Health inspection·July 11, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat one of four sampled residents (Resident 4) with respect and dignity by failing to ensure to maintain Resident 4 ' s bodily privacy during an inspection of her G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach) by LVN 1, which resulted in the resident's gastrointestinal tube being exposed in the resident ' s common Dining Area. This deficient practice had the potential to negatively impact residents leading to shame, depression, and embarrassment, diminishing the importance of emotional and psychological health. Findings: 1. A review of Resident 4 ' s admission Record indicated the resident was admitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing or not able to swallow) and gastro-esophageal reflux (a condition which the stomach contents move up into the throat) disease. A review of Resident ' 4 History and Physical dated 5/21/24, indicated the resident dis not have the capacity to understand and make decisions but is able to make decisions for activities of daily living. A review of Resident 4 ' s Minimum data Set (MDS – a comprehensive assessment used as a careplanning tool) dated 5/28/2024, indicated resident requires maximum assistance for all self-care tasks such as, oral hygiene, toileting, showering, and dressing. A review of Resident 4 ' s Care Plan initiated on 5/28/2024 and revised on 7/5/2024 indicated Enteral feeding through g-tube interventions are to maintain resident ' privacy and respect their rights. 2. A review of Resident 1 ' s admission record indicated the resident was admitted on [DATE], with diagnoses that included obesity (having too much body fat) and gout (pain and swelling of the joints). A review of Resident 1 ' s History and Physical dated 9/25/23, indicated the resident has the capacity to understand and make decisions. A review of Resident 1 ' s Psychiatric Progress Note dated 4/26/2024 indicated Resident has a BIM (Brief interview for mental status) score of 15. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055670 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 07/11/2024 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)