Health inspection·December 19, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (undated), indicated; a) the purpose of this procedure is to ensure timely responses to the resident's requests and needs, b) ensure that the call light is accessible to the resident when in bed or wheelchair in the room, and c) answer the resident call system in timely manner. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated 3/2021, indicated; the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Event ID: Facility ID: 055670 If continuation sheet Page 2 of 32 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 12/19/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed provide a safe and homelike environment for one of two sampled residents (Resident 50) with five plastic bags tied together and used as an extension to pull as a string to turn on and turn off the overhead light above the bed. This deficient practice had the potential to cause accident and created a non homelike environment and frustration to Resident 50 when pulling the string. Findings: During a review of Resident 50's admission Record, indicated the facility originally admitted Resident 50 on 10/27/2023 and readmitted on [DATE] with diagnoses that included Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness), depression (a constant feeling of sadness and loss of interest), and psychosis (loss of contact with reality). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, indicated Resident 50's cognitive status (ability to think and reason) was moderately impaired. The MDS indicated Resident 50 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, personal hygiene and dressing, required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with toileting and sit to stand. During a concurrent observation and interview on 12/16/2024 at 9:50 AM with Licensed Vocational Nurse (LVN) 1 in Resident 50's room, Resident 50 was on his wheelchair next to his bed, the overhead light pull-string over Resident 50's bed had five clear plastic bags tied together to create a an extension to the pull-string. LVN 1 stated, it is not appropriate, and she will call the maintenance right away to fix it. During an interview on 12/17/2024 at 11:12 AM with LVN 1, LVN 1 stated, using plastic bags as an extension to the overhead light pull-string could potentially cause an accident or injury, and did not promote a home like environment for Resident 50. During an interview on 12/17/2024 at 1:30 PM with Resident 50, Resident 50 stated, using plastic for bags as a string for his overhead light, frustrated him, it bothers him, it looked bad, and it is just not right. During an interview on 12/17/2024 at 2:35 PM with Maintenance Supervisor (MS), MS stated, using plastic bags as an extension for a pull-string for the overhead light was not appropriate, that's not how he would repair it. MS stated, it does not look good, and was difficult to clean. The MS stated it was not good for Resident 50. During an interview on 12/18/2024 at 11:30 PM with Assistant Director of Nurses (ADON), ADON stated, it is not appropriate to use plastic bags as a pull string to the overhead lighting, it does not look good, it is not home-like, and it could be hazardous to Resident 50. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 3 of 32 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 12/19/2024 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)

F 0584 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 (P&P) titled, Maintenance and Plant Operations, (undated), indicated; a) maintenance purpose was to provide a functional, comfortable environment, and ensuring all equipment's are kept in operable condition, and b) properly maintain the building fixtures, in good repair and safe operating condition at all times. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 3/2023, indicated; a) Residents are provided with safe, clean, comfortable, and homelike environment, and b) homelike setting includes: clean, sanitary, and orderly environment. Event ID: Facility ID: 055670 If continuation sheet Page 4 of 32 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 12/19/2024 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)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and closed record review, the facility failed to ensure that one of three sampled residents (Resident 58), indicated the reason of discharge or transfer in the Notice of Proposed Transfer/Discharge form (a written notification to the resident or responsible party that included the reason for the transfer or discharge, where the resident will be transferred or discharged to, how to contact the State Long Term Care Ombudsman, and how to appeal the transfer or discharge if necessary) was not completed in accordance with the facility's policy and procedure. This deficient practice violated the residents right and the facility's policy procudere that had the potential for Resident 38 not to be informed about the reasons of his transfer/discharge. Findings: During a review of Resident 58 ' s admission Record (Face Sheet), indicated the facility admitted Resident 58 on 3/20/2023, and readmitted on [DATE] with diagnoses including Alzheimer's disease (progressive brain disorder that affects the person memory, thinking and reasoning), and diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar) . insulin resistance, and relative lack of insulin). During a review of Resident 58's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/19/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During a review of Resident 58 ' s Change in Condition (COC) Evaluation form, dated 12/13/2024, indicated that the resident started having a cough, lung congestion (accumulation of fluids), and diarrhea (loose stool). During a review of the Discharge summary dated [DATE], indicated Resident 58 was transferred to General Acute Care Hospital (GACH) on 12/13/2024. During an interview on 12/18/2024 at 8:20 AM with the Director of Nursing (DON), the DON stated for Resident 58 the Notice of Transfer or Discharge Form was not done and completed. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, indicated Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. It also indicated under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: if an immediate transfer or discharge is required by the resident ' s urgent medical needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 5 of 32 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 12/19/2024 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)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Notification of bed-hold and Return form (a form that indicates the resident's rights to return to the facility after hospitalization) in accordance with the facility's policy and procedures, for two of three sampled residents (Resident 38 and 58) who were transferred to the General Acute Care Hospital (GACH) as ordered by the physician. This deficient practice resulted in the violation of the resident's rights to be informed about the Notification of bed-hold and Return policy and to be aware that he/she can return to the facility after hospitalization as ordered by the physician. Findings: 1. During a review of Resident 38's admission Record (Face Sheet), the facility admitted Resident 38 on 1/14/2023, and readmitted on [DATE] with diagnoses including Alzheimer's disease (end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis), heart failure (a condition in which the heart can't pump enough blood to meet the body's needs). During a review of Resident 38's History and Physical (H&P), dated 6/27/2024 indicated, Resident 38 had the mental capacity to make medical decisions. During a review of Resident 38's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 8/26/2024, indicated the resident's cognitive (the ability to think and process information) skills for daily decisions making) was intact, and was not dependent from the staff for the activities of daily living. During a review of Resident 38's Change in Condition (COC) Evaluation form, dated 6/21/2024, indicated that the resident started had chills, and low-grade fever. During a review of Resident 38's Nurses' Note, dated 6/21/2024, the Nurses' note indicated, nursing staff informed the physician of a change in Resident 38's condition and transferred the resident to the GACH on 6/21/2024 for evaluation. A review of Resident 38's clinical record on 12/18/2024 at 8:20 AM with the Director or Nursing (DON) had no indication that the facility staff discussed with the resident and the resident's responsible party about Notification of bed-hold and Return when the resident transferred to GACH on 6/21/2024. During a review of the Discharge summary, dated [DATE], indicated Resident 38 was transferred to GACH on 6/21/2024. During a record review of Resident 38's Notification of Bed Hold form indicated that a seven-day bed hold notification form was not completed and was left blank at the time of transfer. 2. During a review of Resident 58's admission Record (Face Sheet), the facility admitted Resident 58 on 3/20/2023, and readmitted on [DATE] with diagnoses including Alzheimer's disease, and diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 6 of 32 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 12/19/2024 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)

