Inspection·December 21, 2023

F 0550 and not while standing. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Assistance with Meals, revised 3/22, indicated Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 2 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 did not implement its policy and procedures titled, Theft and Loss Policy and Procedures and Abuse Prevention and Prohibition Program by not thoroughly investigating an alleged misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45). Residents Affected - Few Resident 45 reported missing $1500 on 12/11/23 to the Administrator (the Abuse Coordinator) and the ADM Designee (ADMD) that was not thoroughly investigated by the facility. This deficient practice had resulted in Resident 45's verbalization of feeling sadness for not being able to share money to his family, and a potential to negatively affect Resident 45s quality of life, such as sadness and mistrust to facility staff. Findings: A review of Resident 45s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing), kidney failure (failure of the kidney to remove toxins and excess fluid in the body) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 45s History and Physical Examination, dated 11/7/2023, indicated Resident 45 has the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 11/17/2023, indicated Resident 45s cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 45 required partial/moderate assistance (helper does less than half the effort) with eating, required substantial/maximal assist (helper does more than half the effort) wit oral hygiene, dressing, and dependent (helper does all the effort) with toileting, bathing, roll left and right, and sit to lying, lying to sitting on side of bed. A review of facility document titled CONCERN RECORD -Theft/Loss and Grievance Report, dated 12/11/2023, indicated Resident 45 reported he was missing money in the amount of $1500 to ADMD. During a concurrent observation and interview on 12/18/2023 at 9:55 AM with Resident 45 in Resident 45s room, Resident was sitting in his wheelchair frowning (expression of disapproval, displeasure). Resident 45 stated, last week he reported to the Administrator (ADM) and the ADM Assistant (ADMD) that he was missing $1500, but no one had investigated his claim. Resident 45 stated, he was sad because it was almost Christmas and he wanted to share his money to his family (FAM 1). During an interview on 12/18/2023 at 1:31 PM with ADM, the ADM stated, she knew about Resident 45's allegation regarding missing money since last week. The ADM stated, she informed the Administrator Designee (ADMD) investigate Resident 45's allegation of missing money. The ADM stated, she did not report Resident 45's allegation of missing money to CDPH (California Department of Public Health), the police or any other agency because she was not sure if Resident 45 had the money or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 3 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/20/2023 at 8:49 AM, Resident 45 stated, he gets money from the from the pension plan and directly deposited to his bank. Resident 45 stated, he authorized his FAM 2 to take money from his account monthly, and he keeps around $300 a month and put it in his wallet and keep it in his side table drawer. Resident 45 stated he reported that he was missing $1500 to ADMD on 12/11/2023. Resident 45 stated, the facility staff did not believe he was missing $1500. Resident 45 stated, I feel terrible, and it is almost Christmas and he wanted to give money to the FAM 1. During an interview on 12/20/2023 at 9:04 AM, FAM 2 stated, it was possible for Resident 45 to have $1500 in his possession, because she gives the resident $500 to $600 a month from Resident 45s bank account. FAM 2 stated, the day after Resident 45 went to the hospital on [DATE], and she picked up Resident 45s empty wallet from his room in the facility. FAM 2 stated that was when Resident 45 told her that his money in the amount of $1500 was missing. FAM 2 stated, she and Resident 45 reported to the facility that Resident 45 was missing money on 12/11/2023 (Resident 45 was hospitalized on [DATE] and readmitted to the facility on [DATE]). During an interview on 12/18/2023 at 1:31 PM with ADM, stated, she knew about Resident 45s alleged missing money since last week. The ADM stated, she informed the Administrator Designee (ADMD) to investigate Resident 45's allegation of missing money and a grievance report was initiated. During an interview on 12/20/2023 at 8:49 AM, Resident 45 stated, he gets money from the from the pension plan and directly deposited to his bank. Resident 45 stated, he authorized his FAM 2 to take money from his account monthly, and he keeps around $300 a month and put it in his wallet and keep it in his side table drawer. Resident 45 stated he reported that he was missing $1500 to ADMD on 12/11/2023. Resident 45 stated, the facility staff did not believe he was missing $1500. Resident 45 stated, I feel terrible, and it is almost Christmas and he wanted to give money to the FAM 1 During an interview on 12/20/2023 at 9:04 AM, FAM 2 stated, it was possible for Resident 45 to have $1500 in his possession, because she gives the resident $500 to $600 a month from Resident 45s bank account. FAM 2 stated, the day after Resident 45 went to the hospital on [DATE], she picked up Resident 45s wallet in his drawer at the facility without money. FAM 2 stated that was when Resident 45 told her that his money in the amount of $1500 was missing. FAM 2 stated, she reported that Resident 45 was missing money on 12/10/2023 to the facility. During an interview on 12/20/2023 at 11:36 AM, the ADM stated, the ADM stated, the ADMD (assigned to do the investigation) did not thoroughly investigate Resident 45's alleged missing money because the ADMD only interviewed Resident 45 and FAM 2 on 12/11/23. The ADM stated, Resident 45's allegation of missing money should have been thoroughly investigated by the ADMD per facility policy and procedure. The ADM stated, It was a human error. During a concurrent interview and record review on 12/20/2023, at 11:40 AM, with ADMD, Resident 45s electronic medical records (EMR) was reviewed from 11/10/2023 to 12/20/23, the ADMD stated there were no interdisciplinary team (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of the residents) notes, nurses notes, social service notes, care plans documented to indicate the allegation of Resident 45's missing money was thoroughly investigated. The ADMD stated, he only interviewed Resident 45 and FAM 2 when he investigated the alleged missing money. The ADMD stated, It should have been investigated thoroughly. During a record review of Resident 45's on 12/20/2023, there was documented evidence that the facility and/or nursing staff diligently look for reported lost or stolen items throughout the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 4 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 on 12/11/23 when the resident reported he was missing $1500. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled Theft and Loss Policy and Procedures, (undated), indicated, the social service designee and/or nursing staff will diligently look for reported lost or stolen items throughout the facility. The P&P indicated a report will be filed with the local law enforcement agency within 36 hours when the administrator has reason to believe the patient's stolen property is worth $100 or more. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled Abuse Prevention and Prohibition Program, (undated), indicated, each resident has the right to be free from misappropriation of property. The P&P indicated, facility should promptly and thoroughly investigate reports of resident abuse, mistreatment or criminal acts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 5 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure titled Theft and Loss Policy and Procedures by not reporting to the California Department of Public Health, Ombudsman (state agency that advocates for the residents and the Police Department) within 24 hours, the allegation of misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45) who reported missing $1500.00 to the Administrator (ADM) and Administrator Designee (ADMD) on 12/11/23. As a result of this deficient practice Resident 45 felt sad that he could not give money to his family during the Christmas time. This deficiency could also result in other potential residents to be a subject for theft or loss that could lead to a psychosocial decline and mistrust with the facility staffs. Findings: A review of Resident 45s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), kidney failure (one or both of your kidneys no longer function well on their own), and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 45s History and Physical Examination, dated 11/7/2023, indicated Resident 45 had the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 11/17/2023, indicated Resident 45s cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 45 required partial/moderate assistance (helper does less than half the effort) with eating, required substantial/maximal assist (helper does more than half the effort) wit oral hygiene, dressing, and dependent (helper does all the effort) with toileting, bathing, roll left and right, and sit to lying, lying to sitting on side of bed. A review of facility document titled CONCERN RECORD -Theft/Loss and Grievance Report, dated 12/11/2023, indicated Resident 45 reported he was missing money in the amount of $1500 to ADMD. During a concurrent observation and interview on 12/18/2023 at 9:55 AM with Resident 45 in Resident 45s room, Resident was sitting in his wheelchair frowning (expression of disapproval, displeasure). Resident 45 stated, he reported that his money was missing to the Administrator (ADM) last week, but no one had investigated his claim. Resident 45 stated, he was sad because it was almost Christmas and he wanted to share his money to his family (FAM1). During an interview on 12/18/2023 at 1:31 PM with ADM, stated, she knew about Resident 45s alleged missing money since last week. The ADM stated, she informed the Administrator Designee (ADMD) to investigate Resident 45's allegation of missing money and a grievance report was initiated. The ADM stated, she did not report Resident 45's allegation of missing money to CDPH (California Department of Public Health), the police or any other agency because she was not sure if Resident 45 had the money (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 6 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 or not. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/2023 at 8:49 AM, Resident 45 stated, he gets money from the from his pension plan that directly deposited to his bank. Resident 45 stated, he authorized FAM 2 to withdraw money from his account monthly, and he keeps around $300 a month and put it in his wallet that he keeps in his side table drawer at the facility. Resident 45 stated he reported that he was missing $1500 to ADMD on 12/11/2023. Resident 45 stated, the facility staff did not believe he was missing $1500. Resident 45 stated, I feel terrible, and it is almost Christmas and he wanted to give money to the FAM 1 Residents Affected - Few During an interview on 12/20/2023 at 9:04 AM, FAM 2 stated, it was possible for Resident 45 to have $1500 in his possession, because she gives the resident $500 to $600 a month from Resident 45s bank account. FAM 2 stated, the day after Resident 45 went to the hospital on [DATE], she picked up Resident 45s wallet without money. FAM 2 stated, she and the resident reported that Resident 45 was missing money on 12/10/2023 to the ADM. During an interview on 12/20/2023 at 11:36 AM, the ADM stated, she and the DON, or the ADMD did not document on Resident 45 medical records when the resident reported the incident on 12/11/23 to the ADMD. The ADM stated, the ADMD (assigned to do the investigation) did not thoroughly investigate Resident 45's alleged missing money because the ADMD only interviewed Resident 45 and FAM 2 on 12/11/23. The ADM stated, she reported the alleged missing money to CDPH on 12/18/23 (day survey team arrived and informed ADM) and started interviewing staff on 12/19/2023 (eight days after the alleged missing money was reported). The ADM stated, she should have reported Resident 45's allegation of missing money to the three agencies (CDPH, Ombudsman, Police Department) on 12/11/23 and it should have been thoroughly investigated by the ADMD per facility policy and procedure. The ADM stated, It was a human error. During a concurrent interview and record review on 12/20/2023, at 11:40 AM, with ADMD, Resident 45s electronic medical records (EMR) was reviewed from 11/10/2023 to 12/20/23, the ADMD stated there were no interdisciplinary team (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of the residents) notes, nurses notes, social service notes, care plans documented regarding Resident 45's alleged missing money. The ADMD stated, he only interviewed Resident 45 and FAM 2 when he investigated the alleged missing money. During a record review of Resident 45's on 12/20/2023, there was documented evidence that the facility and/or nursing staff diligently look for reported lost or stolen items throughout the facility on 12/11/23 when the resident reported he was missing $1500. During an interview on 12/20/2023 at 1:07 PM, the Director of Nurses (DON) stated, the facility should have reported Resident 45's alleged missing money to the State agency immediately even though the