Health inspection·July 19, 2024

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 interview, and record review, the facility failed to ensure to administer the morning medications as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility, at 7:45 AM as ordered by the physician. Residents Affected - Some This deficient practice had the potential for worsening Resident 1 ' s medical condition such as fluid overload, high blood pressure, and heart complications. Findings: During a review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis, hyperglycemia (high blood sugar), hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 3/27/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set MDS, a standardized resident assessment and care screening tool) dated 5/2/2024, indicated the resident ' s cognition was moderately impaired. During a review of Resident 1's Order Summary Report Active Orders as of: 7/19/2024, indicated the following physician order, order date 3/16/2024 indicated the following physician orders: Resident 1 to have dialysis treatments on Mondays, Wednesdays and Fridays to the dialysis center via gurney through van transportation, at 7:45 AM. The Order Summary Report indicated medications ordered by the attending physician included: -Amlodipine oral Tablet 5 mg, give one tablet by mouth one time a day for Hypertension -Clopidogrel oral Tablet 75 mg, give one tablet by mouth one time a day for CVA Prophylaxis -Cranberry Capsule 425 mg, give one tablet by mouth one time a day for UTI Prophylaxis -Docusate Sodium 100 mg tablet, give one tablet by mouth one time a day for stool softener Page 1 of 7 055670 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

F 0684 -Lasix 20 mg oral tablet, give one tablet by mouth one time a day for bilateral Edema Level of Harm - Minimal harm or potential for actual harm -Magnesium Oxide 400 mg, give one tablet by mouth one time a day for low magnesium Residents Affected - Some -Namenda XR oral capsule Extended Release 21 mg, give one capsule by mouth one time a day for Dementia -[NAME]-[NAME] Oral Tablet one tablet, by mouth one time a day for Supplement -Vitamin B6 oral tablet 100 mg, give one tablet by mouth one time a day for Supplement for Vitamin B Deficiency -Carvedilol oral tablet 3.125 mg, give one tablet by mouth two times a day for Hypertension -Hydralazine HCL oral tablet 100 mg, give one tablet by mouth two times a day for Hypertension During a review of Resident 1's Medication Administration Record (MAR) for the month of July 2024 9 AM (morning) medications, showed that on 7/1/2024, 7/3/2024, 7/8/2024, 7/10/24, 7/15/24, and 7/17/2024 indicated the code number 5 (Hold/See Progress Notes) and on 7/5/2024 and 7/12/2024 indicated a code number 9 (Other/See Progress Notes). The 9 AM medications were -Amlodipine oral Tablet 5 mg -Clopidogrel oral Tablet 75 mg -Cranberry Capsule 425 mg -Docusate Sodium 100 mg -Lasix 20 mg -Magnesium Oxide 400 mg -Namenda XR oral capsule Extended Release 21 mg -[NAME]-[NAME] Oral Tablet -Vitamin B6 oral tablet 100 mg -Carvedilol oral tablet 3.125 mg -Hydralazine HCL oral tablet 100 mg During an interview on 7/19/2024 at 10:30 AM, Licensed Vocational Nurse (LVN) 1 stated the facility ' s morning medication administration time is 9 AM. LVN 1 stated medications can be administered one hour early and one hour after. LVN 1 stated Resident 1 was on her regular daily resident assignments and goes to the Dialysis center three times a week. LVN 1 stated Resident 1 usually leaves around 6:30 AM to 7:00 AM on dialysis days (Mondays, Wednesdays and Fridays) and comes back around 11:30 to 12 noon. LVN 1 stated when Resident 1 is out of the facility for dialysis treatments, she does not 055670 Page 2 of 7 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administer the 9 AM medications to Resident 1 since the time for administering the 9 AM medications had already passed. LVN 1 stated she did not contact the attending physician to clarify if the licensed nurses could administer the morning medications or hold Resident 1 ' s 9 AM medications. During an interview and record review of Resident 1's MAR for the month of July 2024, on 7/19/2024 at 10:40 AM, LVN 1 stated Resident 1 did not receive her 9 AM medications on 7/1/2024, 7/3/2024, 7/5/2024, 7/8/2024, 7/10/24, 7/12/2024, 7/15/24 and 7/17/2024. During a concurrent interview and record review of Resident 1's MAR for the month of July 2024, on 7/19/2024 at 11:41 AM, the Director of Nursing (DON) stated Resident 1 ' s morning medications (9 AM) are the following: -Amlodipine oral Tablet 5 mg -Clopidogrel oral Tablet 75 mg -Cranberry Capsule 425 mg -Docusate Sodium 100 mg -Lasix 20 mg -Magnesium Oxide 400 mg -Namenda XR oral capsule Extended Release 21 mg -[NAME]-[NAME] Oral Tablet -Vitamin B6 oral tablet 100 mg -Carvedilol oral tablet 3.125 mg -Hydralazine HCL oral tablet 100 mg During the same interview, the DON stated there is no documented evidence that Resident 1 received the 9 AM medications on 7/1/2024, 7/3/2024, 7/5/2024, 7/8/2024, 7/10/24, 7/12/2024, 7/15/24 and 7/17/2024. The DON stated if Resident 1 received the medications it would reflect in the MAR. The DON stated code number 5 in the MAR means hold/see progress note and code number 9 indicated other/see progress note. During an interview and record review of Resident 1's Nurses Progress Note for the month of July 2024 on 7/19/2024 at 11:45 AM, the DON stated the licensed staff documented that Resident 1 was on dialysis treatments on 7/1/2024, 7/3/2024, 7/5/2024, 7/8/2024, 7/10/24, 7/12/2024, 7/15/24 and 7/17/2024 but did not add any other information. The DON stated licensed staff should have clarified with the physician if the 9 AM medications should be administered or held while Resident was out on dialysis. The DON stated there was no physician orders found from the physician that indicated to hold Resident 1 ' s morning medications while out of the facility for dialysis treatments. During an interview on 7/19/2024 at 1:10 PM, Registered Nurse (RN )1 stated if a resident is out of 055670 Page 3 of 7 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility during the time of medication administration due to dialysis treatments, the licensed staff should have clarified with the attending physician if the medications should be administered or held for the day. RN 1 stated the potential outcome of not administering the medications to Resident 1 is fluid overload, high blood pressure, and heart complications. During a review of the facility ' s policy and procedure, revised in March 2023 and titled, Administering Medication, indicated: Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be ''flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 055670 Page 4 of 7 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

