Health inspection·April 4, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (the cause of a disease) of Resident 1's cardiac arrest (when heart stopped beating) was Respiratory/Asphyxia (a condition where the body doesn't get enough oxygen due to a problem with breathing or inhaling). On 4/3/2025 at 5:33 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) regarding the facility's failure to notify Physician 1 or PA 1 of Resident 1's significant change of condition, in accordance with the facility's policy & procedure (P&P) on Change of Condition Notification and physician order to notify the physician for adverse reactions as a result from the use of Eliquis. The surveyor notified the ADM of the IJ situation on 4/3/2025 at 5:33 PM, due to LVN 1 and RNS 1 failures to consult and notify Physician 1 or PA 1 of a resident's significant change in condition on 2/25/2025. On 4/4/2025 at 1:49 PM, the ADM provided CDPH with an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 4/4/2025 at 3:18 PM, the surveyor notified the ADM and the DON that the IJ was removed based on onsite verification/confirmation of the facility's full implementation of the IJ Removal Plan (a detailed plan to address the IJ findings) through observations, interviews, and record reviews. Following the removal of the IJ, the facility's noncompliance remained at a scope (refers to how widespread a deficiency is) and severity (level of harm) of G (isolated [one or a very limited number of residents are affected], actual harm, that is not immediate jeopardy). The acceptable IJ Removal Plan included the following: 1. On 4/3/2025, the DON and Assistant DON (ADON) notified the nursing staff (all licensed nurses) of findings outlined in the IJ dated 4/3/2025 and conducted in-services for all nursing staff (21 licensed nurses and 42 certified nursing assistants (CNAs) regarding the Change of Condition policy. The training covered: a. Utilizing the Interact (electronic records software) early warning toll-stop and watch technique to report any possible resident's changes in condition. b. Utilizing the SBAR [Situation, Background, Assessment, Recommendation] form to record the change of condition to ensure accuracy and completeness that included current vital signs ((measurable indicators that reflect a person's basic physiological functions and overall health status), detailed description of the identified situation, any drainage observed, interventions provided including physician notification. c. The anticoagulant monitoring which includes but not limited to: discolored urine, black tarry stools (dark, sticky, and foul-smelling stools that are a result of digested blood in the digestive tract), nausea/vomiting or diarrhea, bruising/bleeding, abnormal vital signs, shortness of breath, and change in mental status. d. Timely physician notification for the onset of changes in condition, including the identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 2 of 8 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 04/04/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few signs related to anticoagulant adverse reaction monitoring. During the in-service, the DON emphasized the importance of notifying the physician upon identification of the situation to avoid any possible delay. 2. On 4/4/2025, the facility pharmacist was contacted and will complete in-service today to licensed nurses regarding black box warning. During the in-service, the pharmacist will educate the following areas: a. Following physician's orders/instructions for residents with medications labeled black box (most serious warning label, indicating a medication carries a serious risk of adverse effects, including death) warning, such as specific monitoring, laboratory tests, etc., b. Creating and implementing the care plan c. Notifying the physician if any identified signs of adverse reaction 3. On 4/3/2025, the DON notified the staff who could not complete the in-services must receive an in-service upon their return before their shift. 4. On 4/3/2025, the facility notified the facility Medical Director of the IJ and the IJ Removal Plan. The Medical Director reviewed and approved the IJ removal plan. 5. On 4/3/2025, the ADM completed the Quality Assurance and Performance Improvement (QAPI -a structured framework that helps healthcare organizations continuously improve the quality of care and patient safety) Plan for identifying and notifying the physician of resident change of condition. The Medical Director will review the QAPI program for change of condition/physician notification every month and assist the facility in adjusting the measures as necessary. 6. On 4/3/2025, LVN [1] assigned to Resident 1 received disciplinary action pending investigation. The DON provided one-to-one in-service with LVN 1 regarding physician notification prior to the suspension. 7. As of 4/3/2025, a total of 28 current residents are receiving anticoagulant therapy. All 28 residents who have anticoagulant orders have monitoring for adverse reactions in the electronic medication administration record. 