F 0625 mellitus (DM: elevated sugar in the blood). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 58's History and Physical (H&P), dated 11/15/2024 indicated, Resident 58 does not have the mental capacity to make medical decisions. Residents Affected - Few During a review of Resident 58's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/19/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During a review of Resident 58's Change in Condition (COC) Evaluation form, dated 12/13/2024, indicated that the resident started having a cough, lung congestion (accumulation of fluids), and diarrhea (loose stool). During a review of Resident 58's Nurses' Note, dated 12/13/2024, indicated, the nursing staff informed the physician of a change in Resident 58's condition and transferred the resident to the GACH on 12/13/2024 for evaluation. A review of Resident 58's clinical record had no indication that the facility staff discussed with the resident and the resident's responsible party about Notification of bed-hold and Return when the resident transferred to GACH on 6/21/2024. During a record review of Resident 58's Notification of Bed Hold form indicated that a seven-day bed hold notification form was not completed and was left blank at the time of transfer. During a review of the Discharge summary dated [DATE], indicated Resident 58 was transferred to GACH on 12/13/2024. During an interview on 12/18/2024 at 8:20 AM with the Director of Nursing (DON), the DON stated Resident 58's and Resident 38's bed hold notification form should have been acknowledged, signed by either the resident or responsible party, and the bed hold was good for seven days. During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, indicated Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 7 of 32 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 12/19/2024 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)

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67). Residents Affected - Some This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, 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: 1.During a review of Resident 2's admission Record indicated the facility admitted Resident 2 on 4/30/2024 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 hyperlipidemia (a condition where there are high levels of fat in the blood). During a review of Resident 2's MDS summary indicated the Quarterly MDS with Assessment Reference Date (ARD) of 11/12/2024, was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 2's MDS 3.0 Kardex (a form that indicated when the MDS was transmotetd to CMS), indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to the CMS system (nine days late for submission as 12/19/2024). 2. During a review of Resident 24's admission Record indicated the facility admitted Resident 24 on 8/9/2021 and readmitted on [DATE] with diagnoses that included dementia and heart failure (a serious condition that occurs when the heart is unable to pump enough blood to meet the body's needs). During a review of resident 24's MDS Summary, indicated the Quarterly MDS with ARD date was 9/11/2024, was completed on 9/25/2024, and was submitted to CMS system on 11/6/2024 (28 days late for submission). 3. During a review of Resident 25's admission Record indicated the facility admitted Resident 25 on 6/18/2019 and readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes extreme mood shifts, affecting a person's energy, thinking, behavior, and sleep) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of resident 25's MDS Summary, indicated the Quarterly MDS with ARD of 9/127/2024, which was completed on 10/11/2024, was accepted by CMS on 12/18/2024 (68 days late for submission). 4. During a review of Resident 26's admission Record indicated the facility admitted Resident 26 on 5/1/2024 with diagnoses that included Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns) and seizure (a temporary, abnormal burst of electrical activity in the brain that can cause a sudden change in behavior, movement, or consciousness). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 8 of 32 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 12/19/2024 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)

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 26's MDS Summary, indicated the Quarterly MDS with ARD of 11/13/2024, which was completed on 11/13/2024, was due for submission to CMS by 11/27/2024. During a review of Resident 26's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (22 days late for submission as 12/19/2024). 5. During a review of Resident 48's admission Record indicated the facility admitted Resident 48 on 4/25/2022 with diagnoses that included dementia and seizure. During a review of Resident 48's MDS Summary, indicated the Quarterly MDS with ARD of 11/9/2024, which was completed on 11/23/2024, was due for submission by 12/7/2024. During a review of Resident 48's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/9/2024, was ready to be exported but no indication that it was transmitted to CMS timely (12 days late for submission as 12/19/2024). 6. During a review of Resident 61's admission Record indicated the facility admitted Resident 61 on 1/29/2024 and readmitted on [DATE] with diagnoses that included dementia and heart failure. During a review of Resident 61's MDS Summary, indicated the Quarterly MDS with ARD of 11/12/2024, which was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 61's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (nine days late for submission as 12/19/2024). 7. During a review of Resident 55's admission Record indicated the facility admitted Resident 55 on 8/3/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 55's MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/4/2024, which was completed on 9/18/2024, was accepted by CMS 12/18/2024 (91 days late for submission). 8. During a review of Resident 67's admission Record indicated the facility admitted Resident 67 on 7/17/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 67's MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/7/2024, which was completed on 9/21/2024, was accepted by CMS on 12/18/2024 (88 days late for submission). During an interview on 12/18/2024 at 11:16 AM with the MDS Nurse (MDSN), the MDSN stated she was responsible to make sure all the residents' MDS assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) system timely. The MDSN stated once the MDS assessment was completed, the facility has 14 days to transmit the MDS to the CMS system. The MDSN stated she was aware that the facility had not ensure all the MDS assessments were transmitted timely, even with the extra help of a part time MDSN who was hired in October this year. The MDSN stated she was busy with other tasks and did not have time to transmit the MDS timely and she was not 100 percent doing her job. The MDSN stated the late submission of the MDS would delay the accuracy of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 9 of 32 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 12/19/2024 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)