facility initiated the investigation internally. The DON stated, no one documented on Residents 45 medical records about the alleged missing money and there were initially only two interviews regarding the investigation until the survey team mentioned it to the ADM on 12/18/2023. DON stated, the facility did not thoroughly investigate the alleged missing money or reported to the State agency within 24 hours as per facility's policy. A review of the facility's policy and procedure (P&P) titled Theft and Loss Policy and Procedures, (undated), indicated, the social service designee and/or nursing staff will diligently look for reported lost or stolen items throughout the facility. The P&P indicated a report will be filed with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 7 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete local law enforcement agency within 36 hours when the administrator has reason to believe the patient's stolen property is worth $100 or more. A review of the facility's policy and procedure (P&P) titled Abuse Prevention and Prohibition Program, (undated), indicated, each resident has the right to be free from mistreatment , neglect abuse, involuntary seclusion., and misappropriation of property. The P&P indicated, the facility will report allegations of abuse, misappropriation of resident property, or other incident that qualify as a crime, no later than 24 hours after forming the suspicion- if alleged violation (misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the ombudsman. The P&P indicated, the administrator will provide the state survey agency and the ombudsman with a copy of the investigative report within 5 days of the incident. Event ID: Facility ID: 055670 If continuation sheet Page 8 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to ensure the comprehensive Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long-Term Care) data base within the required time frame for two of 14 selected residents (Resident 42 and Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 42 and Resident 62. Findings: 1.A review of Resident 42's admission Record dated 12/20/23 indicated, Resident 42's most recent admission date to the facility was 8/23/19, with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], hypertension (high blood pressure), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear) A review of Resident 42's annual comprehensive MDS indicated October 19, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, the MDS Coordinator stated, Resident 42's annual comprehensive MDS should had been completed and submitted to the CMS data base on 10/19/23. The MDS Coordinator stated completed the review of completion of the MDS on 12/16/23 and submitted on the MDS on 12/19/23 (57 calendar days late). During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Nurse was in charge for updating and transmitting the MDS quarterly and annually, and there should not be any reason why he did not complete and transmit the MDS to the CMS data base timely. The DON stated it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. 2. A review of Resident 62's admission Record dated 12/20/23 indicated, Resident 62's most recent admission date to the facility was 6/13/23, with diagnosis that included hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), and type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood). A review of Resident 62's comprehensive Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) indicated October 22, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident) following a significant change in status. During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator stated, Resident 62's comprehensive MDS should had been completed and submitted to the CMS data base on 10/22/23 due to the resident's signification change in condition of admission to hospice (an end-of-life care) on 10/9/23. The MDS Coordinator stated he completed the comprehensive MDS review on 12/17/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 9 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 and submitted the MDS on 12/19/23 (69 calendar days late). Level of Harm - Minimal harm or potential for actual harm A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated April 2012, indicated for the comprehensive MDS completion date must be no later than 14 calendar day after determination that significant change in resident's status occurred. Residents Affected - Few A review of the facility's policy and procedure titled, Resident Assessment, undated, indicated Assessment including admission, quarterly, annual, significant change will be completed as per RAI instructions/guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 10 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a standardized assessment and screening tool) were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) data base within the required time frame for 5 of 14 sampled residents (Residents 26, 65, 58, 28, 40). Residents Affected - Some This deficient practice had the potential to negatively affect the provision of necessary care and services and care planning to ensure they meet their highest potentials for Residents 26, 65, 58, 28, 40). Findings: 1. A review of Resident 26's admission Record, dated 12/20/23 indicated, Resident 26's was admitted on [DATE], with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 26's quarterly MDS, dated [DATE], as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM the MDS Coordinator stated, Resident 26's quarterly MDS should have been completed and submitted on 11/3/23. MDS Coordinator stated, he had not completed the MDS yet and was already more than 14 calendar late for quarterly MDS completion. 2. A review of Resident 65's admission Record dated 12/20/23 indicated, Resident 65's most recent admission date to the facility was 8/1/23 with diagnosis that included depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 65's quarterly MDS indicated November 10, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 65's quarterly MDS should have been completed and submitted on 11/10/23. The MDS Coordinator explained, he completed and submitted the MDS to the CMS data base on 12/19/23 (which was 39 calendar days past due) for the quarterly MDS completion. 3. A review of Resident 58's admission Record dated 12/20/23 indicated, Resident 58's most recent admission date to the facility was 4/25/23 with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 58's quarterly MDS indicated November 9, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 58's quarterly MDS should have been completed and submitted the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 11 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assessment to the CMS data base on 11/9/23. The MDS Coordinator stated, he had not completed transmitting the MDS assessment in the CMS data base (which was already 40 calendar days late) for quarterly MDS completion. 4. A review of Resident 28's admission Record dated 12/20/23 indicated, Resident 28's most recent admission date to the facility was 3/24/23 with diagnosis that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of Resident 28's quarterly MDS indicated October 18, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 28's quarterly MDS should have been completed and submitted on 10/18/23 (which was 51 calendar days late). The MDS Coordinator stated, the MDS assessment was completed on 12/15/23, and submitted to the CMS data base on 12/19/23 (which was 4 calendar days late). During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Coordinator was in charge for updating and transmitting the MDS quarterly and annually, and there should not be any reason why he did not complete and transmit MDS timely. The DON stated it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated April 2012, indicated for the non-comprehensive quarterly MDS assessment, the MDS completion date must be no later than 14 calendar days following the ARD. A review of the facility's policy and procedure titled, Resident Assessment, undated, indicated Assessment including admission, quarterly, annual, significant change will be completed as per RAI instructions/guidelines. 5. A review of Resident 40's admission Record dated 12/20/23 indicated, Resident 40's most recent admission date to the facility was 5/6/23 with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 40's quarterly MDS indicated November 13, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 40's quarterly MDS should have been completed and submitted to the CMS data base on 11/13/23. MDS Coordinator stated, he did not check if the MDS assessment was completed, and he did not transmit the MDS to the CMS data base on 11/13/23 (which was 36 days calendar late) for quarterly MDS completion. During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Coordinator was in charge for updating and transmitting the MDS quarterly and annually, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 12 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there should no reason why he did not complete and transmit the MDS in the CMS data base timely. The DON stated it was important to complete and transmit the MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated April 2012, indicated for the non-comprehensive quarterly MDS assessment, the MDS completion date must be no later than 14 calendar days following the ARD. A review of the facility's policy and procedure titled, Resident Assessment, undated, indicated Assessment including admission, quarterly, annual, significant change will be completed as per RAI instructions/guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 13 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of 14 sampled residents (Resident 68). Residents Affected - Few This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: During a review of Resident 68's admission Record indicated the facility admitted Resident 68 on 4/15/23 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and end stage renal disease [a condition in which the kidneys (human organ) lose the ability to remove waste and balance fluids. During a review of Resident 68's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/23/23, indicated Resident 68 had severely impaired memory and cognition (ability to think and reasonably). The MDS indicated Resident 68 required setup or clean-up assistance with eating and supervision or touching assistance with personal hygiene, dressing, toilet hygiene, shower/bath self, and chair/bed-to-chair transfer. The MDS indicated the completion date of Resident 68's Quarterly MDS Assessment was 11/6/23. During a record review and interview on 12/19/23 at 11:27 AM with the MDS nurse, the MDS nurse stated he was supposed to transmit (transfer the information to the CMS system) Resident 68's quarterly MDS scheduled on 10/23/23 that was completed on 11/6/23. The MDS Nurse stated he had 14 days to transmit the MDS after it was completed, which was supposed to be transmitted on 11/20/23. The MDS Nurse stated he transmitted the quarterly MDS for Resident 68 on 12/18/23 (28 days late) late because he was busy with other tasks. During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Nurse was in charge for updating and transmitting the MDS quarterly and annually, and there should not be any reason why he did not complete and transmit MDS timely. The DON stated it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. During a review of CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 4/12, indicated quarterly MDS Assessment should be transmitted no later than 14 calendar days from the MDS completion date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 14 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 obtain a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of three sampled residents (Residents 9 and 66). Residents Affected - Few This failure had the potential to result in Resident 9 and Resident 66 not to receive the necessary mental health services which can negatively affect their quality of life. Findings: 1. A review of Resident 9's face sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of dementia (a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities), anxiety disorder (a feeling of unease, such as worry or fear, that can be mild or severe) and psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them, this might involve hallucinations or delusions). A review of Resident 9s History and Physical Examination, dated 5/11/2023, indicated Resident 9 did not have the capacity to understand and make decisions. A review of Resident 9's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 9/24/2023, indicated Resident 9's had severely impaired cognitive status (ability to think remember, and reason). The MDS indicated Resident 9 required supervision (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with bed mobility, transfer, locomotion, eating, required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with personal hygiene, and required extensive assistance(resident involved in activity, staff provide weight bearing support) with dressing and toilet use. A review of Resident 9's letter from Department of Health Care Services (DHCS) - PASRR Section, dated 2/24/2022, indicated, Resident 9 had positive PASRR Level 1 Screening and required a PASRR Level II mental health evaluation. A review of Resident 9's Order Summary Report (OSR), dated 12/1/2023, indicated to give Depakote sprinkles (medication used to treat mood disorder) 125 mg (a unit of mass measurement) 2 capsules by mouth three times a day for uncontrollable mood swings. During a review of Resident 9's care plan (CP) revised 10/26/2023, indicated the resident had Altered behavior patterns related to psychosis and anxiety, indicated Resident 9 had episodes of yelling through the night. During an observation on 12/18/2023 at 11 AM in Resident 9's room, Resident 9 was in bed staring at the ceiling and unable to be interviewed (non-verbal). 