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 interview and record review the facility failed to ensure a resident was free from significant medication error by failing to administer insulin as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility. Residents Affected - Few This deficient practice had the potential for Resident 1 to have high blood sugar and complication such as Diabetic ketoacidosis (condition develops when body does not have enough insulin and glucose can't enter cells for energy, blood sugar level rises, and body begins to break down fat for energy which produces toxic acids called ketones. Ketones accumulate in the blood and eventually spill into the urine. Diabetic ketoacidosis can lead to a diabetic coma that can be life-threatening. Findings: During a review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis, hyperglycemia (high blood sugar), hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 3/27/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set MDS, a standardized resident assessment and care screening tool) dated 5/2/2024, indicated the resident ' s cognition was moderately impaired. During a review of Resident 1's Order Summary Report Active Orders as of: 7/19/2024, indicated the following physician order, order date 3/17/2024 indicated the following physician orders: -Resident 1 to have dialysis treatments on Mondays, Wednesdays and Fridays to the dialysis center via gurney through van transportation, at 7:45 AM. -Insulin Aspart Solution 100 UNIT/ML inject 12 unit,, subcutaneously with meals for Diabetes with meals , HOLD FOR Blood Sugar(BS) less than 70. During a review of Resident 1's Medication Administration Record (MAR) for the month of July 2024 7 AM medications, showed the following information: 7/2/2024 indicated a code number 2 (Drug Refused) 7/5/2024 indicated a code number 9 (Other/See Progress Notes) 7/7/2024 indicated a code number 14 (Other/See Progress Notes) 7/11/2024 indicated a code number 2 (Drug Refused) 7/17/2024 indicated the code number 5 (Hold/See Progress Notes) 055670 Page 5 of 7 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