F 0640 assessment and affect resident's care negatively. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/19/2024 at 2:35 PM, with the Administrator (ADM), the ADM stated she was aware that some of the MDS assessments were transmitted late to the CMS system. The ADM stated all the MDS assessment should be transmitted in a timely manner to ensure quality of care for the residents by conducting proper assessment on the resident was conducted and developing and implementing the plan of care accordingly. Residents Affected - Some 9. During a review of Resident 14's admission Record indicated the facility originally admitted Resident 14 on 7/31/2024 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), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries that supply blood to the heart). During a concurrent interview and record review, on 12/18/2024, at 1 PM, with MDS Nurse (MDSN), indicated Resident 14's Electronic Health Records (EHR) of the Quarterly MDS was completed on 11/21/2024 and was transmitted to CMS by 12/5/2024. MDSN stated, the submission of the MDS was late, it should have been submitted 14 days after completion date on 11/21/2024. The MDSN stated, she was not able to submit the MDS timely, since she was just busy with my other responsibilities as an MDS Nurse. 10. During a review of Resident 49's admission Record indicated the facility admitted Resident 49 on 4/29/2024 with diagnoses that included schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), Chronic Obstructive Pulmonary Disease (COPD- a common lung disease that makes it difficult to breathe), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a concurrent interview and record review, on 12/18/2024, at 1:30 PM with MDSN, Resident 49's EHR indicated, the Quarterly MDS was completed on 11/24/2024 and was transmitted to CMS on 12/18/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 12/8/2024, which was 14 days after completion date on 11/24/2024. 11. During a review of Resident 71's admission Record indicated the facility admitted Resident 71 on 9/3/2024 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), kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), and gastroparesis (paralysis of the stomach). During a concurrent interview and record review, on 12/18/2024, at 3:47 PM with MDSN, Resident 71's EHR indicated the admission MDS was completed on 9/16/2024, and was transmitted to CMS on 10/7/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 9/30/2024, which was 14 days after completion date. During an interview on 12/19/2024 at 2:30 PM with Director of Nurses (DON), 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 plan of care that could be developed based on the residents' status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 10 of 32 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 12/19/2024 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)

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's Policy and Procedure (P&P), titled Resident Assessment, dated 3/2022, indicated the facility to follow the RAI (Resident Assessment Instrument) User's Manual on timing and submission of assessments. During a review of CMS Long-Term Care Facility MDS 3.0 RAI User's Manual, updated 10/2024, indicated MDS assessment must be submitted to the CMS system within 14 days of the MDS completion date. Event ID: Facility ID: 055670 If continuation sheet Page 11 of 32 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 12/19/2024 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)