2. A review of Resident 66's face sheet indicated the resident was initially admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 15 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE], and readmitted on [DATE] with diagnoses of dementia, anxiety disorder, and psychosis (causes people to perceive or interpret things differently from those around them. it involves hallucinations or delusions). A review of Resident 66's History and Physical Examination, dated 11/29/2023, indicated Resident 66 did not have the capacity to understand and make decisions. A review of Resident 66's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/3/2023, indicated Resident 66's had severely impaired cognitive status. The MDS indicated Resident 66 required substantial/maximal assist (helper does more than half the effort) with eating, and dependent (helper does all the effort) with roll left to right, sit to lying, lying to sitting, sit to stand, chair to bed transfer, toilet transfer, toileting hygiene, oral hygiene, and dressing. A review of the Resident 66's letter from Department of Health Care Services (DHCS) - PASRR Section, dated 9/12/2023, indicated, Resident 66 had positive PASRR Level 1 Screening and required a PASRR Level II mental health evaluation. A review of Resident 66's Order Summary Report (OSR), dated 12/1/2023, indicated to give Divalproex (medication used to treat manic-depressive illness) 250 mg every 8 hours for bipolar disorder, Donepezil ( medication used to treat confusion) 5 mg daily for dementia, Memantine (medication used to slow the neurotoxicity) 10 mg two times a day for dementia, and Risperidone ( medication used for irritability related to psychosis) 0.25 mg two times a day for psychosis. During a review of Resident 66's care plan (CP) revised 10/13/2023, indicated the resident had Major depressive disorder manifested by mood swings causing stress, indicated Resident 66 had episodes of screaming and yelling for no apparent reason despite needs being met. During an observation on 12/18/2023 at 10:30 AM in Resident 66's room, Resident 66 was in bed screaming and mumbling on and off. During an interview on 12/18/2023 at 4:22 PM, RN 1 stated, the facility does not have a system in place to log or follow up those residents who needed a Level 2 PASRR. RN 1 stated, PASRR level 2 evaluation is important for the residents' mental health. During an interview on 12/19/2023 at 11:08 AM, the DON stated, the facility just started a log the previous day (12/18/2023) to have a system to follow up the residents who required a Level 2 PASRR. The DON stated but the facility did not have one prior. DON stated, PASRR 2 evaluation is important for the resident's mental health. A review of the facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASSR), release date 7/1/2023, indicated the following information: Purpose: to ensure each resident with serious mental illness (SMI) and/or intellectual/development disability/related conditions (ID/DD/RC) will have the appropriate setting as well as if any specialized services and/or rehabilitative services would be needed . If the DHCS/DDS contractor deems a Level II evaluation is necessary, the facility will assist the DHCS contractor with additional information, face-to-face visit for further evaluation as needed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 16 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 The facility designated staff will follow up on the DHCS/DDS contractor Level II determination/recommendation and document and maintain the records . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 17 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services to one of one sampled resident (Resident 27) by ensuring the resident was assisted immediately when calling for help to change a soaking wet brief from urine incontinence (no control) and to ensure the call light was within reach to be used by the resident who needed assistance with ADL (Activities of Daily Living) as indicated in the residents plan of care and facility's policy and procedures. Residents Affected - Few This failure resulted in Resident 27's developing skin damaged from prolonged sitting on a wet incontinent brief and a high risk for resident to fall and sustain injuries when unable to use a call light for assistance. Findings: A review of Resident 27's admission Record, dated 12/19/23, the record indicated, Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized weakness, gastrostomy (a surgical procedure in which a tube is inserted in the stomach used to deliver fluids and medications), dementia (a progressive brain disorder that results in a decline in memory, change in thought process and ability to reason). A review of Resident 27's History and Physical, dated 9/22/23, the record indicated, Resident 27 did not have the capacity to understand and make decisions. A review of Resident 27's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/13/23, the MDS indicated, Resident 27 was severely impaired with cognitive (ability to think and reason) patterns for daily decision making and required subtaintial to maximal assistance (helper does more than [NAME] of the effort, helper lifts or holds trunk or limbs and provides more than half the effort) in activity of daily livings such as toileting hygiene, and personal hygiene. The record also indicated, Resident 27 was always incontinent (no control) for urination and bowel movement and at risk of developing pressure ulcers (a skin damage resulting from prolonged unrelieved pressure and skin friction). A review of Resident 27's care plan, dated 10/2/23, the record indicated, Resident 27 had alteration in elimination patterns related to bowel always incontinent and unable to identify urgency to void with cognitive and ADL. The interventions included: monitor for bowel incontinence, monitor for incontinent episodes, change brief promptly when soiled/soaked, keep clean, dry and odor free, keep call light within reach and encourage to use for assistance. During an observation on 12/18/23 at 12:20 p.m., in Resident 27's room, Resident 27 was observed sitting on a wheelchair with her back facing her bed. The wheelchair was observed on the left side toward the end of the bed. Resident 27 was observed calling Please help me! multiple times. During an interview on 12/18/23 at 12:25 p.m., with Resident 27, Resident 27 stated, she usually used the call light to get help from being wet but could not find the call light anywhere close to her wheelchair at this time. During an observation on 12/18/23 from 12:30 p.m. to 12:45 p.m., in the hallway just outside of Resident 27's room, six staff's members were observed walking by when Resident 27 was calling Help! (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 18 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Please help me! multiple times and the staffs did not stop to by the resident's room to assist and/or ask what the resident needed help on. During a concurrent observation and interview on 12/18/23 at 12:45 p.m. with Certified Nurse Assistant (CNA) 2 in Resident 27's room, Resident 27 was observed anxious, and irritated. A call light was observed laying on the floor on the other side of Resident 27's bed that the resident could not reach. Resident 27 stated, she was wet and needed help to be cleaned up. CNA 2 stated, the call light should not be on the floor and the resident should not be on the wheelchair far away from the bed because it could cause harm to the resident's safety. CNA 2 also added, they were busy passing out the lunch trays at this hour, so she was not aware that Resident 27 was wet and needed help. During a concurrent observation and interview on 12/18/23 at 12:50 p.m. with CNA 2, CNA 2 was assisting Resident 27's with incontinent brief, the brief was observed soaked with urine Resident 27's perineal skin area (groin area) was red. CNA 2 stated, Resident 27 probably had been sitting on it for a while. During an interview on 12/21/23 at 3:57 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, CNAs are supposed to check incontinent residents at least every two hours and the call light must always be kept within a resident' reach because if not, the staff would not be able to attend to the resident's needs timely and accidents or falls. During an interview on 12/21/23 at 4 p.m. with Registered Nurse Supervisor (RNS), RNS stated, incontinent residents are at high risk for skin break down, rashes, and moisture associated skin problem due to sitting on the wet diaper for too long. RNS stated, all staffs are responsible to help the resident when the resident verbally calling for help and the call light should always be placed close to the resident at all times. A review of the facility's protocol and procedure (P&P) titled, Certified Nursing Assistant Job Description, dated 8/18/11, indicated, CNAs must leave the resident room with call light accessible and maintain incontinent residents clean, dry, free of odor. A review of the facility's P&P titled, Incontinent Care, undated, indicated, incontinent care is given to keep incontinent residents clean, dry and free of odor, and to prevent skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 19 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion (limited ROM-joint that has a reduction in its ability to move) to receive Restorative Nursing Assistant (RNA) assisted active range of motion (AAROM) exercises followed by application and removal of left elbow splint (a plastic device used to immobilize elbow to support healing and to prevent further damage) to increase, prevent, or maintain the ROM mobility as ordered by the physician's for one of two residents (Resident 15). Residents 15 did not receive RNA assisted exercises on 12/18/23, left elbow splint application and removal with wear time of at least four hours a day on 12/12/23, 12/13/23, 12/15/23, 12/19/23 was not placed. As a result of these deficient practices Resident 15 verbalized being upset and angry and concerned of further risk for increasing left arm contractures (a condition that results in muscles, tendons, joints, or other tissues to tighten or shorten causing a deformity, pain and permanent loss of movement in the joint). Findings: A review of Resident 15's admission Record, dated 12/19/23, the record indicated, Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (or a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes (disease that occurs when blood sugar is too high), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), hypertension (high blood sugar), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 15's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/11/23, the MDS indicated, Resident 15 was cognitively intact, able to express ideas/wants and understand others. The MDS also indicated, Resident 15 had impairment on upper extremity, dependent (helper does all of the effort) in eating, needs partial or moderate assistance (helper does less than half the effort) in oral hygiene, upper body dressing, and personal hygiene. A review of Resident 15's History and Physical, dated 4/28/23, the record indicated, Resident 15 had the capacity to understand and make decisions. A review of Resident 15's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 9/14/23, indicated, Resident 15 had a new onset of decrease in strength with impaired left upper extremity range of motion and shoulder joint, and was referred to OT for recommendations to increase bilateral upper extremities strength. The record also indicated, Resident 15 had left elbow flexion stiffness with risk of developing left flexion contracture. A review of Resident 15's Order Summary Report, dated 12/19/23, the record indicated, the physician ordered Resident 15 to receive RNA assisted bilateral (both sides) upper extremities AAROM exercises daily for five days a week followed by application and removal of left elbow splint with wear time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 20 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 of at least four hours a day. Level of Harm - Minimal harm or potential for actual harm A review of Resident 15's Care Plan, dated 12/19/23, the record indicated, Resident 15 had limitation in range of motion and contractures related to fracture with the goal was to minimize decreased mobility or contracture complications. The interventions included for the RNA to assist resident daily with bilateral upper extremities five days a week followed by application and removal of left elbow splint with wear time of at least four hours a day. Residents Affected - Few During a concurrent observation and interview on 12/18/23 at 9:12 a.m. with Resident 15, Resident 15 was observed with left arm contracture without a splint on the left elbow. Resident 15 stated he had a splint on his left arm, which helped prevent his arm contracted, but his splint had been missing which made him very upset and angry. During an interview on 12/18/23 at 2 p.m. with Resident 15, Resident 15 stated his splint had been missing all week last week, which caused his left arm to be more irritated, and contracted. During a concurrent observation and interview on 