F 0760 During a review of Resident 1's Progress Notes for the month of July 2024 indicated : Level of Harm - Minimal harm or potential for actual harm 7/2/2024 and timed 6:26AM documented Resident refused insulin due to BS being 90 7/5/2024 and timed 6:14AM documented Held insulin BS is 72 Residents Affected - Few 7/5/2024 and times 6:58AM documented Resident left the facility at 0658am, assisted by 2 transporters. Paperwork and Sack lunch provided for resident. 7/7/2024 and timed 6:18AM documented Held insulin BS is 75 7/7/2024 and times 6:50AM documented Resident left the facility at 06:50 AM, assisted by 2 transporters. Paperwork and Sack lunch provided for resident. 7/11/2024 and timed 6:11 AM documented Explained risk and benefits .Offered x3 .Resident still refused. 7/17/2024 and timed 6:44 AM documented BS is 75 During a review of Resident ' s 1 care plan indicated MULTIPLE MEDICATIONS. Resident is on multiple medications. At risk for ill effects from multiple drug use. As intervention indicated : verify all medications to physician on admission and ask physician to review all medications every visit. Monitor for any signs and symptoms of adverse reaction. During a review of Resident ' s 1 care plan indicated Resident on Hemodialysis due to diagnosis of ESRD and at Risk for: adverse effect of dialysis, compromise of dialysis access port, alteration in fluid volume: risk: edema, alteration in Skin integrity; as intervention indicated: Explain to the resident the schedule of dialysis treatment , why is it important. prior to dialysis make sure the following is done: Resident to have breakfast prior to dialysis and pack lunch, meds and communications properly relayed to dialysis clinic. During an interview and record review of Resident 1's MAR for the month of July 2024, on 7/19/2024 at 10:53 AM, Licensed Vocational Nurse (LVN) 2 stated Resident 1 did not receive insulin on 7/5/2024 , 7/7/2024, and 7/17/2024 .LVN 2 was unable to explain why Resident 1 did not receive insulin stated if BS less than 70 staff should held the insulin. Stated potential outcome of not getting insulin is Resident blood sugar will be high which can lead to confusion and coma. LVN 2 stated there is no communication with the physician about if insulin should have be administered or not during dialysis days. During a concurrent interview and record review of Resident 1's MAR for the month of July 2024, on 7/19/2024 at 11:41 AM, the Director of Nursing (DON) stated there is no documented evidence that Resident 1 received the 7 AM insulin on 7/5/2024, 7/7/2024, and 7/17/2024. The DON stated if Resident 1 received the medications it would reflect in the MAR. The DON stated code number 5 in the MAR means hold/see progress note and code number 9 and 14 indicated other/see progress note. During an interview and record review of Resident 1's Nurses Progress Note for the month of July 2024 on 7/19/2024 at 11:47 AM, the DON stated the licensed staff documented that Resident 1 was on dialysis treatments on 7/5/2024, 7/7/2024, and 7/17/2024. The DON stated licensed staff should have clarified with the physician insulin should be administered or held while Resident was out on dialysis. 055670 Page 6 of 7 055670 07/19/2024 Broadway Manor Care Center 605 West Broadway Glendale, CA 91204

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated there was no physician orders found from the physician that indicated to hold Resident 1 ' s insulin while out of the facility for dialysis treatments. During a review of the facility ' s policy and procedure, revised in March 2023 and titled, Administering Medication, indicated: Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be ''flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. During a review of the facility ' s policy and procedure, revised in February 2022 and titled, The Resident Care Plan, indicated: The Resident care plan shall be implemented for each resident on admission , and developed throughout the assessment process. Identification of medical, nursing, and psychosocial needs; Goals stated in measurable/observable terms; Approaches (staff action) to meet the above goals; Discipline/staff responsible for approaches; It is the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. If a resident requires the services of a professional not currently involved in the resident's care, the assigned staff shall arrange for the appropriate services, and request the professional. visit the resident; that the professional chart observations, treatment, and opinions; and that the professional contribute to the resident care plan. 055670 Page 7 of 7