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 follow up 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) evaluation for two of two sampled residents (Residents 49 and 69): Residents Affected - Few 1. For Resident 49 who assessed as having positive level 1 screening on 4/29/2022, indicated required a level II mental health screening. 2) for Resident 69 who assessed as having negative level 1 screening on 6/3/2024, indicated to resubmit a PASRR level 1 screening if the resident remained at the facility longer than 30 days. (Resident 69 remained in the facility for more than six months and still in the facility. This failure had the potential to result in Resident 49 and Resident 69 not to receive care and services in the most integrated setting appropriate to their needs, which can negatively affect their quality of life. Findings: 1. During a review of Resident 49's face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included Schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), anxiety disorder (a feeling of unease, such as worry or fear, that can be mild or severe) and major depressive disorder (a persistent feeling of sadness and loss of interest). During a review of Resident 49's History and Physical Examination, dated 6/16/2024, indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/10/2024, indicated Resident 49's cognitive status (ability to think remember, and reason) was severely impaired. The MDS indicated Resident 49 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with toileting, personal hygiene, and dressing, and partial/moderate assistance (helper does less than half the effort) with bathing. During a review of Resident 49's letter from Department of Health Care Services (DHCS) - PASRR Section, dated 4/29/2022, indicated, Resident 49 had positive PASRR Level 1 Screening and required a PASRR Level II mental health evaluation. During a review of Resident 49's Order Summary Report (OSR), dated 12/17/2024, indicated to give Risperdal (medication used to treat certain mental/mood disorders) 3 mg (a unit of mass measurement) one tablet every eight hours for schizophrenia manifested by uncontrollable extreme mood swings causing anger. During a concurrent observation and interview on 12/17/2024 at 12:00 PM with Certified Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 12 of 32 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 12/19/2024 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assistant (CNA) 1 in Resident 49's room, Resident 49 with episodes of yelling and using profanity, and episodes of talking to himself. CNA 1 stated, Resident 1 do have episodes of yelling and screaming profanity, the staff just monitor the behavior, and we approach Resident 49 calmly and redirect his attention. During an interview on 12/17/2024 at 2:30 PM with Assistant Director of Nurses (ADON), ADON stated, she missed following up PASRR level II screening for Resident 49, and Resident 49 continue to have episodes of yelling and screaming profanity. ADON stated, in general, it is important for residents to have a PASRR evaluation to ensure they receive appropriate care and services they need. 2. During a review of Resident 69's face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). During a review of Resident 49's History and Physical Examination, dated 6/5/2024, indicated Resident 69 did not have the capacity to understand and make decisions. During a review of Resident 69's MDS, dated [DATE], indicated Resident 69's cognitive status (ability to think remember, and reason) was moderately impaired. The MDS indicated Resident 69 dependent (helper does all the effort) with eating, bathing, toileting, dressing, and personal hygiene. During a review of Resident 69's letter from Department of Health Care Services (DHCS) - PASRR Section, dated 6/3/2024, indicated, Resident 69 had a negative PASRR Level 1 Screening with instruction to resubmit a new level 1 screening if Resident 69 remained at the facility longer than 30 days (Resident 69 had been in the facility for more than six months) . During a review of Resident 69's OSR, dated 12/17/2024, indicated to give Venlafaxine (medication used for depression) 37.5 mg one capsule one time a day for depression manifested by feelings of hopelessness/helplessness. During an observation on 12/17/2024 at 8:15 AM in Resident 69's room, Resident in bed fed by staff with a sad look. During an interview on 12/17/2024 at 2:30 PM with ADON, ADON stated, Resident 69 had been in the facility for more than 30 days and had been monitored for depression and she should have resubmitted a new level 1 screening as a resident review as per instructions on the 31st day. ADON stated, in general, it is important for residents to have a PASRR evaluation to ensure they receive appropriate care and services they need. During a review of the facility's policy and procedure (P&P) titled, Policy: Preadmission Screening and Resident Review (PASRR), dated 7/1/2023, indicated; a) the purpose is to ensure resident with serious mental illness (SMI) and/or intellectual/developmental disability/related conditions (ID/DD/RC) will have the appropriate setting, as well as if any specialized services and/or rehabilitative would be needed, b) the facility designated staff will complete and submit a level 1 PASRR for all admitted residents except for residents transferred from GACHs until further notice, c) If the DHCS/DDS contractor deems Level II evaluation is necessary, the facility will assist the DHCS contractor with additional information, face-to-face visit for further evaluation as indicated, and d) the facility designated staff will follow up on the DHCS/DDS contractor level II determination/recommendation and document and maintain the records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 13 of 32 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 12/19/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20) who had a right heel blood filled blister, had an air loss mattress ( LAL- mattress designed to prevent and treat pressure sore [a skin breakdown due to unrelieved pressure and friction to the skin]) setting was not set according to residents weight, the manufacturer's guidelines was set based on the resident's weight to prevent and/or minimize skin pressure on the bony prominences of the body. Residents Affected - Few This deficient practice had the potential to delay healing, worsened pressure sore and that negatively affect Resident 20's quality of life. Findings: A review of Residents 20's admission Record indicated the resident was admitted , on 11/6/2024 with diagnoses that included atherosclerosis on native arteries of extremities, bilateral legs (cause long-term poor blood flow in your legs), peripheral vascular disease (PVD-a condition where blood vessels in your arms or legs become narrowed, preventing enough blood from reaching those areas), diabetes mellitus (lifelong condition that causes a person's blood sugar level to become too high), difficulty walking and muscle weakness. A review of Resident 20's History and Physical (H&P) dated 12/10/2024 indicated Resident 20 is able to make decisions for activities of daily living. A review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024, indicated Resident 20 mental status was moderately impaired. The MDS indicated Resident 20 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, substantial/maximal assist (helper does more than half the effort) with personal hygiene, dressing, toileting, and roll left and right. A review of Resident 20's care plan (CP) for risk of developing pressure sore and other types of skin breakdown related to the aging process and diabetes, revised 12/2/2024, intervention included to use a pressure relieving devices as needed. A review of Resident 20's facility document titled Braden Scale for Predicting Pressure Sore Risk, dated 12/10/2024, indicated Resident 20 was at risk of developing pressure sore. During a concurrent observation and interview on 12/16/2024 at 8:40 AM with Licensed Vocational Nurse (LVN) 1 in Resident 20's room, Resident in bed laying straight on his back noted LAL mattress was set at 240 pounds. LVN 1 stated, the LAL mattress setting was incorrect, Resident 20 ' s current weight was 184 pounds, and the LAL mattress was not set according to the Resident ' s weight. LVN 1 stated, it was important that LAL mattress was at the correct setting for pressure sore management especially for Resident 20 who has right heel blister. A review of Resident 20's facility document titled Order Summary Report (OSR), dated 12/17/2024, the document indicated, to use Low Air Loss Mattress for wound care and management. During an interview on 12/17/2024 at 12:48 PM with Assistant Director of Nurses (ADON), ADON stated, it was the practice of the facility to set the LAL mattress according to the Residents weight, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 14 of 32 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 12/19/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few otherwise it defeats the purpose of using it. ADON stated, Resident 20 has PVD, that affects his wound healing especially in his lower extremity. ADON stated, it was important to set the LAL mattress on the right setting and especially important for wound care and management of Resident 20 ' s right heel, if set incorrectly, the wound may delay healing. A review of Resident 20's facility document titled Monthly Weight Report, dated 12/18/2024, The document indicated Resident 20 ' s December 2024 weight was 184 ponds. During a concurrent observation and interview on 12/19/2024 at 3:00 PM with Treatment Nurse (TN) 1 in Resident 20 ' s room, observed a dark colored blister on Resident 20 ' s right heel, while TN 1 was doing the wound treatment. TN 1 stated, it is important LAL mattress to be set according to the resident ' s weight, otherwise it may delay the process of wound healing of Resident 20 ' s right heel wound. A review of manufactures guidelines for the LAL mattress (Protekt Aire 4000DX/5000DX), (undated), indicated, users can adjust air mattress to desired firmness according to patient ' s weight or the suggestion from a healthcare professional. A review of the facility ' s policy and procedure (P&P) titled, Policy Pressure Reducing Mattress, (undated), indicated, the facility to provide mattresses that will prevent and/or minimize pressure on the skin. A review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised 4/2018, indicated; a) the physician will order pertinent wound treatments, including pressure reduction surfaces, b) the physician will help identify medical interventions related to wound management, and c) the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 15 of 32 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 12/19/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of three sample residents (Resident 70) who was incontinent (no control) of bladder receives appropriate treatment and services for the urinary indwelling catheter (or Foley Catheter is a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent urinary tract infection (UTI an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to: 1. Assess and document presence of sediments (visible solid particles in the urine containing blood, crystals and bacteria, including sloughing of tissue (debris), or cells) in the urine which commonly due to urinary tract infection (UTI). 2. Notify the physician presence of sediments in Resident 70's urine. 3. Securely anchor Resident 70's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent from pulling tractions and dislodgement of the catheter that may result in urethral (a muscular structure that helps keep urine in the bladder until voiding can occur). These deficient practices had the potential to result in accidental dislodgement of the indwelling cathter and result in urethral and bladder trauma, pain and infection that was not treated which could result in urosepsis (severe infection in the blood due to UTI). Findings: During a review of Resident 70 ' s admission Record (Face Sheet), the facility admitted Resident 70 on 11/ 17/2024, with diagnoses including muscle weakness, and chronic kidney disease (the gradual loss of kidney function), with indwelling catheter for benign prostate hyperplasia (BPH - enlarge prostate gland that can cause uncomfortable urinary symptoms). During a review of Resident 70 ' s History and Physical (H&P), dated 11/18/2024 indicated, Resident 70 does not have the mental capacity to make medical decisions. During a review of Resident 70's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/24/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and required extensive assistance from the staff for the activities of daily living. The MDS also indicated Resident 2 had an indwelling urinary catheter. During a review of Resident 70's Care Plan indicated the resident had an alteration in urinary elimination and at risk for UTI secondary to use of Foley Catheter due to: BPH initiated 11/17/2024, indicated. The goal indicated reduce the risk of infection daily through next assessment. One of the interventions was to monitor urine for sediment, cloudiness, odor, blood, and amount of urine output. During a review of the Treatment Administration Record (TAR) indicated Resident 70's urine had no sediments, cloudiness, or foul odor on 12/17/2024 and 12/18/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 16 of 32 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 12/19/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 12/17/2024 at 11:07 AM, in Resident ' s 70 room, Resident 70's indwelling urinary catheter tubing was observed with cloudy urine and sediments. During a concurrent observation and interview on 12/18/2024 at 12:45 PM, in the presence of the Infection Prevention Nurse (IPN), Resident 70's indwelling urinary catheter was observed with sediments in the urine and Resident 70's indwelling urinary catheter tubing was not anchored. IP nurse stated the resident's urinary catheter tubing should be anchored securely to Resident 70's leg to prevent pulling or dislodgement of the catheter. During a review of Resident 70's Order Summary Report, dated 12/17/2024, the Order Summary Report indicated an order on 11/18/2024, indicated the following: 1. Indwelling urinary catheter care every shift 2. Catheter: Monitor Foley Catheter urinary drainage bag and document the following: Color, consistency, odor, hematuria, bladder distention, burning sensation (+) = presence of S/S of UTI, (0)= absence of S/S (signs and symptoms) of UTI and document 'Y' if monitored and any of the above observed, Notify MD (medical doctor/physician) and document in nurses' progress notes. every shift 3. Secure the urinary indwelling catheter tubing with anchor everyday shift to minimize dislodging of catheter. During an interview on 12/19/2024 at 8:25 AM with the Director of Nursing (DON), stated that the TAR did not accurately reflect Resident 70's urine characteristics from the urinary indwelling catheter. DON stated that nursing staff are responsible for monitoring residents' urine daily, reporting any abnormal findings to the physician, and completing a Change of Condition (COC) assessment to document and address such findings. DON stated the urinary indwelling catheter should be anchored securely to prevent dislodgment and decrease the risk of infection or trauma. During a review of the facility's undated policy of Foley Catheter Maintenance indicated to secure Foley tubing with anchor. During a review of the facility's policy and procedure (P&P) titled, Urinary Tract Infections/BacteriuriaClinical Protocol, indicated the staff will identify individual with a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, kidney stones, urinary outflow obstruction etc.) for UTI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 17 of 32 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 12/19/2024 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)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN)/ License Practical Nurse (LPN) per shift on 11/17/2024 up to 12/17/2024 (one month) accordance with the facility ' s policy and procedure titled Posting Direct Care Daily Staffing Numbers. Residents Affected - Many This deficient practice of posting inaccurate nurse staffing information had the potential to cause misleading information to the residents and the visitors of the nursing care provided to the residents. Findings: During a review of the facility documents titled Nursing Hours Projection Staffing Report, dated 11/17/2024 up to 12/17/2024 (one month), the document indicated, the posting nursing hours showed hours worked by License Nurses per shift (not specific to hours worked by RN and/or LVN/LPN). During a concurrent interview and record review, on 12/17/2024, at 3:41 PM, with Director of Nurses (DON), the facility document titled Nursing Hours Projection Staffing Report, dated 12/17/2024 was reviewed. The document indicated the posting nursing hours showed hours worked by License Nurses per shift (not specific to hours worked by RN and/or LVN/LPN). DON stated, the daily nursing posting did not indicate specific hours worked by an RN and/or LVN/LPN as per nursing posting policy. DON stated, the daily nursing postings are to inform the residents and the visitors of the type of nursing care provided to the residents in the facility, so an inaccurate posting may cause misinformation of nursing care. During an interview on 12/17/2024 at 4:15 PM with the Administrator (ADM), stated, she was not aware that the facility ' s daily nursing posting was inaccurate, and she had been using the format for a while. ADM stated, she will make changes right away to adhere to the regulations and the facility ' s policy. During a review of the facility ' s policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised 8/2022, indicated; a)the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to resident, b) within two hours of the beginning of each shift the number of licensed nurses (RNs, LPNs, and LVNs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in clear and readable format, and c) the information recorded on the form shall include, type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility, and the actual time worked during that shift for each category and type of nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 18 of 32 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 12/19/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a supply of Norco (a medication used to treat pain) was available pursuant to an active physician order for one of five residents (Resident 44) observed for medication administration. The deficient practice of failing to maintain an adequate supply of Resident 44 ' s pain medication increased the risk for the resident to experience pain at a higher level for longer than necessary due to the unavailability of his medication that could lead to a decline in his quality of life. Findings: A review of Resident 44 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 12/18/24, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including osteoarthritis of the knee (a medical condition caused by a gradual wearing down of protective cartilage between the bones in the knee joints causing stiffness, swelling, and pain.) A review of Resident 44 ' s History and Physical (H&P - a record of a comprehensive physician ' s assessment), dated 11/15/24, indicated he had the capacity to understand and make decisions. A review of Resident 44 ' s Medication Administration Record (MAR - a summary of all medications administered to a resident), for December 2024, indicated on 11/14/24, Resident 44 ' s attending physician prescribed Norco 5/325 milligrams (mg - a unit of measure for mass) by mouth every four hours as needed for severe pain - pain score 7-10 (a subjective scale for a resident to rate their pain with 0 being no pain and 10 being the worst possible pain.) During an observation and concurrent interview on 12/17/24 at 9:42 AM, Resident 44 was observed with pain, and in an interview Resident 44 rated his pain as 7/10 in both knees and his left shoulder. During an observation on 12/17/24 at 9:54 AM, the Licensed Vocational Nurse (LVN 1) was observed preparing medications for Resident 44 which did not include Norco or any other medication to treat pain. Further observation of the medication cart indicated Resident 44 ' s supply of Norco 5/325 mg was unavailable. During a concurrent interview, LVN 1 stated, according to the physician ' s order, for 7/10 pain, Resident 44 is supposed to receive a dose of the Norco 5/325 mg. LVN 1 stated Resident 44 ' s Norco is unavailable because the resident rarely requests it and typically requests acetaminophen (APAP - a medication used to treat mild pain) instead. LVN 1 stated she will not administer any pain medication until she can call his physician to obtain an order for a higher dose of APAP than is currently available. LVN 1 stated if the resident does not have Norco available, he could experience pain at a higher level or longer than necessary. LVN 1 stated the facility is required to have available all medications for residents for which there is a current, active physician order. LVN 1 stated if Resident 44 uses Norco infrequently, the physician should be contacted to clarify the orders for APAP and discontinue the Norco if necessary. A review of the facility ' s policy Administering Medications, revised 3/2023, indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 19 of 32 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 12/19/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any time frame . A review of the facility ' s policy Ordering and Receiving Medications from the Dispensing Pharmacy, dated April 2008, indicated Medications and related products are received from the dispensing pharmacy on a timely basis reorder medications five days in advance of need to assure an adequate supply is on hand. Event ID: Facility ID: 055670 If continuation sheet Page 20 of 32 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 12/19/2024 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)