12/19/23 at 12:32 a.m. with RNA 1 in Resident 15's room, Resident 15 was observed with contracted left arm and without a splint on the left elbow. The RNA 1 stated, the splint should be next to Resident 15's bed but she could not find the splint anywhere in Resident 15's room. During a concurrent interview and record review on 12/19/23 at 12:37 p.m. with Director of Rehabilitation (DOR), Resident 15's Occupational Therapy Discharge Summary, dated 10/10/23, was reviewed. The DOR stated, Resident 15 was discharged from OT with recommendation for RNA to assist the resident on upper extremities bilateral AAROM exercises and left elbow splint application for contracture prevention and management. The DOR also stated, it was important to have the splint on Resident 15's left elbow as ordered to prevent further contracture, joint pain, muscle pain and further decrease in range of motion. A review of Resident 15's Documentation Survey Report, dated 12/19/23, indicated, no RNA exercise and application of splint on 12/18/23 was provided. During a concurrent interview and record review on 12/20/23 at 6:54 a.m. with RNA 2, Resident 15's Documentation Survey Report, dated 12/19/23, was reviewed. RNA 2 stated, he did not provide splint application on 12/12/23, 12/13/23, 12/15/23, 12/19/23. RNA 2 stated, he documented on those dates but overlooked the order, he provided RNA exercises to Resident 15's bilateral upper extremities but did not apply the left elbow splint to the resident. A review of the facility's policy and procedure (P&P) titled, Job Description, dated 1/27/22, the P&P indicated, RNAs are responsible to monitors placement of restorative devices/equipment to ensure proper utilization, assist with cones/splints/contracture care and provide residents with routine restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. A review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program, no dated, the P&P indicated, The Restorative Nursing Program is to include residents with limited mobility due to physical impairments, musculature deterioration, contractures and other physical and cognitive limitations. Each resident shall be given care to prevent formation of decubiti, contracture, deformities, and decline in functional activities. Such care shall include using adaptive equipment to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 21 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 enhance functional independence in ADLs. Restorative services nursing staff shall follow the directions of the physical therapist as noted in Care Plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 22 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide a hazard free environment by ensuring one of one sampled resident (Resident 47) who smokes did not possess a pack of cigarettes and a lighter in his pocket while in the facility as indicated in the resident's plan of care. This deficient practice had the potential to result in an accidental fire in the facility and can lead to injury to the residents. Findings: During a review of Resident 47's admission Record indicated the facility initially admitted Resident 47 on 9/7/22 and readmitted him on 10/4/22 with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and suicidal ideations (thinking or planning to kill or hurt himself) During a review of Resident 47's Interdisciplinary Team (IDT- a team of staffs from different disciplines that develops the plan of care for the residents) Education Regarding Smoking Policy and Need for Supervision, dated 4/25/23, indicated the possibility of limiting the accessibility of matches and lighters was discussed with Resident 47. During a review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/15/23, indicated Resident 47 had intact memory and cognition (ability to think and reasonably). During a review of Resident 47's Smoker Risk Assessment, dated 3/15/23, indicated Resident 47 required supervision while smoking. During a review of Resident 47's Care Plan, dated 10/5/23, indicated Resident 47 needed supervision while smoking and will have no access to matches and lighters. During an observation on 12/19/23 at 8:40 AM, in the designated smoking area, Resident 47 was sitting on a wheelchair and wearing the safety apron. The Activity Aid (AA) was standing at his left side. Resident 47 took out a pack of cigarettes and a lighter from the pocket of his jacket. Resident 47 lighted a cigarette with the lighter to smoke, then, he put the pack of cigarettes and the lighter back to his jacket pocket. During an interview on 12/19/23 at 8:41 AM with Resident 47, Resident 47 stated he keeps his own cigarettes and lighter in his jacket clothes. During an interview on 12/19/23 at 8:45 AM with the AA, the AA stated Resident 47 was alert and it was fine to let him keep his own lighter and cigarettes in his possession. During an interview on 12/19/23 at 10:15 AM with the Director of Activity (DA), the DA stated they were aware of Resident 47 having a lighter in his possession. The DA stated it was dangerous that Resident 47 had access to a lighter and cigarettes. The DA stated the staff tried to remove lighters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 23 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from him in the past, but when the family came to visit, and they would give him a new lighter. The DA stated they had not told the family to stop giving Resident 47 lighters. The DA stated they should tell the family not to give a lighter to Resident 47. The DA stated Resident 47 should not have a lighter in his possession to prevent an accidental fire and ensure safety for all residents in the facility. During an interview on 12/19/23 at 12 PM with Resident 47, Resident 47 stated the staff did not take away his lighter before and they did not tell his family members that he should not have a lighter or cigarettes in his possession. During a review of the undated facility's policy and procedure (P&P) titled, Smoking indicated the facility recognized the resident's right to smoke and ensure the safety. The P&P indicated the Care Plan would be completed related to smoking, based on Smoking Assessment and IDT. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 24 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 55), received the Jevity 1.5 (feeding formula) as ordered by the physician, and was not administered Glucerna 1.5 (a feeding formula). This failure had a potential to result in Resident 55's unplanned weight loss/weight gain and/or an allergic reaction to the formula. Findings: A review of Resident 55's admission Record, dated 12/19/23, the record indicated, Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), cerebral infarction (or a stroke, occurs as a result of disrupted blood flow to the brain due to narrowing of the blood vessels, blood clot and bleeding), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, which may cause memory loss, trouble thinking, and trouble with daily activities). A review of Resident 55's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/15/23, the MDS indicated, Resident 55 severely impaired with cognitive patterns for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in activity of daily livings. A review of Resident 55's Order Summary Report, dated 12/19/23, the record indicated, Resident 55 had an active doctor's order for Jevity1.5 (a type of tube feeding formula) to run at 70 cc (centimeter-a unit of measurement) per hour for 20 hours via pump (machine used to regulate the amount of the feeding formula to be delivered to the resident) daily since 11/15/23. A review of Resident 55's Nutrition/Dietary Note, dated 11/14/23, the record indicated, the Registered Dietician (person in charge of the nutritional need of the residents) recommendation Resident 54 to receive Jevity 1.5 to run at 70 cc per hour for 20 hours to provide 2100 kcal per day due to weight loss trend. A review of Resident 55's Care Plan, dated 8/14/23, the record indicated, Resident 55 had a G-tube feeding related to dysphagia (swallowing difficulties), with the goal to maintain adequate nutrition and hydration for weight and height daily, and the interventions included to administer enteral feeding as ordered by the physician. A review of Resident 55's Care Plan, dated 11/15/23, the record indicated, Resident 55 had alteration in nutritional status, and at risk for malnutrition due to G-tube feeding, with the goals to minimize any unplanned weight changes and reduce the risk of dehydration (a condition of having fluid deficit in the body) daily by providing diet as ordered. During a concurrent observation and interview on 12/19/23 at 9:21 a.m. with Licensed Vocational Nurse (LVN) 1 and LVN 4 in Resident 55's room, Resident 55's G-tube feeding was pump was set and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 25 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few delivering with Glucerna 1.5 (a type of tube feeding formula) and not Jevity 1.5 as ordered by the physician for the resident. LVN 1 stated, this is a wrong tube feeding formula. LVN 4 stated, the night shift LVN took the wrong feeding bottle without checking if it was the correct formula. During a concurrent interview and record review on 12/21/23 at 2:30 p.m. with Registered Nurse (RN), the facility's tube feeding guideline titled, Tube Feeding Formulas Cross References or Equivalent, undated, was reviewed. The guideline indicated, Glucerna 1.5 cannot be used to substitute for Jevity 1.5. The RN stated, if the wrong tube feeding was used, there could be a potential harm to the residents for weight loss and allergic reaction. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding Monitoring, undated, the P&P indicated, the facility will ensure that the total enteral feeding prescribed is administered as ordered. Licensed nurse will check physician's order for formula type, rate, hours and total cc's that are to be delivered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 26 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure the Minimal Date Set (MDS- a comprehensive standardized assessment and screening tool) (MDS) Coordinator had necessary skill sets and competency to complete and transmit to CMS (Centers for Medicare and Medical Services) data base the MDS assessments for all the facility residents in accordance with the facility's policy and procedure. This failure had a potential to result in inaccurate MDS assessment, documentation, late or missed completion and submission of MDS assessment to the CMS data base, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: During an interview on 12/19/23 at 3:18 PM with the MDS Coordinator, MDS coordinator stated, he did not have certification for MDS and admitted he did not have any proof that he attended the MDS trainings for completion and transmission of the MDS assessments. During an interview on 12/20/23 at 10:32 AM, with the Administrator (ADM), the ADM stated, according to the MDS Coordinator job description, the MDS certificate was required to be qualified for the position. If the MDS coordinator did not have an MDS certificate, the facility will make sure to enroll the new hired MDS coordinator in the training program to become certified. The ADM stated, she could not find any certificate in the MDS Nurse's employee file. ADM stated, the Director of Staff Development (DSD) was the one to make sure the employee's qualifications were verified and will keep the record in the file. The ADM stated, the previous DSD was no longer with the facility, and so the MDS coordinator was not followed up for competency to ensure the MDS Coordinator received certification or trainings. The ADM stated, it was important to follow up on the competencies to make sure the MDS Coordinator had the knowledge to complete and transmit the MDS assessment to the CMS data base and to be competent in the job. During an interview on 12/10/23 at 11:28 AM with the Director of Nursing (DON), the DON stated, it was important to have competent MDS Coordinator because the MDS assessment information was used to develop the residents' plan of care by the IDT (Interdisciplinary Team- team of facility staffs from different disciplines that assesses and develops the plan of care for the residents). The MDS Nurse needed to have the required knowledge to be responsible for timely completing and submitting the quarterly, annually and after a significant change in resident's status MDS. A review of the facility's MDS Coordinator job description, dated 8/23/11, indicated that certificates, licenses, and registrations are required for the facility's MDS Coordinator including the MDS Coordinator in-house facility certificate. A review of the facility's MDS Coordinator job description, dated 8/23/11, indicated MDS Nurse's responsibilities included the completion of MDS for all residents according to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) guidelines. MDS Nurse is also responsible to timely complete and audit all MDS, CAAs and Care Plan to accurately reflect resident's condition, update care plans as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 27 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure titled Resident Assessment, undated, indicated, the comprehensive assessment shall be used to develop a comprehensive care plan to allow the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI User's Manual Version 3.0, dated April 2012, indicated the comprehensive assessment information is used to identify problem, causes, contributing factors, and risk factors related to the problems. Subsequently, the care team must evaluate the information to develop a care plan that address those findings in the context of the resident's strengths, problems, and needs. Event ID: Facility ID: 055670 If continuation sheet Page 28 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to failure of the licensed staffs to follow the facility's policy and procedure on medication administration for three of four selected residents (Residents 26, 13 and 28) during medication administration observation. Residents Affected - Some These deficient practices resulted in four (4) medication errors out of twenty-seven opportunities (medications observed administered or attempted to administer) which resulted in a medication administration error rate of fifteen percent (15%), that exceeded the five (5) percent threshold. Cross reference to F760 Findings: During an observation of the medication pass, on 12/20/23, there were three medication errors, which included: 1. A review of Resident 26's admission Record, dated 12/19/23, the record indicated, Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach used to deliver medication and food in fluid form), and dysphagia (difficult swallowing) A review of Resident 26's Order Summary Report, dated 12/21/23, indicated, Resident 26 had a physician's order for Morphine Sulfate (MS, a pain control medication) solution to give via G-tube route started on 11/8/23. During an observation on 12/20/23 at 9 a.m., Licensed Vocational Nurse (LVN) 1 attempted to administer Morphine Sulfate (MS-a medication used to relieve sever pain) solution via mouth instead of via the gastrostomy tube (G-tube, a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) as ordered by the physician. 