8. Effective 4/3/2025, the DON will conduct a monthly in-service for nursing staff (licensed nurses and CNAS) regarding change in condition for three months. 9. Effective 4/3/2025, the DON and/or ADON will review the change of condition daily, to ensure timely physician notification of any onset signs or symptoms. 10. On 4/3/2025, the DON created a change of condition monitoring log, which includes the physician notification of any changes. The DON notified nursing staff of the monitoring process and will document the findings and corrective action in the monitoring log for three months. If any issues are identified, the DON will extend the monitoring period for an addition of three months. 11. The DON/RNS will make daily rounds (a planned visit by facility staff, to assess a resident's condition and check what type of care/assistance is needed) to ensure that any resident changes in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 3 of 8 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 04/04/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety condition is being reported and addressed. The DON/RNS would provide a one-to-one inservice if any issues identified. 12. On 4/3/2025, the facility initiated a QAPI for physician notification of changes in condition to address the findings outlined in the IJ template. The facility will review the progress every month for 3 months and adjust the measures as needed to ensure an effective and consistent plan. Residents Affected - Few Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 5/1/2024, with diagnoses that included Parkinsonism (a term used to describe a collection of movement symptoms associated with several conditions), dysphagia (difficulty swallowing), and long-term use of anticoagulants (the ongoing and indefinite use of medication to prevent blood clots). During a review of Resident 1's History & Physical (H&P) assessment dated [DATE] signed by PA 1, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had the following present illnesses: orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), hypertension (high blood pressure), chronic kidney disease (progressive damage and loss of function in the kidneys), and seizures (a sudden, temporary alteration of behavior, movement, or consciousness caused by abnormal electrical activity in the brain). During a review of Resident 1's Minimum Data Set (MDS, a federally required assessment and screening tool) dated 2/13/2025, the MDS indicated Resident 1 had severely impaired (significantly limits one person's physical or mental ability to do basic work activities) cognition (thought process). The MDS indicated Resident 1 required substantial/maximal assistance (a helper provides more than half of the effort required for a patient or resident to complete an activity) for chair/bed-to-chair transfer, sit to stand position, and bathing. The MDS indicated Resident 1 required partial/moderate assistance for personal hygiene, eating, toileting hygiene, rolling left and right, and sit to lying position. During a review of Resident 1's care plan titled Apixaban (generic name for Eliquis): At risk for adverse effect from black box medication dated 8/13/2024, the care plan indicated Resident 1's risk for the use of a black box medication and would be monitored/identified by the licensed nurse. The care plan indicated the physician would be notified promptly of any adverse reactions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician orders: a. A physician's order dated 9/3/2024, to administer Eliquis Oral Tablet 2.5 milligrams (mg, unit of measure) give 1 tablet by mouth two times a day for deep vein thrombosis (DVT -a condition where a blood clot forms in a deep vein, typically in the lower legs or thighs) prophylaxis (action taken to prevent disease). b. A physician's order dated 9/28/2024, to monitor anticoagulation medication (Eliquis) for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of mental alertness, sleepy), bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifice, and abnormal labs; to document 'N' (No), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 4 of 8 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 04/04/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few if monitored and none of the above observed. Document 'Y' (Yes), if monitored and any of the above observed. The order indicated to notify physician and document in nurses' progress notes, every shift. During a review of Resident 1's Change of Condition (COC) Form - Situation Background Assessment Recommendation (SBAR) dated 2/25/2025 timed at 1:25 PM, written by LVN 1, the SBAR indicated on 2/25/2025 at 7:10 AM, Resident 1 was seen in bed by LVN 1 with chest rising up and down, responsive to verbal and tactile stimuli (any form of touch or physical contact that is perceived by the skin), resident was provided breakfast and ate 20% of breakfast . The SBAR indicated at 8:42 AM, Resident 1's vital signs obtained during medication administration indicated a BP at 108/84, pulse at 76 beats per minute (normal rate between 60 to 100 beats per minute), respiratory