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 the entire dose of warfarin (a blood-thinning medication used to prevent life-threatening blood clots from forming) 2.5 milligrams (mg - a unit of measure for mass) was administered via gastrostomy tube (g-tube - a tube surgically implanted in the stomach for feeding and medication administration) in accordance with the physician ' s order on 12/17/24 for one of five residents (Resident 279) who observed during medication administration. Residents Affected - Few The deficient practice of failing to administer Resident 279's entire dose of warfarin 2.5 mg could increase the risk of the resident to develop blood clot and result in a stroke (interruption of blood flow to the brain) or heart attack (lack of or interruption of blood flow to the heart) due to blood clot and/ or other complications resulting from blood clots that could lead to hospitalization or death. Findings: A review of Resident 279 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 12/18/24, indicated she was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation (an irregular heartbeat that comes and goes caused by the formation of blood clots in the heart ' s upper chambers.) A review of Resident 279 ' s History and Physical (H&P - a record of a comprehensive physician ' s assessment), dated 5/22/24, indicated she was able to make decisions for activities of daily living. A review of Resident 279 ' s Order Summary Report (a summary of all active physician orders), dated 12/18/24, indicated on 12/14/24, Resident 279 ' s attending physician prescribed warfarin 2.5 mg via g-tube once daily for afib (atrial fibrillation) for two weeks. During an observation on 12/17/24 at 8:53 AM, the Licensed Vocational Nurse (LVN) 1 was observed preparing Resident 279 ' s dose of warfarin 2.5 mg by crushing the blue/green colored tablet and mixing the resulting powder with approximately 10 milliliters (ml - a unit of measure for volume) of water. During an observation on 12/17/24 at 9:15 AM, LVN 1 was observed administering a portion of the dose of warfarin to Resident 279 via the g-tube. Further observation indicated a significant amount of blue/green residue in the medication dosage cup remained after the administration of warfarin. During an interview on 12/17/24 at 9:22 AM, LVN 1 stated she failed to administer the complete dose of warfarin for Resident 279. LVN 1 stated she estimated she administered approximately half of the dose based on the amount of blue/green residual left in the medication cup. LVN 1 stated warfarin was used as a blood thinner to prevent blood clots from forming and not administering the full dose could put the resident at increased risk for strokes or other medical complications which could be life-threatening. A review of Resident 279 ' s Medication Administration Record (MAR - a record of all medications administered to a resident), for December 2024, indicated on 12/17/24 the administration of warfarin indicated other/see progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 21 of 32 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 12/19/2024 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)