2. A review of Resident 13's admission Record, dated 12/21/23, indicated, Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, atrial fibrillation (a-fib, an irregular and often very rapid heart rhythm), hypertension (high blood pressure), and hyperlipidemia (an abnormally high concentration of fat particles in the blood). A review of Resident 28's admission Record, dated 12/21/23, indicated, Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dysphagia (difficult swallowing), dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities), and gastronomy with a GT. A review of Resident 28's Order Summary Report, dated 12/1/23, indicated, Resident 28 had physician's orders for Vitamin C tablet 500 mg to give one tablet by month one time a day for supplement and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 29 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Zinc Sulfate Capsule 220 mg to give one capsule by mouth one time a day for wound healing. Level of Harm - Minimal harm or potential for actual harm During an observation on 12/21/23 at 8:55 a.m. in Resident 28's room, Licensed Vocational Nurse (LVN) 3 was observed crushing Vitamin C tablet and Zinc Sulfate Capsule and administered both medications via GT route, not by mouth as ordered by the physician. Residents Affected - Some On 12/20/24 at 9:39 a.m., Resident 13 the LVN 2 failed to check the resident's apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) before administering Digoxin (a heart medication used to decreased heart rate) as ordered by the physician. 3. A review of Resident 28's admission Record, dated 12/21/23, indicated, Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dysphagia (difficult swallowing), dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities), and gastronomy with a GT. A review of Resident 28's Order Summary Report, dated 12/1/23, indicated, Resident 28 had physician's orders for Vitamin C tablet 500 mg to give one tablet by month one time a day for supplement and Zinc Sulfate Capsule 220 mg to give one capsule by mouth one time a day for wound healing. During an observation on 12/21/23 at 8:55 a.m. in Resident 28's room, Licensed Vocational Nurse (LVN) 3 was observed crushing Vitamin C tablet and Zinc Sulfate Capsule and administered both medications via GT route, not by mouth as ordered by the physician. For Resident 28, the licensed nurse did not verify the physician's orders for Vitamin C tablet (vitamin supplement) and Zinc Sulfate (mineral supplement used for wound healing) capsule by mouth to Resident 28, who had difficulty swallowing. A review of facility's policy and procedure titled, Administering Medications, dated March 2023, indicated Medications are administered in accordance with prescriber orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 30 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. 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 its residents were free from significant medication error as indicated in the facility's policy and procedure related to medication administration by failing to: Residents Affected - Some 1. For Resident 26, the licensed nurse attempted to administer Morphine Sulfate (MS-a medication used to relieve sever pain) solution via mouth instead of via the gastrostomy tube (G-tube, a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) as ordered by the physician. 2. For Resident 13, the licensed nurse failed to check the resident's apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) before administering Digoxin (a heart medication) as ordered by the physician. 3. For Resident 28, the licensed nurse did not verify the physician's orders for Vitamin C tablet (vitamin supplement) and Zinc Sulfate (mineral supplement used for wound healing) capsule by mouth to Resident 28, who had difficulty swallowing. These deficiency practices had the potential to put the facility's residents at risk for significant medication errors, aspiration (choking) and/or result in adverse reaction (undesired effect) to medications and lead to complications and/or death. Findings: 1. A review of Resident 26's admission Record, dated 12/19/23, the record indicated, Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach used to deliver medication and food in fluid form), and dysphagia (difficult swallowing). A review of Resident 26's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/15/23, the MDS indicated, Resident 26 had severely impaired cognitive (ability to think, reason and remember) patterns for daily decision making, and was dependent (helper does all the effort, resident does none of the effort to complete the activity) in all activities of daily living. A review of Resident 26's Order Summary Report, dated 12/21/23, indicated, Resident 26 had a physician's order for Morphine Sulfate (MS, a pain control medication) solution to give via G-tube route started on 11/8/23. During a concurrent observation and interview on 12/20/23 at 9 a.m. in Resident 26's room, Licensed Vocational Nurse (LVN) 1 was observed preparing to give 0.25 ml (milliliter, a measure unit) MS solution in a syringe and attempted to administer to Resident 26 by mouth. Resident 26 observed moving her head from side to side to avoid the syringe. LVN 1 stated, she did not check the physician's order to check what route the MS was ordered to be administered. LVN 1 stated, she tried to give sublingually (under the tongue) because it was how Morphine Sulfate solution was usually ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 31 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/20/23 at 11:45 a.m., with the Director of Nursing (DON), the DON stated, it was important for all LVNs to administer the prescribed medications via the right route as ordered by the physician because if a resident had trouble swallowing and the medications were administered by mouth, there would be a high risk for the resident to aspirate (choke). 2. A review of Resident 13's admission Record, dated 12/21/23, indicated, Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, atrial fibrillation (Afib, an irregular and often very rapid heart rhythm), hypertension (high blood pressure), and hyperlipidemia (an abnormally high concentration of fat particles in the blood). A review of Resident 13's History and Physical, dated 5/19/23, the record indicated, Resident 13 had the capacity to understand and make decisions. A review of Resident 13's MDS, dated [DATE], the MDS indicated, Resident 13 needed partial to moderate assistance (helper does less than half the effort. Helper lifts holds, or supports trunk or limbs, but provides less than half the effort) in oral hygiene, upper body dressing, and personal hygiene. A review of Resident 13's Order Summary Report, dated 12/1/23, indicated, Resident 13 had a physician's order for Digoxin oral (given by mouth) tablet 125 mcg (microgram, a weight measure unit) to give one tablet one time a day for Afib and to hold if apical pulse below was 60 beats per minute. During an observation on 12/20/23 at 9:39 a.m. in Resident 13's room, LVN 2 was observed checking the blood pressure manually for Resident 13 without checking for the resident's pulse before administering Digoxin. During an interview on 12/20/23 at 9:50 a.m. with LVN 2, LVN 2 stated she briefly checked the Resident 13's pulse in the wrist area (radial pulse), which was not the apical pulse. LVN 2 stated, she forgot that the apical pulse should be checked in the chest area. During an interview on 12/20/23 at 10:05 a.m. with Registered Nurse Supervisor (RNS), RNS stated, apical pulse was different than the pulse on the wrist pulse, it was very important to follow the physician order to make sure the apical pulse was within the acceptable range before administering Digoxin because the medication could drop the heart rate and cause harm to the resident. During an interview on 12/20/23 at 11:45 a.m. with the DON, the DON stated Digoxin could drop the heart rate to a dangerous range that could lead to dead. 3. A review of Resident 28's admission Record, dated 12/21/23, indicated, Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dysphagia (difficult swallowing), dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities), and gastronomy with a GT. A review of Resident 28's History and Physical, dated 3/27/23, the record indicated, Resident 28 did not have the capacity to understand and make decisions. A review of Resident 28's MDS, dated [DATE], indicated, Resident 28 was dependent (helper dose all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 32 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) in oral hygiene, toileting, shower and personal hygiene. A review of Resident 28's Order Summary Report, dated 12/1/23, indicated, Resident 28 had physician's orders for Vitamin C tablet 500 mg to give one tablet by month one time a day for supplement and Zinc Sulfate Capsule 220 mg to give one capsule by mouth one time a day for wound healing. During an observation on 12/21/23 at 8:55 a.m. in Resident 28's room, Licensed Vocational Nurse (LVN) 3 was observed crushing Vitamin C tablet and Zinc Sulfate Capsule and administered both medications via GT route, not by mouth as ordered by the physician. During an interview on 12/21/23 at 9:25 a.m. with Minimum Date Set (MDS) Coordinator, the MDS Coordinator stated, LVNs were responsible to review the physician's orders before preparing and administering them to the residents. If there were any orders that the LVN suspected to be incorrect, or not a usual route, the LVN should clarify with the physician right away and reorder if needed before continuing their medication administration. During an interview on 12/21/23 at 10 a.m., LVN 2 stated she did not see that the physician's orders for Vitamin C and Zinc was to be given via oral and not via GT. LVN 2 stated, all licensed nurses were responsible to review the orders and clarify if the orders were for the wrong route. A review of facility's policy and procedure (P&P) titled, Administering Medications, dated March 2023, indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. A review of facility's P&P titled, Physician Orders and Telephone Orders, dated 1/04, indicated, the new month's orders are to be compared with the previous month's orders, a qualified person, preferable by a licensed nurse, shall review all orders for accuracy, completeness, and clarity, and include signature and date the computer orders to indicate that these have been reviewed, corrected, and are accurate. A review of facility's P&P titled, LVN Job Description, dated 8/23/11, indicated LVNs are responsible to prepare and pass medications as indicated, administer medication following regulatory guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 33 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 54) who was assessed by the facility as allergic to fish, was not served fish with the meal as indicated in Resident 54's plan of care and the facility's policy and procedure. This deficient practice had the potential to result in Resident 54 to experience an allergic reaction and anaphylactic shock (a severe, potentially life-threatening allergic reaction that can develop rapidly) which could lead to death. Findings: During a review of Resident 54's admission Record indicated the facility initially admitted Resident 54 on 1/19/23 and readmitted him on 11/10/23 with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 54's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/15/23, indicated Resident 54 had severely impaired memory and cognitive (ability to think and reasonably) impairment. The MDS indicated Resident 54 required partial/moderate assistance with eating and dependent with toileting hygiene and shower/bath self. During a review of Resident 54's Care Plan, dated 2/2/23, indicated Resident 54 was allergic to fish and would not receive any food that contains allergen daily. During