rate (normal rate between 12 to 20 breaths per minute) of 18 breaths per minute, oxygen saturation of 97% on room air, no pain, temperature of 97.8 degrees Fahrenheit (F, unit of measurement - normal range of temperature between 96 to 99 degrees Fahrenheit). Resident 1 received all due medication administered as ordered by the physician with no ASE (adverse side effects) noted. The SBAR indicated that at 9 AM, Resident 1 remained in bed awake and was assisted with activities of daily living (ADLs - basic tasks individuals perform daily for self-care and personal independence, such as bathing, dressing, toileting, and eating) by the CNA. The SBAR indicated Resident 1 had one episode of emesis. The SBAR indicated that at 11 AM, Resident 1 was in bed with nonlabored (easy, effortless, and comfortable) breathing, awaken to administer due medication. No ASE noted. resident kept clean and dry and comfortable. The SBAR further indicated that at 11:30 AM, Resident 1 had another episode of emesis, no shortness of breath (SOB) or distress noted. The SBAR further indicated that at 12:40 AM, Resident 1 was in bed sitting up and awake, the CNA (unknown) tried to assist with lunch and Resident 1 did not eat. The SBAR noted Resident 1 was left in bed with the head of bed (HOB) elevated with bed in the lowest position, call light within reach. The SBAR further indicated that at 1 PM, During rounds, [Resident 1] was in bed, no SOB or pain or discomfort noted. The SBAR further indicated that at 1:25 PM, during [RNS 1] rounds, Resident 1 was noted with SOB and pale skin color. Vitals signs obtained with BP at 98/72 mm/Hg, pulse was 81 beats per minute, respiratory rate at 17 breaths per minute, oxygen saturation was 87% on room air and 92% with non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen) at 15 liters (L, unit of measure) per minute . The SBAR indicated 911 emergency services was called due to Resident 1's desaturation (abnormal drop in blood oxygen levels) and hypotension. The SBAR further indicated that EMS arrived (no time indicated) and took over. The SBAR indicated, during EMS assessment the resident had one more episode of emesis. The SBAR Note indicated Resident 1's Physician Assistant (PA 1) was made aware and Family member (FM) 1 was notified. The SBAR indicated that at 1:36 PM, Resident 1 was transferred to GACH 1 via 911 EMS. During a review of Resident 1's Transfer Record dated 2/25/2025 timed at 1:30 PM, handwritten by RNS 1, the Transfer Record indicated Resident 1's reason for transfer were ALOC, desaturation, and three episodes of emesis. The record indicated Resident 1's vital signs were temperature of 97.4 F, pulse 118 beats per minute, respiratory rate was at 17 breaths per minute, BP was at 68/78 mm/Hg, and oxygen saturation of 86%. The Transfer Record indicated Resident 1's additional reason for transfer was altered mental status (a general term referring to a change to your average mental function), weakness, and shortness of breath. During a review of Resident 1's EMS Report dated 2/25/2025, the EMS Report indicated upon EMS arrival to the facility at 1:32 PM, Resident 1 was lying in bed. The EMS report indicated a facility staff (unknown staff) stated they contacted EMS due to resident being altered (any condition which is significantly different from a normal waking state) approximately one hour prior to EMS arrival. The EMS report indicated Resident 1 was found in respiratory failure and ventilated (to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 5 of 8 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 04/04/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety force air in and out of the lungs of a person who cannot breathe easily on their own), with bag-valve-mask (BVM, a medical device used to provide air and oxygen to person who are not breathing or breathing adequately). The EMS report indicated Resident 1 was hypotensive and apneic (breathing is interrupted by the airway blocking the flow of air) and lifted onto the gurney (wheeled stretcher) and loaded into the ambulance. The EMS report indicated [Resident 1] had coffee ground emesis prior to EMS arrival (at the facility) and was suctioned multiple times throughout treatment and transport. Residents Affected - Few During a review of Resident 1's GACH 1 record titled Emergency Documentation dated 2/25/2025 documented at 3:12 PM, the GACH 1 record indicated Resident 1 was presented in by EMS to GACH 1 for cardiac arrest. The GACH 1 record indicated that according to EMS verbal report, the facility reported to EMS that [Resident 1] was altered from this (2/25/2025) morning and was also noted to have coffee-ground emesis around his mouth. The GACH 1 record indicated upon EMS arrival to GACH 1, [Resident 1] was found to be in respiratory arrest (a state in which a patient stops breathing but maintains a pulse) and shortly thereafter, went into cardiac arrest. During a telephone interview with Family (FM) 1 on 4/2/2025 at 2:07 PM, Family 1 stated she received a call from RNS 1 on 2/25/2025 at around 1:27 PM to inform FM 1 that EMS was