F 0760 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 LVN 1 ' s progress note entry for warfarin, dated 12/17/24 at 10:56 AM, indicated During med pass for 9AM meds, approximately 50% was administered. MD made aware, Awaiting for new orders. A review of the facility ' s policy Administering Medications, revised March 2023, indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any time frame . Event ID: Facility ID: 055670 If continuation sheet Page 22 of 32 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 12/19/2024 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare and served food and menus that meet resident choices including their nutritional needs by failing to: 1. Ensure [NAME] 1 and [NAME] Assistant uses and have access to preparation guides and recipes during food preparation or puree diet (blended until they reach a smooth consistency) and thickened liquids for 18 of 18 residents receiving puree diet. 2. Ensure one of three sampled residents ( Resident 17) received double portion of meat as specified in the physician's order. This had the potential for residents to not receive the nutrition they need that could lead to food dissatisfaction and weight loss. Findings: 1.During a tray line observation on 12/17/2024 at 11:45 AM, [NAME] 1 was observed preparing a puree diet by scooping a powder of thickener (products used to modify the consistency of drinks, helping people with dysphagia (difficulty swallowing to control the way they swallow ) directly from the jar and adding it to the mixture using a 4-ounce cup. This process was repeated three additional times, resulting in a total of four full cups of thickener into the liquid. During a tray line observation on 12/17/2024 at 11:49 AM, the cook assistant was observed preparing puree vegetables without referencing from the facility's recipe or procedure guide. During an interview on 12/17/2024 at 11:49 AM with the Dietary Supervisor (DS), DS stated that [NAME] 1 did not have a preparation guide or recipe available during the process, DS stated that food preparation guide should be readily available when preparing food. DS stated that using a food preparation guide ensures that the correct ingredients, portions, and preparation methods are followed to meet these dietary restrictions and provide safe, nutritious meals. DS stated that incorrect proportions of food ingredients can affect the texture and taste, causing liquids to be too thick or too thin. DS stated that following the food preparation guide ensures the right consistency and safety when consumed by the residents with problems with swallowing. DS stated there were currently 18 residents receiving pureed diets. During a review of the Recipe: Pureed Meats, indicated to add stabilizer (an agent added to food products to help maintain or enhance their original texture, physical and chemical characteristics) to increase the density of the pureed food if needed. If using commercial food thickener, check can for directions on usage, otherwise see above for recommendation amount of stabilizer. Recommendations for a 24 serving amount required 12 to 24 Tablespoon (Tbsp) an equivalent to ¾ -1 ¼ cups of instant food thickener. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, indicated that all recipes in use shall be standardized and will be maintained in a file or book accessible to the dietary staff. Recipes used are consistent with what is on the menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 23 of 32 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 12/19/2024 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm 2. uring a review of Resident 17 ' s admission Record (Face Sheet), the facility admitted Resident 17 on 11/09/2024 , and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis), and diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Residents Affected - Few During a review of Resident 17 ' s History and Physical (H&P), dated 7/9/2024 indicated, Resident 17 does not have the mental capacity to make medical decisions. During a review of Resident 17's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/14/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and needed moderate assistance from the staff for the activities of daily living. During a review of Resident 17's Order Summary Report, dated 11/25/2024, the Order Summary Report indicated an order on 7/9/2024 to give Resident 17 a Renal 80g (grams a unit of measurement), controlled carbohydrate (CCHO), No Added Salt (NAS) diet, regular texture, and thin consistency, with a specific instruction to provide a double portion of protein at all meals. During dining observation on 12/16/2024 12:15 PM, in the dining room, Resident 17 was not provided double portion of protein diet. The meal ticket did not indicate to provide the resident double portion of protein at all meals and one slice of fish was served in the resident ' s plate. During the tray line observation on 12/17/2024 11:55 PM, Resident 17 ' s meal ticket did not indicate the need to provide a double portion of protein, as specified in the resident's diet ordered by the physician. During a dining observation on 12/17/2024 12:25 PM, in the dining room, Treatment Nurse (TN) was assisting in the dining room and passing meal trays. TN verified using the diet order form listed that Resident 17 ' s diet did not indicate double portion of protein. TN stated that following the correct dietary order is essential to ensure residents receive the proper nutrition necessary for their health and well-being. During an interview on 12/17/2024 12:25 PM, with the DS, the DS stated that nursing staff provided her with updated dietary orders, and she was responsible for updating the meal tickets accordingly.DS stated that she must have missed the order specifying the double portion of protein for the Resident 17. DS stated that as a result, the resident did not receive the correct meal as prescribed in their dietary order. During an interview on 12/17/2024 at 1:35PM, the Assistant Director of Nursing (ADON), stated that new dietary orders are placed in a binder and provided to the dietary department for updates. During a review of the binder with the ADON, the ADON stated there was no order update found for Resident 17 indicating a double portion of protein. During a review of the facilities policy Diet Orders, indicated that upon admission, Nursing will transcribe the diet order as it is written by the physician on the Diet Order Communication form. Forms are sent to the Dietary Department prior to meal services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 24 of 32 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 12/19/2024 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)

