Health inspection·November 18, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm A review of facility's policy and procedure titled, Assistance with Meals, revised on 7/2017, indicated residents would be fed with attention to safety, comfort, and dignity by not standing over residents while assisting them with meals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 2 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 one of four sampled residents (Resident 44) had an interdisciplinary team (IDT, a team of professionals responsible for planning and coordinating a resident's care) assessment and physician order for self-administration of medications. During a medication pass observation, Resident 44 self-administered Symbicort (a medication used to treat breathing problems) without an assessment or physician's order indicating the resident was safe to do so. Residents Affected - Few This deficient practice had the potential for the resident to administer medications incorrectly, which could result in over or under medicating and negatively impact the resident's overall health and well-being. Findings: A review of Resident 44's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), essential hypertension (high blood pressure that doesn't have a known secondary cause), and glaucoma (group of eye conditions that can cause blindness). A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/17/21, indicated the resident was cognitively (thinking and reasoning) intact and able to make needs known. The MDS indicated Resident 44 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from staff with bed mobility, transferring, dressing, toileting, and personal hygiene. A review of Resident 44's Physician Order Report for the month of November 2021, indicated an order for the resident to receive Symbicort HFA aerosol inhaler to inhale two puffs orally twice a day. The order also indicated, clinician administration (intended for a licensed nurse to administer the medication). During a medication administration observation on 11/16/21 at 9:43 AM, a Licensed Vocational Nurse 1 (LVN 1) handed Resident 44's Symbicort inhaler to the resident. Resident 44 was observed administering a dose of inhaler to himself while LVN 1 watched. Resident 44 opened his mouth and talked to LVN 1 after administering one puff of inhaler, not following LVN 1's instructions to hold his breath for at least 10 seconds. Resident 44 did not wait for a minute before he was observed administering the second puff of the inhaler. During an interview on 11/16/21 at 11:22 AM, Resident 44 stated he usually takes his Symbicort inhaler by himself everyday with the facility's LVNs supervising him. Resident 44 stated he felt that his Symbicort inhaler was not effective as compared to his previous inhaler medication (resident was on a different medication). During an interview on 11/16/21 at 11:27 AM, LVN 1 stated she did not administer the Symbicort inhaler to Resident 44 as indicated on the resident's physician's orders. LVN 1 stated Resident 44 administered the inhaler medication himself while she supervised. LVN 1 stated after verifying the facility's policy with her supervisor, LVN 1 stated that she understood in order for a resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 3 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-administer medications, the facility needed an IDT assessment and physician's approval even if the resident seemed capable. LVN 1 stated that it was important to administer the medications to the resident directly to ensure proper technique and medication was performed. During an interview on 11:45 AM, a Registered Nurse 1 (RN 1) confirmed Resident 44 did not have an IDT assessment or physician's order for self-administration of medications. RN 1 stated RN supervisors must complete a self-administration medication evaluation to determine if residents could safely self-administer medications. During an interview on 11/18/21 at 1:34 PM, the Director of Nursing (DON) stated residents must be evaluated first if the resident was able to self-administer medication safely. The DON stated that the RN supervisor must complete a self-administration of medication evaluation form and the resident needed to sign it. The DON stated after completing the self-administration of medication evaluation, the resident's physician needed to approve and give an order indicating the resident was safe to self-administer medications. The DON stated licensed nurses must still supervise and observe residents who were cleared to self-administer their medications. A review of the facility's policy and procedure titled, Self-Administration of Medications, revised on 2/2021, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it was clinically appropriate and safe for the resident to do so. The policy indicated if it was deemed safe and appropriate for a resident to self-administer medications, this was documented in the medical record, care plan and reassessed periodically based on changes in the resident's medical and/or decision-making status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 4 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0641 Ensure each resident receives an accurate assessment. 