a review of Resident 54's Order Summary Report, dated 11/10/23, indicated Resident 54 diet order indicated the resident was not to be served fish due to an allergy. During a review of Resident 54's History and Physical (H&P), dated 11/13/23, indicated Resident 54 did not have the capacity to understand and make decisions. During a record review of Resident 54's Tray Ticket, dated 12/18/23, indicated Resident 54 was allergic to fish and nuts. During an observation and concurrent record review of the meal ticket on 12/18/23 at 12:55 PM, in Resident 54's room, Resident 54 was sitting up on her bed eating by herself. A meal tray for lunch was on a bedside tray table in front of her. Resident 54 scooped a piece of fish from the plate and ate it. A review of the tray Ticket, dated 12/18/23, with Resident 54's picture, name, diet order that Resident 54 was allergic to fish. The Surveyor immediately stopped Resident 54 from eating the fish and informed Licensed Vocational Nurse (LVN 4). During a concurrent observation, interview, and record review on 12/18/23 at 12:56 PM, with LVN 4, Resident 54 had a half-eaten piece of fish on the plate with a Tray Ticket that indicated Resident 54 was allergic to fish. LVN 4 stated fish should not be had been served to Resident 54's meal tray. During a concurrent observation, interview and record review on 12/18/23 at 12:58 PM with Registered Nurse (RN), Resident 54 had a half-eaten piece of fish on the plate with a Tray Ticket that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 34 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 54 was allergic to fish. The RN stated Resident 54 could have had an allergic reaction or anaphylactic shock. During an interview on 12/18/23 at 1:25 PM, with Certified Nursing Assistant (CNA) 3. CNA 3 stated she passed the lunch meal tray to Resident 54 today and she did not check Resident 54's Tray Ticket that indicated Resident 54 was allergic to fish and she did not realize there was fish was on Resident 54's plate. CNA 3 stated she should have checked the tray ticket and what was on the plate to make sure resident receive appropriate food to prevent harms. During an interview on 12/19/23 at 12:35 PM, with the Infection Preventionist Nurse (IPN). The IPN stated he checked every resident's meal tray against Tray Card and the weekly menu, and diet report to make sure residents receive food that was consistent with the physician's diet orders, likes and dislikes and allergies, before CNAs passed the meal trays to the residents. The IPN stated he did not know how he missed to check Resident 54's meal tray yesterday and Resident 54 ate fish while the Tray Card indicated allergic to fish. The IPN stated he should have checked more carefully to make sure everything matched with the physician's order and the Tray Ticket to ensure safety to all residents. During an interview on 12/19/23 at 3:32 PM, with Dietary [NAME] (DC). The DC stated yesterday at lunch (12/18/23) she was responsible in reading the tray cards to the cook, receiving the plates with food from the cook, and placing the plates to the resident's meal trays containing resident's Tray Card. The DC stated she was aware of Resident 54 was allergic to fish and she misplaced the wrong plate which had fish on Resident 54's meal tray because she was so busy. The DC stated she should double check the plate and the tray card to prevent harms to Resident 54. During a review of the facility's policy and procedure titled, Menu, dated 2019, indicated the Dietary Services Supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed. During a review of the facility's policy and procedure titled, Diet Order, dated 2019, indicated The resident's name, diet order, food likes and dislikes, allergies will be noted on the resident's Profile Card and tray card for staff reference. During a review of the facility's policy and procedure titled, Job Description for Dietary Cook, dated 10/12/11, indicated dietary cook's essential duties and responsibilities included Reads orders on color coded cards or posted board to assure residents' dietary orders and restrictions are followed. During a review of the facility's policy and procedure titled, Job Description for Certified Nursing Assistant, dated 8/23/11, indicated CNA's essential duties and responsibilities included to assist residents with tray pass and appropriate diet as indicated/ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 35 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on observation interview and record review the facility failed to follow professional standards for food service safety, in accordance with the facility's policy and procedure on Refrigerator / Freezer Storage, by failing to: 1. Label and date 31 covered glasses of milk in the refrigerator. 2. Label and date an open bag of hashbrown in the freezer. 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. Findings: During an initial kitchen observation conducted with the Dietary Service Supervisor (DSS) on 12/18/2023 at 8:30 AM, the facility's refrigerator had 31 covered glasses of milk without a label or date. In a concurrent interview, the DSS stated, the glasses of milk should be dated to ensure it is used first and the milk is still fresh, not spoiled for the residents to consume. The DSS stated, spoiled milk can harbor bacteria and cause foodborne illnesses. During a concurrent observation and interview on 12/18/2023 at 8:35 AM, with the DSS, the refrigerator had five pieces of hashbrown in an open bag without a label or date. The DSS stated, the bag of hashbrown should have been dated to ensure that it is used first and not too old for residents' consumption. The DSS stated, an old bag of hashbrown may have bacteria buildup and cause foodborne illnesses. During a review of the facility's policy and procedure titled, Refrigerator / Freezer Storage, revised 2019, indicated left over food or unused portion of packaged food should be covered, dated, and labeled to ensure the will be used first. A review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. The Food Code 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 36 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 did not dispose garbage and refuse properly by not covering two of two metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing garbage bags, leaving 10 trash bags on the ground next to the dumpster, while waiting for trash to be picked up by the garbage truck. Residents Affected - Some This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 70 of 70 facility residents and affect including staff and visitors. Findings: During an observation of the dumpster area outside of the facility side entrance on 12/18/2023 at 8 AM, two out of two metal dumpsters were not covered due to overflowing trash bags leaving 10 trash bags on the ground next to the dumpster. During a concurrent observation of the dumpster area outside the facility side entrance and interview with Dietary Service Supervisor (DSS) dated 12/18/2023 at 8:40 AM, the DSS stated that the two-metal dumpsters were overflowing with trash bags and 10 trash bags were found on the ground. The DSS stated, everyone in the facility uses the metal dumpster for trash. The DSS stated, overflowing dumpster could attract pest and be a source of infection. During a concurrent observation of the dumpster area outside the facility side entrance and interview with the Housekeeping Supervisor (HKSS) on 12/18/2023 at 8:50 AM. The HKS stated the two-metal dumpster were overflowing with trash bags. The HKS stated, the two-metal dumpster should not be left open with overflowing trash bags, and the trash bags should not be left on the ground because it could attract animals and pest. During an interview on 12/18/2023 at 9 AM with the Administrator (ADM), the ADM stated the two-garbage bins outside the facility should be kept always closed. The ADM stated, if the two-garbage bins are full, she should have been called so she could have called the garbage company for immediate pick up. The ADM stated, leaving the two-garbage bins open due to overflowing trash bags could not only attract animals and pest, but it could also be a source of infection that could affect the residents and staff of the facility. A review of the facility's policies and procedures (P&P) titled Waste Control and Disposal, revised 2019, indicated, outside garbage bin should be kept closed at all times and surrounding area should be kept clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 37 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility's Quality Assurance Performance Improvement ([QAPI] performed a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to identify facility and resident care issues, develop, and implement appropriate plans of action, in accordance with the facility's policy and procedures on Continuous Quality Improvement Program (QAPI), by failing to: Residents Affected - Few 1a. Ensure the QAPI committee identified and developed measures to ensure the Minimum Data Set-a resident assessment and care planning tool (MDS) were completed and transmitted timely to the CMS data System timely by the MDS Coordinator after reviewed by the DON for eight of eight residents (Residents 42, 62, 26, 65, 58, 28, 40 and 41). 1b. Ensure the QAPI committee evaluated that competency of the MDS coordinator to ensure timely completion and submission of the MDS assessments to the Center for Medicaid and Medicare System (CMS). These deficient practices had resulted in incomplete and/or late MDS transmission to the CMS data system that affects the care planning and quality of care and quality of life of the residents. 2. Ensure the QAPI committee systematically implemented and evaluated measures related to water safety in the facility by testing the water for Legionella (a bacteria that can cause serious type of pneumonia ([lung infection] that is contracted by breathing in small droplets of water or accidently swallow water containing Legionella into the lungs). This deficient practice could result in widespread infection of the Legionella in the facility that affects the lives of the residents, visitors and staffs. Cross reference to F636, F638 And F640. Findings: 1a. A review of Resident 42's admission Record dated 12/20/23 indicated, Resident 42's most recent admission date to the facility was 8/23/19, with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], hypertension (high blood pressure), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear) A review of Resident 42's annual comprehensive MDS indicated October 19, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, the MDS Coordinator stated, Resident 42's annual comprehensive MDS should had been completed and submitted to the CMS data base on 10/19/23. The MDS Coordinator stated completed the review of completion of the MDS on 12/16/23 and submitted on the MDS on 12/19/23 (57 calendar days late). During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Nurse was in charge for updating and transmitting the MDS quarterly and annually, and there should not be any reason why he did not complete and transmit the MDS to the CMS data base timely. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 38 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. 1b. A review of Resident 26's admission Record, dated 12/20/23 indicated, Resident 26's was admitted on [DATE], with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 26's quarterly MDS, dated [DATE], as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM the MDS Coordinator stated, Resident 26's quarterly MDS should have been completed and submitted on 11/3/23. MDS Coordinator stated, he had not completed the MDS yet and was already more than 14 calendar late for quarterly MDS completion. 1c. A review of Resident 65's admission Record dated 12/20/23 indicated, Resident 65's most recent admission date to the facility was 8/1/23 with diagnosis that included depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 65's quarterly MDS indicated November 10, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 65's quarterly MDS should have been completed and submitted on 11/10/23. The MDS Coordinator explained, he completed and submitted the MDS to the CMS data base on 12/19/23 (which was 39 calendar days past due) for the quarterly MDS completion. 1d. A review of Resident 58's admission Record dated 12/20/23 indicated, Resident 58's most recent admission date to the facility was 4/25/23 with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 58's quarterly MDS indicated November 9, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 58's quarterly MDS should have been completed and submitted the MDS assessment to the CMS data base on 11/9/23. The MDS Coordinator stated, he had not completed transmitting the MDS assessment in the CMS data base (which was already 40 calendar days late) for quarterly MDS completion. 1e. A review of Resident 28's admission Record dated 12/20/23 indicated, Resident 28's most recent admission date to the facility was 3/24/23 with diagnosis that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of Resident 28's quarterly MDS indicated October 18, 2023, as the assessment reference (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 39 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 date (ARD- last day of the observation period that the assessment covers for the resident). Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 28's quarterly MDS should have been completed and submitted on 10/18/23 (which was 51 calendar days late). The MDS Coordinator stated, the MDS assessment was completed on 12/15/23, and submitted to the CMS data base on 12/19/23 (which was 4 calendar days late). Residents Affected - Few During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Coordinator was in charge for updating and transmitting the MDS quarterly and annually, and there should not be any reason why he did not complete and transmit MDS timely. The DON stated it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. 1f. A review of Resident 40's admission Record dated 12/20/23 indicated, Resident 40's most recent admission date to the facility was 5/6/23 with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 40's quarterly MDS indicated November 13, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident). During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator, MDS Coordinator stated, Resident 40's quarterly MDS should have been completed and submitted to the CMS data base on 11/13/23. MDS Coordinator stated, he did not check if the MDS assessment was completed, and he did not transmit the MDS to the CMS data base on 11/13/23 (which was 36 days calendar late) for quarterly MDS completion. During an interview on 12/20/23 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS Coordinator was in charge for updating and transmitting the MDS quarterly and annually, and there should no reason why he did not complete and transmit the MDS in the CMS data base timely. The DON stated it was important to complete and transmit the MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a care plan could be developed based on the residents' status. 1g. A review of Resident 62's admission Record dated 12/20/23 indicated, Resident 62's most recent admission date to the facility was 6/13/23, with diagnosis that included hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), and type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood). A review of Resident 62's comprehensive Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) indicated October 22, 2023, as the assessment reference date (ARD- last day of the observation period that the assessment covers for the resident) following a significant change in status. During a concurrent interview and record review on 12/19/23 at 3:18 PM with MDS Coordinator stated, Resident 62's comprehensive MDS should had been completed and submitted to the CMS data base on 10/22/23 due to the resident's signification change in condition of admission to hospice (an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 40 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few end-of-life care) on 10/9/23. The MDS Coordinator stated he completed the comprehensive MDS review on 12/17/23 and submitted the MDS on 12/19/23 (69 calendar days late). 1h. During a review of Resident 68's admission Record indicated the facility transmission admitted Resident 68 on 4/15/23 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and end stage renal disease [a condition in which the kidneys (human organ) lose the ability to remove waste and balance fluids. During a review of Resident 68's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/23/23, indicated Resident 68 had severely impaired memory and cognitive (ability to think and reasonably) impairment. The MDS indicated Resident 68 required setup or clean-up assistance with eating and supervision or touching assistance with personal hygiene, dressing, toilet hygiene, shower/bath self, and chair/bed-to-chair transfer. The MDS indicated the completion date of Resident 68's Quarterly MDS Assessment was 11/6/23. During a review of MDS Assessment, dated 12/20/23, indicated Resident 68's quarterly Assessment for 10/23/23 was accepted on 12/19/23. During an interview on 12/19/23 at 11:27 AM with the MDS nurse, the MDS nurse stated he transmitted Resident 68's quarterly MDS for 10/23/23 after the recertification survey started on 12/18/23. The MDS nurse stated he transmitted the MDS late and he should transmit it in 11/23. During an interview on 12/20/2 at 11:28 AM with the Director of Nursing (DON), the DON stated the MDS nurse was in charge for updating MDS quarterly and annually and it should not be any reason why he did not complete and transmit MDS timely. The DON stated it was important to complete and transmit MDS timely because the facility could know if the resident had any significant changes or condition to develop the plan of care based on the residents' status. 2. During an interview on 12/21/23 at 10:45 AM with the Maintenance Supervisor (MS), the MS stated he was not aware of the facility conducting water testing for legionella. During a concurrent interview and record review on 12/21/23 at 11:30 AM with the MS, the MS stated they could not find any records of water being tested for legionella in the facility and they did not know for how long the facility had not tested water for legionella. The MS stated if the water was not tested, they would not know if the water had legionella and they were not able to monitor the water safety. The MS stated it was important to test the water for legionella to prevent resident form contracting legionella disease. During an interview on 12/21/2023, at 1:41 PM, with the ADM, the ADM stated the facility did not identify and addressed concerns on any of their QAPI meeting in the past 6 months regarding the water testing for legionella in the facility and the timely completion and submission of MDS. During a record review of the undated facility's policy and procedure (P&P) titled, Continuous Quality Improvement Program (QAPI), indicated the facility should establish and maintain the development, implementation, monitoring and follow-up of the QAPI that was designed to improve resident care and to correct any adverse problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 41 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 implement the facility's policy and procedure on infection control to prevent spread of infection by failing to Residents Affected - Some 1. ensure the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was changed weekly for Resident 60 and Resident 61. 2. ensure to date the gastrostomy (a creation of an artificial external opening into the stomach for nutritional support) feeding tubing for Resident 28 and Resident 37. 3. ensure the facility staff to perform hand hygiene and wear proper personal protective equipment before providing care to Resident 26. 4. ensure the facility to conduct water testing for legionella (bacteria most found in water, including groundwater, fresh and marine surface waters that causes severe pneumonia [severe infection in the lungs]) These deficient practices had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. Findings: 1b. During a review of Resident 61's admission Record indicated the facility initially admitted Resident 61 on 5/22/22 and readmitted on [DATE] with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (high blood pressure). During a review of Resident 61's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/14/23, indicated Resident 61 had severely impaired memory and cognitive (ability to think and reasonably) impairment. The MDS indicated Resident 61 required partial/moderate assistance with eating, shower/bathe self, and chair/bed-to-chair transfer. During a review of Resident 61's Order Summary Report, dated 12/14/23, indicated Resident 61 to receive oxygen at two liter per minute (l/min, a measurement unit) via nasal cannula (NC-a device used to deliver supplemental oxygen to people), and to change NC and oxygen tubing every night shift every Sunday. During an observation on 12/18/23 at 10:48 AM, with Licensed Vocational Nurse (LVN) 4, in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 42 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm 61's room, next to Resident 61's bed was an oxygen concentrator connected to a NC tubing with a label dated 12/5/23. LVN 4 stated Resident 61 was on oxygen and the NC tubing should be changed weekly. LVN 4 stated the NC tubing for Resident 61 was dated 12/5/23 and it should be discarded and replaced with a new NC tubing by 12/12/23. LVN 4 stated she was not sure why the NC tubing was not changed. LVN 4 stated if the NC tubing was not changed weekly, and it might cause infection to the residents. Residents Affected - Some During a review of the facility's undated policy and procedure titled, Oxygen Administration, indicated Oxygen tubing should be changed weekly and as needed and the date, time and initials should be noted on oxygen equipment when it is initially used and when changed. 4. During an interview on 12/21/23 at 10:45 AM with the Maintenance Supervisor (MS), the MS stated he was not aware of the facility conducting water testing for Legionella. During a concurrent interview and record review on 12/21/23 at 11:30 AM with the MS, the MS stated they could not find any records of water being tested for Legionella in the facility and they did not know for how long the facility had not tested water for Legionella. The MS stated if the water was not tested, they would not know if the water had Legionella bacteria and they were not able to monitor the water safety. The MS stated it was important to test the water for Legionella to prevent resident form contracting Legionella disease. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised on 7/2017, indicated the water management program included Specific measures used to control the introduction and/or spread of legionella; The control limits or parameters that are acceptable and that are monitored; a diagram of where control measures are applied; and a system to monitor control limits and the effectiveness of control measures. Findings: 3. A review of Resident 26's admission Record, dated 12/19/23, the record indicated, Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities), gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach used to deliver medication and food in fluid form), bacteremia (the presence of bacteria in the blood). A review of Resident 26's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 11/15/23, the MDS indicated, Resident 26 had severely impaired cognitive (ability to think, reason and remember) patterns for daily decision making, and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in all activities of daily living. A review of Resident 26's History and Physical, dated 10/25/22, Resident 26 had history of MRSA bacteremia (presence of multidrug-resistant bacteria in the blood). A review of Resident 26's Care Plan, dated 5/3/23, the record indicated, Resident 26 was at moderate risk for infection related to G-tube placement. To reduce the risk for multidrug-resistant organisms (MDRO, bacteria that resist treatment with more than one antibiotic) transmission, the interventions included, the staff will perform hand hygiene, wear gowns and gloves while performing high contact activities such as morning and evening care, changing linens, providing hygiene, incontinence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 43 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 care and provide enhanced standard precaution as indicated. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 12/18/23 at 9:55 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 26's room, an Enhanced Standard Precaution (ESP) signage was observed on the wall next to the entrance of the room with a Personal Protective Equipment (PPE, specialized clothing or equipment, worn by an employee for protection against infectious materials) storage cart. CNA 1 was observed walking into the room without washing hands, wearing gowns or gloves. Then, CNA 1 was observed lifting Resident 26's gown and touching the G-tube feeding. CNA 1 stated, he was about to give Resident 26 a bed bath. Residents Affected - Some During an observation on 12/18/23 at 9:56 a.m. in Resident 26's room, Infection Prevention (IP) Nurse was observed walking in the room and reminded CNA 1 to come out of the room to wear gloves and gown because Resident 26 was a high risk for infection due to the presence of G-tube feeding. During an interview on 12/18/23 at 9:56 a.m. with CNA 1, CNA 1 stated, he always made sure to wear PPE but he forgot to do it this time. CNA added, it was important to wear gown and gloves to protect high risk residents and prevent the spread of infection. During an observation on 12/18/23 at 9:57 a.m. outside of Resident 26's room, CNA 1 was observed preparing to enter Resident 26's room and put on a gown and put on gloves without washing his hands. CNA 1 stated, I'm sorry, I forgot to wash my hands. During an interview on 12/18/23 at 10 a.m., the IP Nurse stated, Resident 26 had G-tube feeding and a history of MRSA ( Methicillin-resistant Staphylococcus aureus (MRSA)infection caused by a type of staph bacteria that's become resistant to many of the antibiotics-medication used to treat infection), so all staffs were supposed to wash hands, wear gloves and gown before providing direct care to Resident 26. The IP Nurse also stated, without washing hands, gown up and wear gloves, there was a high chance that Resident 26 could get an or transmit infection to other residents and health care providers. During a review of the facility's policy and procedure (P&P) titled, Enhanced Standard Precaution, undated, the P&P indicated, ESP is an infection control intervention designed to reduce transmission of MDRO. ESP involve gown and glove use during high contact resident care activities for resident known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. All residents will be assessed for the need of ESP