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 proper sanitation and food handling practices in accordance with the facility ' s policy and procedure by failing to ensure the scoop was not left inside the thickener (products used to modify the consistency of drinks, helping people with dysphagia [difficulty swallowing to control the way they swallow]) container/bin after each use. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) food. Findings: During a kitchen observation on 12/17/24 12:30 PM, in the presence of the Dietary Supervisor (DS), a scoop was found inside the thickener container with its handle touching the contents. DS stated that the scoop should not have been left inside the container because the handle could introduce bacteria or other contaminants, leading to cross-contamination (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility's policy and procedure (P&P) titled, Storage of Canned and Dry Goods indicated food, and supplies will be stored properly in a safe manner. In addition, the scoops should not be left in the container and will be cleaned after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 25 of 32 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 12/19/2024 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)

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-a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to develop and evaluate a QAPI plan to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) were transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67) which was an identified care area concern from the last annual recertification survey conducted from 12/18/2023 to 12/21/2023. Residents Affected - Some These deficient practices had resulted in the late MDS transmission to the CMS data system that affects the care planning, quality of care and quality of life of the residents. Findings: 1. During a review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 4/30/2024 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 hyperlipidemia (a condition where there are high levels of fat in the blood). During a review of Resident 2 ' s MDS summary indicated the Quarterly MDS with Assessment Reference Date (ARD) of 11/12/2024, was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 2 ' s MDS 3.0 [NAME], indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to the CMS system (nine days late for submission as 12/19/2024). 2. During a review of Resident 24 ' s admission Record indicated the facility admitted Resident 24 on 8/9/2021 and readmitted on [DATE] with diagnoses that included dementia and heart failure (a serious condition that occurs when the heart is unable to pump enough blood to meet the body's needs). During a review of resident 24 ' s MDS Summary, indicated the Quarterly MDS with ARD date of 9/11/2024, was completed on 9/25/2024, and was submitted to CMS on 11/6/2024 (28 days late for submission). 3. During a review of Resident 25 ' s admission Record indicated the facility admitted Resident 25 on 6/18/2019 and readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes extreme mood shifts, affecting a person's energy, thinking, behavior, and sleep) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of resident 25 ' s MDS Summary, indicated the Quarterly MDS with ARD of 9/127/2024, which was completed on 10/11/2024, was accepted by CMS on 12/18/2024 (68 days late for submission). 4. During a review of Resident 26 ' s admission Record indicated the facility admitted Resident 26 on 5/1/2024 with diagnoses that included Parkinson ' s disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns) and seizure (a temporary, abnormal burst of electrical activity in the brain that can cause a sudden change in behavior, movement, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 26 of 32 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 12/19/2024 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)