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 Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for two of four sampled residents (Residents 58 and 43). Residents Affected - Some 1. Resident 58's MDS, dated [DATE], did not accurately reflect the resident's active diagnoses for anxiety (intense, excessive, and persistent worry and fear about everyday situations). 2. Resident 43's MDS Section I (Active Diagnosis) did not indicate schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) as one of the diagnosis. These deficient practices had the potential for the residents to not receive appropriate treatment and/or services. Findings: 1. A review of Resident 58's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disorder (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia (a loss of mental functions that is severe enough to affect your daily life and activities), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 58's MDS, dated [DATE], indicated Resident 58 required extensive assistance (staff provide weight bearing support) from staff for transferring, dressing, toileting, and personal hygiene. Resident 58's MDS, under Section I, did not indicate anxiety disorder for psychiatric/mood disorder. A record review of Resident 58's Physician's Orders indicated an order for buspirone (a medication used to treat certain anxiety disorders or to relieve the symptoms of anxiety) 5 milligram (mg, a unit of measurement) tablet, two times a day for anxiety manifested by striking out and leading to resisting care. A review of Resident 58's Psychiatric Exam, dated 10/1/2021, indicated under chief complaint, anxious diagnoses with major depression and anxiety. During a concurrent interview and record review of Resident 58's MDS, on 11/18/2021 at 12:55 PM, Minimum Data Set Coordinator (MDSC) stated Resident 58's MDS, dated [DATE], was the current and completed quarterly MDS. MDSC stated when completing a resident's MDS, resident medical records and assessments were reviewed, along with the resident's current presenting state with a seven (7) day lookback period. MDSC stated Resident 58's MDS Section I should include the resident's diagnosis of anxiety. MDSC stated that the resident's MDS was inaccurate and could affect the resident's plan of care. 2. A review of Resident 43's Face Sheet indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection of the lungs), heart failure (a condition when your heart doesn't pump enough blood for your body's needs), and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 5 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0641 schizophrenia (a brain disorder that affects a person's ability to think, feel, and behave clearly). Level of Harm - Minimal harm or potential for actual harm A review of Resident 43's Psychiatric Examination, dated 8/9/2021, indicated a diagnosis of schizophrenia, major depression, and insomnia (inability to sleep). Residents Affected - Some A review of Resident 43's MDS, dated [DATE], indicated the resident was cognitively impaired and required extensive assistance from staff for transferring, dressing, bathing, and toileting. On 11/17/2021 at 2:05 PM, during a concurrent interview and record review, MDSC stated that if a resident had a mental disorder diagnosis, then it would be coded on the MDS as an active diagnosis. MDSC stated Resident 43's Psychiatric Examination, dated 8/9/2021, indicated schizophrenia as one of Resident 43's diagnosis. MDSC stated Resident 43's MDS, dated [DATE], under Section I did not indicate schizophrenia as an active diagnosis. MDSC stated the coding for schizophrenia as a diagnosis was missed and that the MDS was coded inaccurately. A review of the facility's policy and procedure tilted, MDS Completion and Submission Timeframes, revised October 2010, indicated the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. A review of the facility policy and procedure titled, Resident Assessment Instrument, revised September 2010, indicated all person who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 6 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive, resident-centered care plan for four of 20 sampled residents (Residents 58, 20, 31, and 17). 1. Resident 58's care plan did not have a measurable goal to address the resident's diagnosis of anxiety. 2. Resident 20's care plan did not indicate a measurable goal for tracking behaviors of psychosis (a mental disorder characterized by a disconnection from reality) for the use of quetiapine (a medication used to treat bipolar disorder, schizophrenia, and depression). 3. The facility did not develop an individualized plan of care for Resident 31's use of Eliquis (a medication used to prevent blood clots). 