upon admission and quarterly: Presence of feeding tube. Perform hand hygiene, wear gowns and gloves while performing the following tasks associated with the greatest risk for MDRO contamination of health care providers' hands, clothes and the environment: any care activity where close contact with the resident is expected to occur such as bathing, peri-care (perineal care), assisting with toileting, changing incontinence (no control urine and bowel movement) briefs, transferring. Findings: 1. a. During a review of Resident 60s admission Record dated 12/19/2023, indicated Resident 60 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-a disease that cause airflow blockage in the lungs and difficulty breathing). During a review of Resident 60s Minimum Data Set (MDS) -a standardized assessment and screening tool dated 11/03/23, the MDS indicated Resident 60 had moderately impaired cognitive (ability to think, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 44 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some remember and reason). The MDS indicated Resident 60 required substantial/maximal assistance (helper does more than half the effort) with roll left to right, sit to lying, lying to sitting on side of the bed, chair/bed to chair transfer, toilet transfer, dressing, and required partial/moderate assistance (helper does more than half the effort) with personal hygiene. During a concurrent observation and interview on 12/18/2023, at 10:05 AM with Licensed Vocational Nurse (LVN) 5 in Resident 60s room, Resident 60 was using NC labeled with the date 12/5/2023. LVN 5 stated, the NC tubing was old and could have bacteria and cause diseases that could affect the residents and staff. LVN 5 explained, the NC should have been changed weekly. During a review of Resident 60s Order Summary Report (a physician's order), dated 11/1/2023, indicated to administer oxygen at two liters (unit of capacity) per minute via NC continuously. And to change the NC/mask every Sunday. During an interview on 12/19/23 at 2:25 PM with the infection Preventionist Nurse (IPN), the IPN stated, the NC should be changed once a week and as needed, because it could harbor bacteria and can be a cause of infection to residents and staff. A review of the policy and procedure (P&P) titled, Oxygen Administration, (undated), the P&P indicated, the oxygen tubing should be changed weekly and as needed, including changing the mask, cannula sand nebulizer equipment. The P&P indicated, the date, time and initials should be noted on oxygen equipment when it is initially used and when changed. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 4/2023, the P&P indicated, an infection prevention and control program (IPCP) were established and maintained to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P indicated, prevention of infection incudes; identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination (to spread), educating staff and ensuring that they adhere to proper techniques and procedures. 2. a. During a review of Resident 37s admission Record, dated 12/19/2023, indicated Resident 37 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included respiratory failure (a condition in which the lungs fail to meet the body's oxygen demand and cause difficulty breathing), hypertensive heart disease (the presence of elevated blood pressure for a long time),diabetes mellitus (a condition of having high blood sugar), and dysphagia (difficulty swallowing). During a review of Resident 37s MDS, dated [DATE], the MDS indicated Resident 37s cognitive status was severely impaired. The MDS indicated Resident 37 required extensive assistance(resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, locomotion in the unit, and required total dependence (full staff performance every time during entire 7-day period) with locomotion off unit, dressing, eating, toilet use, personal hygiene. During a concurrent observation and interview on 12/18/2023, at 11 AM with LVN 5 in Resident 37s room, Resident 37 had GT without a label that indicated the date the GT was changed or to be changed. LVN 5 stated, the GT should have been dated. LVN 5 stated, GT could be old and an infection control issue because no one could tell when it was changed. LVN 5 stated, old tubing could cause bacteria build up, and a potential for infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 45 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/19/23 at 2:25 PM with the infection Preventionist Nurse (IPN), IPN stated, the GT should be change daily and should be dated when it was changed. The IPN stated the GT could be old and a source of infection that could negatively affect residents and staff health. 2.b. During a review of Resident 28s admission Record, dated 12/20/2023, indicated, Resident 28 was admitted on [DATE], and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), hyperlipidemia (abnormally high levels of fats (lipids) in the blood), and dementia (a syndrome (a group of related symptoms associated with an ongoing decline of the brain and its abilities). During a review of Resident 28s, MDS, dated [DATE], the MDS indicated Resident 28 cognitive status was severely impaired. The MDS indicated Resident 28 required extensive assistance with bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene, and required total dependence (full staff performance every time during entire 7-day period) with eating. During a concurrent observation and interview on 12/18/2023, at 11:10 AM with LVN 5 in Resident 28s room, Resident 28 had a GT without a label of the date it was changed and when to be changed. LVN 5 stated, GT should have been labeled with the date. LVN 5 stated, the GT should have been dated. LVN 5 stated, GT could be old and an infection control issue because no one could tell when it was changed. LVN 5 stated, old tubing could cause bacteria build up, and a potential for infection. A review of the policy and procedure (P&P) titled, Enteral Feeding Monitoring, (undated), the P&P indicated, enteral tubing will be labeled with time and date with initials. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 4/2023, the P&P indicated, an infection prevention and control program (IPCP) were established and maintained to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P indicated, prevention of infection incudes; identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination (to spread), educating staff, and ensuring that they adhere to proper techniques and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 46 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 62), was informed of the benefits and potential side effects (undesired effect) of Influenza (Flu- a type of respiratory infection due to virus) vaccine (a substance injected into the muscle with the use of a needle to stimulate immunity [defense against fight infection] to a particular infectious disease) prior to administration. Residents Affected - Few As a result of this failure Resident 62 was not able to exercise his right to have informed consent prior to accepting to receive or not receive the annual influenza vaccine. Findings: A review of Resident 62's admission Record, dated 12/19/23, the record indicated, Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (or a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes (disease that occurs when blood sugar is too high), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 62's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 8/2/23, the MDS indicated, Resident 62 needs extensive assistance (resident involved in activity, staff provide weight-bearing support) in dressing, toilet use, personal hygiene, and limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) in bed mobility. A review of Resident 62's History and Physical, dated 6/15/23, the record indicated, Resident 62 was able to make decision for activities of daily livings. A review of Resident 62's Order Summary Report, dated 12/19/23, the record indicated, Resident 62 was to receive seasonal influenza vaccine to be given annually between October and March for immunization (vaccination). A review of Resident 62's Resident Flu Vaccine Record, dated 10/7/23, the record indicated, Resident 62 consented and was given the influenza vaccine without being informed of the benefits and potential side effects of the vaccine. During an interview on 12/21/23 at 12:11 p.m. with Resident 62, Resident 62 stated, the facility staffs did not inform him of the risks and benefits of Influenza vaccine prior to the administration of the vaccine. Resident 62 added, the facility just brought him a paper and did not explain what he was signing, then the staff asked him to sign the paper. Resident 62 stated he did not know anything about the side effects of Influenza vaccine. During a concurrent interview and record review on 12/21/23 at 12:16 p.m. with Infection Control Nurse (IPN), Resident 62's Update Immunization, dated 10/10/23 indicated, there was no documented evidence that Resident 62 or his representative was informed about the side effects of Influenza vaccine of prior to administration of Flu vaccine. The IPN stated, it was not acceptable to administer Flu (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 47 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete vaccine without informing the residents of the risks and benefits of Flu vaccine and because it was the resident's right to accept or refuse Flu vaccine after the resident was informed. A review of the facility's policy and procedure (P&P) titled, Influenza Immunization, undated, the P&P indicated, before offering the influenza immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. The medical record of the resident will include documentation that indicates: The resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization. Event ID: Facility ID: 055670 If continuation sheet Page 48 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 33 out of 44 rooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 ,26, 27, 28, 29, 30, 31, and 32 measured less than 80 sq. ft. per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents. Findings: During a concurrent interview and record review on 12/20/23 at 3:30 PM, with the Administrator (ADM), the Client Accommodations Analysis (CAA- a form used to identify the room sizes and number of beds in the room), dated 12/20/23, indicated there were 42 resident's bedrooms in the facility that measured less than 80 sq. ft. per resident care area. The CAA indicated 42 resident's bedrooms did not measure 80 sq. ft. per resident as listed below: Rooms Required Square Footage Square Footage Number of Beds Number of Resident 1 160 151.2 2 2 2 160 144.88 2 2 3 160 134.88 2 1 4 160 156.76 2 2 6 160 159.18 2 2 7 160 141.47 2 2 8 160 149.54 2 2 9 160 141.47 2 2 10 160 149.66 2 1 11 160 141.47 2 2 12 160 141.69 2 2 14 320 314.27 4 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 49 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 15 320 291.48 4 4 Level of Harm - Potential for minimal harm 16 320 291.48 4 4 17 320 291.48 4 4 Residents Affected - Some 18 160 144.42 2 2 19 160 144.54 2 2 20 320 291.48 4 2 21 320 291.48 4 4 22 160 144.54 2 2 23 320 291.48 4 3 24 160 144.58 2 2 25 320 291.48 4 4 26 160 149.85 2 2 27 160 148.01 2 2 28 160 138.99 2 1 29 160 145.91 2 2 30 160 138.99 2 0 31 160 145.91 2 1 32 160 138.92 2 0 During an interview on 12/19/23 at 12:05 PM, with Resident 47. Resident 47 stated he and his roommate shared a room and the current room size was enough to ambulate and move around. Resident 47 stated the current room size did not affect his comfort and care. During an interview on 12/20/23 at 4:12 PM, with Resident 66's responsible party (RP 1). RP 1 stated he stated he visited Resident 66 every day and he did not see any issue with the current size of the room. RP 1 stated Resident 66 uses a wheelchair, and the current room space was sufficient to transfer her from bed to the wheelchair and get in and out of the room. During an interview on 12/20/23 at 5:50 PM, with Restorative Nursing Assistant (RNA) 1, RNA 1 stated there was no space issue for all the rooms and they were able to use move different equipment into the room to provide exercise for resident without restriction. RNA 1 stated they were able to work with current room size and safely transfer residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 50 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadway Manor Care Center 605 West Broadway Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some During an interview on 12/20/23 at 5:54 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated there was no problem with the current room size and they could move around the bed or nightstand to make space to allow other equipment to go in and out of the room if needed. LVN 2 stated the current room size did not affect the staff providing care to the residents. During the re-certification survey observations, and interviews with residents and facility staff between 12/18/23 and 12/21/23, the above listed rooms had sufficient space for the residents' freedom of movement. The rooms 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 present any adverse effect on the residents' personal space, nursing care, and comfort. During the review of the facility's Variance request, dated 12/20/23, indicated that granting the variance will not adversely affect the residents' health and safety or impede the ability of any residents to obtain their highest level of partible wellbeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 51 of 51