called for Resident 1 due to low oxygen saturation and blood pressure. Family 1 stated she was informed by RNS 1 that Resident 1 was fine the morning of 2/25/2025, until staff noticed Resident 1's BP and oxygen saturation were low. FM 1 stated RNS 1 did not mention any other symptoms from Resident 1. FM 1 stated she requested for a verbal report of what happened to Resident 1, from the facility and was told later by the former Director of Nursing (DON 2) that Resident 1 had vomited. FM 1 stated when FM 1 was cleaning out Resident 1's belongings, Resident 1's roommate at that time (on 2/25/2025) told FM 1 that the CNAs got Resident 1 out of bed to use the bathroom. Family 1 stated that facility staff have never taken Resident 1 to the bathroom. FM 1 stated she was unsure if the facility gave FM 1 a reliable report about what happened to Resident 1 on 2/25/2025. FM 1 stated she received a copy of Resident 1's EMS report and was questioning what really happened that day. Family 1 stated if the facility noticed the coffee ground emesis, why would the facility's licensed nurses not act upon Resident 1's change in condition right away? Family 1 stated she felt the facility's licensed nurses should have done something to help Resident 1 sooner. During a concurrent interview on 4/2/2024 at 3:17 PM with LVN 1 and record review of Resident 1's COC and SBAR notes dated 2/25/2025 documented at 1:25 PM, LVN 1 stated she documented Resident 1's SBAR on 2/25/2025. LVN 1 stated Resident 1 had an episode of emesis at 9 AM and 11:30 AM, however, LVN 1 stated she could not recall the color and consistency of Resident 1's emesis. LVN 1 stated after lunch on 2/25/2025, RNS 1 was doing her rounds and saw Resident 1's oxygen saturation was under 90%. LVN 1 stated she could not recall the exact time RNS 1 found Resident 1 and stated Resident 1 was given oxygen supplement via non-rebreather mask and was effective because Resident 1's oxygen saturation level was going back up. LVN 1 stated she could not recall what Resident 1's vital signs were. LVN 1 stated she could not recall who called the EMS on 2/25/2025. LVN 1 stated Resident 1 was confused most of the time and was alert and oriented to only his name. LVN 1 stated she was in Resident 1's room when EMS arrived, and they took over care Resident 1. LVN 1 stated Resident 1 had vomited but could not recall what the vomit looked like, including the color of Resident 1's vomit. LVN 1 stated Resident 1's vomiting occurred during the time the EMS was in the facility and LVN 1 stated she could not recall if Resident 1 had any other episodes of emesis earlier that day. LVN 1 stated if a resident would have 2 to 3 episodes of emesis, the licensed staff would monitor the resident and report to the physician. LVN 1 stated she did not remember calling Resident 1's physician or PA 1. LVN 1 stated she could not recall much of what happen to Resident 1 on 2/25/2025. LVN 1 stated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 6 of 8 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 04/04/2025 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 0580 1 could not recall if Resident 1 had other symptoms earlier that morning of 2/25/2025. Level of Harm - Immediate jeopardy to resident health or safety During an interview with RNS 1 on 4/2/2025 at 3:31 PM, RNS 1 stated she arrived at the facility for work at 12:30 PM on 2/25/2025. RNS 1 stated she conducted her resident rounds and noticed Resident 1's skin was pale and had shortness of breath. RNS 1 stated she took Resident 1's vital signs and Resident 1's BP was low. RNS 1 stated Resident 1's systolic pressure (the top number in blood pressure) was below 90 mm/Hg and could not recall if she documented Resident 1's low BP in the resident's record. RNS 1 stated that on 2/25/2025 when RNS 1 saw Resident 1, Resident 1 was not alert or talking. RNS 1 stated she placed Resident 1 on oxygen via a non-rebreather mask. RNS 1 stated when the EMS arrived at the facility, Resident 1 had an episode of emesis that appeared dark. RNS 1 stated she could not recall if Resident 1 had an episode of emesis earlier that day, on 2/25/2025. RNS 1 stated if resident had an episode of emesis, per protocol she would notify the physician. RNS 1 stated she remembered notifying Resident 1's family and PA 1 after 911 EMS took Resident 1 to GACH 1. Residents Affected - Few During an interview with LVN 1 on 4/2/2025 at 4:03 PM, LVN 1 stated she recalled seeing emesis on the gurney Resident 1 was transferred onto by EMS but could not recall what Resident 1's emesis looked like. LVN 1 stated she still could not recall Resident 1's episodes of emesis as documented in Resident 1's SBAR note on 2/25/2025. LVN 1 stated that if Resident 1 had episodes of emesis earlier that day, on 2/25/2025, LVN 1 acknowledged that she would have notified the physician. LVN 1 stated Resident 1 could have an underlying condition, and she should have documented Resident 1's vital signs and a description of the emesis episodes at the time. During a telephone interview with CNA 1 on 4/2/2025 at 5:48 PM, CNA 1 stated when