4. The facility failed to develop an care plan for Resident 17's for risk for falls upon readmission on [DATE]. These deficient practices had the potential for the residents to not have person-centered interventions addressing the residents' specific needs, potentially resulting in a decline in emotional, physical, psychosocial well-being, and quality of life. Findings: 1. During an observation, on 11/15/2021 at 9:13 AM, Resident 58 was observed lying in bed sleeping. Resident 58 had bilateral landing mats and the bed was in a low position. Resident 58's bedside table was within reach with a pink pitcher placed on top. Resident 58 did have a roommate. A review of Resident 58's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disorder (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia (a loss of mental functions that is severe enough to affect your daily life and activities), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 58's History and Physical, dated 6/29/2021, indicated Resident 58 did not have the capacity to understand and make decisions. A review of Resident 58's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/10/2021, indicated Resident 58 required extensive assistance (staff provide weight bearing support) from staff for transferring, dressing, toileting, and personal hygiene. Resident 58's MDS Section I (Active Diagnoses) did not indicate anxiety disorder for psychiatric/mood disorder. A record review of Resident 58's monthly Physician's Orders for November 2021 indicated order for the following medications: a. Buspirone (a medication used to treat certain anxiety disorders or to relieve the symptoms of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 7 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some anxiety) 5 milligram (mg, a unit of measurement) tablet, two times a day for anxiety manifested by striking out and leading to resisting care. b. Paroxetine hydrochloride (a medication used to treat depression, panic attacks, and obsessive-compulsive disorder), 10 mg one tablet daily for depression manifested by verbalization of sadness. A review of Resident 58's Psychiatric Exam, dated 10/1/2021, indicated under chief complaint the resident had anxious diagnoses with major depression and anxiety. A record review of Resident 58's care plan titled, Alteration in Mood Behaviors and psycho-social well-being related to anxiety, dated 10/10/2021, indicated Resident 58 would have reduce episodes of striking out leading to resisting care daily. The care plan did not indicate a specific measurable goal. 2. During an observation, on 11/16/2021 at 2:18 PM, Resident 20 was seated on the side of her bed, folding the facility language communication board, and banging it on the resident's mattress. Resident 20 was then observed pulling on the right side of the bed rails up and down. Resident 20 then retrieved her white linen from her bedside and started to wipe the bed rails and stated she was cleaning the bed. A review of Resident 20's Face Sheet indicated the resident admitted to the facility on [DATE] with diagnoses that included heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), dementia, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 20's History and Physical, dated 8/22/2021, indicated Resident 20 did not have the capacity to understand and make decisions. A review of Resident 20's Psychiatric Progress Note, dated 11/3/2021, indicated Resident 20 was delusional (a false belief that is based on an incorrect interpretation of reality), with auditory hallucinations (false perceptions of sound). A review of Resident 20's monthly Physician Order for November 2021, indicated an order for quetiapine 25 mg one tablet, once a day for schizophrenia leading to hitting, flipping objects with the potential for self-injury and others. A review of Resident 20's Medication Administration Record (MAR) for November 2021, indicated to monitor the resident's behavior for schizophrenia leading to hitting, flipping objects with the potential for self-injury and others. The MAR also indicated special instructions for staff to add frequency (how often the resident's behavior occurred) and intensity (how resident responded to redirection) onto the MAR for tracking (monitoring the behavior) every shift. A review of Resident 20's care plan titled, Alteration in mood, behaviors, due to psychosis, leading to hitting, flipping objects, dated 9/8/2021, indicated a goal to reduce episodes of psychosis. The care plan did not indicate a specific, measurable goal. During an interview, on 11/18/2021 at 10:11 AM, Licensed Vocational Nurse 5 (LVN 5) stated Resident 20 had usual behaviors of banging on her bed, flipping objects, such as the bed mattress in Resident 20's room, and talking to herself. LVN 5 stated Resident 20's behavior had decreased from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 8 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some previous month. LVN 5 stated upon monitoring of behaviors of psychosis, Resident 20 seldom scored zero (0, having no episodes of behavior). LVN 5 could not state what the expected number of episodes manifested by Resident 20 was acceptable to track if quetiapine was effective for Resident 20. During a concurrent interview and record review of Resident 20's care plan for Alteration in mood and behaviors, on 11/18/2021 at 1:33 