F 0865 or consciousness). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 26 ' s MDS Summary, indicated the Quarterly MDS with ARD of 11/13/2024, which was completed on 11/13/2024, was due for submission to CMS by 11/27/2024. Residents Affected - Some During a review of Resident 26 ' s MDS 3.0 [NAME], indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (22 days late for submission as 12/19/2024). 5. During a review of Resident 48 ' s admission Record indicated the facility admitted Resident 48 on 4/25/2022 with diagnoses that included dementia and seizure. During a review of Resident 48 ' s MDS Summary, indicated the Quarterly MDS with ARD of 11/9/2024, which was completed on 11/23/2024, was due for submission by 12/7/2024. During a review of Resident 48 ' s MDS 3.0 [NAME], indicated the status for Quarterly Assessment, dated 11/9/2024, was ready to be exported but no indication that it was transmitted to CMS timely (12 days late for submission as 12/19/2024). 6. During a review of Resident 61 ' s admission Record indicated the facility admitted Resident 61 on 1/29/2024 and readmitted on [DATE] with diagnoses that included dementia and heart failure. During a review of Resident 61 ' s MDS Summary, indicated the Quarterly MDS with ARD of 11/12/2024, which was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 61 ' s MDS 3.0 [NAME], indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (nine days late for submission as 12/19/2024). 7. During a review of Resident 55 ' s admission Record indicated the facility admitted Resident 55 on 8/3/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 55 ' s MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/4/2024, which was completed on 9/18/2024, was accepted by CMS 12/18/2024 (91 days late for submission). 8. During a review of Resident 67 ' s admission Record indicated the facility admitted Resident 67 on 7/17/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 67 ' s MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/7/2024, which was completed on 9/21/2024, was accepted by CMS on 12/18/2024 (88 days late for submission). During an interview on 12/18/2024 at 11:16 AM with the MDS Nurse (MDSN), the MDSN stated she was responsible to make sure all the residents ' MDS assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) system timely. The MDSN stated once the MDS assessment was completed, the facility has 14 days to transmit the MDS to the CMS system. The MDSN stated she was aware that the facility had not ensure all the MDS assessments were transmitted timely, even with the extra help of a part time MDSN who was hired in October this year. The MDSN stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 27 of 32 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 12/19/2024 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)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some busy with other tasks and did not have time to transmit the MDS timely and she was not 100 percent doing her job. The MDSN stated the late submission of the MDS would delay the accuracy of the resident ' s assessment and affect resident ' s care negatively. 9. During a review of Resident 14's admission Record indicated the facility originally admitted Resident 14 on 7/31/2024 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), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries that supply blood to the heart). During a concurrent interview and record review, on 12/18/2024, at 1 PM, with MDS Nurse (MDSN), indicated Resident 14's Electronic Health Records (EHR) of the Quarterly MDS was completed on 11/21/2024 and was transmitted to CMS by 12/5/2024. MDSN stated, the submission of the MDS was late, it should have been submitted 14 days after completion date on 11/21/2024. The MDSN stated, she was not able to submit the MDS timely, since she was just busy with my other responsibilities as an MDS Nurse. 10. During a review of Resident 49's admission Record indicated the facility admitted Resident 49 on 4/29/2024 with diagnoses that included schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), Chronic Obstructive Pulmonary Disease (COPD- a common lung disease that makes it difficult to breathe), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a concurrent interview and record review, on 12/18/2024, at 1:30 PM with MDSN, Resident 49's EHR indicated, the Quarterly MDS was completed on 11/24/2024 and was transmitted to CMS on 12/18/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 12/8/2024, which was 14 days after completion date on 11/24/2024. 11. During a review of Resident 71's admission Record indicated the facility admitted Resident 71 on 9/3/2024 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), kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), and gastroparesis (paralysis of the stomach). During a concurrent interview and record review, on 12/18/2024, at 3:47 PM with MDSN, Resident 71's EHR indicated the admission MDS was completed on 9/16/2024, and was transmitted to CMS on 10/7/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 9/30/2024, which was 14 days after completion date. During an interview on 12/19/2024 at 2:30 PM with Director of Nurses (DON), 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 plan of care that could be developed based on the residents' status. During an interview on 12/19/2024 at 2:30 PM, with the Administrator (ADM), the ADM stated she and the Director of Nursing (DON) were overseeing the completion and submission of the MDS assessment, and they were aware that the facility had the deficiency of late submission of the MDS assessment during the previous recertification survey. The ADM stated they noticed some of the MDS assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 28 of 32 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 12/19/2024 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)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were submitted late in September this year, so they verbally communicated the issue and hired a part-time MDS Nurse to assist the current full time MDSN on 10/2/2024 to try to complete and transmit the MDS assessment timely. The ADM stated the late submission of the MDS assessment was still an ongoing issue, but they did not have any documentation of addressing this issue and developing a plan to resolve this issue in the facility ' s QAPI until now. The ADM stated there was no excuse for the facility to transmit the MDS assessment late and they would monitor the MDS assessment on a weekly basis and working with the corporate MDS consultant and the staff to ensure timely submission. During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program, revised on 2/2020, the P&P indicated the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for their residents. The QAPI committee oversees implementation of the QAPI plan, a written component, which describes the process for identifying and correcting quality deficiencies. Key components of this process include: A. tracking and measuring performance. b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing deficiencies, d. systematically analyzing underlying causes of systematic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities. f. monitor or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 29 of 32 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 12/19/2024 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)

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 30 out of 31 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 that measured less than 80 sq. ft. per resident. This deficient practice had the potential to affect the delivery of care and services of the staffs the residents which can affect the privacy to the residents. Findings: During a concurrent interview and record review on 12/17/2024 at 10:30 AM, 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 12/17/2024, indicated there were 30 resident bedrooms in the facility that measured less than 80 sq. ft. per resident care area. The CAA indicated 30 resident bedrooms did not measure 80 sq. ft. per resident as listed below: Rooms - Sq. Ft Number Beds/Resident 1 151.2 2/2 2 144.88 2/1 3 134.88 2/2 4 156.76 2/2 6 159.18 2/2 7 141.47 2/ 2 8 149.54 2/2 9 141.47 2/2 10 149.66 2/2 11 141.47 2/2 12 141.64 2/2 14 314.27 4/4 15 291.48 4/4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 30 of 32 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 12/19/2024 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)

F 0912 16 291.48 4/4 Level of Harm - Potential for minimal harm 17 291.48 4/4 18 144.42 2/2 Residents Affected - Some 19 144.51 2/2 20 291.48 4/4 21 291.48 4/4 22 144.54 2/2 23 291.48 4/4 24 144.58 2/2 25 291.48 4/4 26 149.85 2/2 27 148.01 2/2 28 138.99 2/2 29 145.91 2/2 30 138.99 2/2 31 145.91 2/2 32 138.92 2/2 During a concurrent observation and interview on 12/18/2024 at 1:16 PM, with Resident 38. Resident 38 was wheeling himself in the hallway to his room. Resident 38 stated he shared a room with a roommate and the current room size was enough for him to transfer from bed to the wheelchair and move in and out the room. Resident 38 stated the room size did not affect his comfort and care. During an interview on 12/19/2024 at 8:54 AM, with Resident 24. Resident 24 stated he did not have any issue with the current size of the room. During an interview on 12/19/2024 at 10:20 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated some of the rooms were smaller in size, but they were able to move around the bedside tables, the bed or equipment around to provide safe and necessary care to the residents. During an interview on 12/19/2024 at 10:31 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated there was no issue with the current room size of the rooms in the facility. LVN 2 stated they could maneuver wheelchair, shower chair and Hoyer lift (a device used to transfer residents from bed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 31 of 32 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 12/19/2024 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)

F 0912 chair and chair to bed) in the room, and provided care to the residents safely. Level of Harm - Potential for minimal harm During the re-certification survey observations, and interviews with residents and facility staff between 12/18/2024 and 12/19/2024, 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. Residents Affected - Some During the review of the facility ' s Variance request, dated 12/17/2024, 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 32 of 32