he came to work during the morning shift (7AM to 3 PM) on 2/25/2025 and conducted resident rounds he noticed Resident 1 looked off (something is not quite right or that someone is not functioning or appearing as expected). CNA 1 stated Resident 1 was looking off for a while during that morning (2/25/2025). CNA 1 stated Resident 1 did not look too well, Resident 1 was pale in color, confused and not talking. CNA 1 stated that on the same day, he was instructed by LVN 1 to take Resident 1 to the bathroom. CNA 1 stated prior to taking Resident 1 to the bathroom, Resident 1 appeared pale and weak, but CNA 1 still assisted Resident 1 to the bathroom. CNA 1 stated he could not recall if Resident 1 had an episode of emesis that day, but CNA 1 was accompanied by CNA 2. CNA 1 stated after taking Resident 1 to the bathroom, that is when RNS 1 saw Resident 1's condition and called 911. CNA 1 stated EMS arrived and since there were so many staff he backed away. During a telephone interview with CNA 2 on 4/2/2025 at 6 PM, CNA 2 stated he remembered Resident 1 did not have a bowel movement so together with CNA 1, they brought Resident 1 to the bathroom. CNA 2 stated after Resident 1 had a bowel movement, RNS 1 stated Resident 1 did not look well, so RNS 1 called 911. CNA 2 stated Resident 1 was puking (vomiting), but could not recall how many times Resident 1 puked. CNA 2 stated Resident 1's puking occurred before the 911 EMS arrived at the facility. CNA 2 stated when Resident 1 was brought back to bed he saw puke at the side of Resident 1's bed and it was Black, it was something dark. CNA 2 stated when CNAs see something unusual, CNAs would notify the nurse. CNA 2 stated he recalled They (licensed nurses) were saying he [Resident 1] was puking something dark during the day. CNA 2 stated [LVN 1] said he [Resident 1] was puking something like that (dark) during the day. During a telephone interview with PA 1 on 4/3/2025 at 1:18 PM, PA 1 stated she manages Resident 1's care while residing at the facility. PA 1 stated she was notified by the facility of Resident 1 being transferred to GACH 1 via text message on 2/25/2025, after 911 EMS took Resident 1. PA 1 stated she looked back at her text messages, but that was the only time she was notified what happened to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 7 of 8 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 04/04/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident 1 on 2/25/2025. PA 1 stated she was not notified by LVN 1 or RNS 1 about any episodes of emesis prior to Resident 1 being transferred by 911 EMS to GACH 1. PA 1 stated if Resident 1 had any episodes of emesis earlier that day (2/25/2025) PA 1 would have expected the licensed staff to notify her, and PA 1 would have ordered the licensed nurses to call 911 EMS immediately or earlier that day. PA 1 stated she spoke with Resident 1's family (FM 1) (unknown date) and FM 1 mentioned Resident 1 had vomited that day (2/25/2025) prior to 911 arriving at the facility. PA 1 stated In hindsight (refers to the ability to understand or judge an event or situation only after it has happened), they did tell me the resident had coffee ground emesis earlier that day (2/25/2025). PA 1 stated the licensed nurses were even pretty good at reporting when Resident 1 vomits once before. PA 1 stated Yes, I did not find out about [Resident 1's] coffee ground emesis until a week later. When asked, PA 1 stated it was the ADM that told her Resident 1 had coffee ground emesis. PA 1 stated having coffee ground emesis could mean something was obviously going on internally in Resident 1 like bleeding. During a review of the facility's policy and procedure (P&P) titled Anticoagulation-Clinical Protocol dated 3/2023 indicated to assess for any signs or symptoms related to adverse drug reactions due to medication alone in combination with other medications. The P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. The P&P indicated if an individual on anticoagulation therapy shows signs of excessive bruising hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. During a review of the facility's policy and procedure (P&P) titled First Aid Treatment-Crash Cart/Emergency Response dated 3/2023, the P&P indicated to contact the EMS immediately for the following situations: unconsciousness or altered consciousness, difficulty or absence of breathing, severe bleeding, vomiting blood or blood in stool, condition is not clear or is worsening. The P&P indicated regardless of the nature or severity, any resident's injury/situation shall be reported to the resident's attending physician and family and documented in the resident's medical record. During a review of the facility's P&P titled Change in a Resident's Condition or Status dated 3/2023, the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a (an): significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/treatment center; specific instruction to notify the physician of changes in the resident's condition. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055670 If continuation sheet Page 8 of 8