daily to provide a clean and sanitary environment for the residents. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, dated 2/2021, the P&P indicated the facility to provide a safe, clean, and comfortable environment. 055523 Page 28 of 28