PM, the Director of Nursing (DON) stated that care plans were individualized to each resident and that the Registered Nurse Supervisor and licensed nurses were responsible for initiating care plans. The DON stated care plans were a representation of the resident's care, and that the care plan was indicative on how to care for the resident and the approaches necessary to obtain the specific goals for the resident. The DON stated the care plan must be very specific and that when monitoring behaviors, a determination of efficacy (ability to perform a task to a satisfactory or expected degree) must be identified by clearly indicating the allowable threshold (the level above which the medication has a reasonable likelihood of achieving the most clinical benefit) of behaviors. The DON stated Resident 20's care plan did not specify a measurable goal by tracking how many acceptable behaviors was allowed in determining the effectiveness of the medication for quetiapine use for Resident 20. 3. A review of Resident 31's Face Sheet indicated the resident admitted to the facility on [DATE], with diagnosis that included heart failure (a condition when your heart doesn't pump enough blood for your body's needs), COPD, and generalized muscle weakness. A review of Resident 31's MDS, dated [DATE], indicated the resident was cognitively impaired and required extensive assistance from staff for transferring, dressing, and personal hygiene. A review of Resident 31's physician's orders, dated 6/01/2021, indicated to provide Eliquis 2.5 mg 1 tablet by mouth twice a day for the diagnosis of deep vein thrombosis (DVT, a blood clot in a deep vein, usually in the legs). On 11/17/2021 at 10:40 AM, during a concurrent interview and record review, RN Supervisor (RN 1) reviewed Resident 31's care plans and stated she was unable to find an individualized plan of care to address Resident 31's use of the medication Eliquis. RN 1 stated care plans should be developed upon admission, readmission, change of condition, and/or any identified problem and revised as needed. RN 1 stated it was important to develop a comprehensive care plan for the use of Eliquis to establish goals and implement interventions in the event the resident experienced unusual bleeding, which was a side-effect of the medication. 4. A review of Resident 17's Face Sheet indicated the resident initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, unspecified (A chronic condition in which the heart doesn't pump blood as well as it should) and muscle weakness. A review of Resident 17's John Hopkins Fall Risk Assessment Tool (a screening tool to measure an individual's fall risk), dated 5/9/2021, indicated Resident 17 was at moderate fall risk. A review of Resident 17's Physical Therapy Evaluation, dated 5/10/2021, indicated Resident 17 had impaired strength, impaired aerobic capacity and impaired balance. The patient is at risk for falls, decreased ability to return to prior living environment, decreased participation in functional tasks and increased dependency on caregivers. A review of Resident 17's History and Physical, dated 7/20/2021, indicated Resident 17 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 9 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0656 medical history of advanced dementia and complete blindness of the right eye. Level of Harm - Minimal harm or potential for actual harm During an observation on 11/15/2021 at 9:10 AM, Resident 17 was observed seated in her wheelchair by the foot of her bed falling asleep without any supervision. Resident 17's call light was not within reach. During the same observation, there were no fall identifiers in place (for example, armband, sticker, star, etcetera). Residents Affected - Some During an observation and interview, on 11/16/2021 at 8:10 AM, a Certified Nursing Assistant 1 (CNA 1) stated that Resident 17's bed was not positioned at the lowest position and that the bed was positioned about four (4) feet (ft, a unit of measurement) from the floor. During a concurrent observation and interview, on 11/16/2021 at 8:15 AM, CNA 1 stated the resident always does that. She gets the bed remote and puts her bed in a high position because she wants to be closer to the bedside table. CNA 1 stated the fall risk identifier for the residents were a red sticker next to their name upon entry to the room. There was no identifier (red sticker) next to Resident 17's name outside the resident's room. Resident 17 had one fall mat that on the left side of the resident's bed (between the resident and her roommate). Resident 17's body was observed to be leaning on the right side, grabbing onto the right-side rail located on the head of the bed. During an interview on 11/16/2021 at 10:58 AM, the DON stated that a fall was considered to be a change of condition. The DON stated some interventions that were applied to prevent a fall included: placing the bed in the lowest position with fall mats in place. The DON stated newly admitted residents and re-admitted residents have a fall risk assessment completed. The DON stated that, In the beginning we always assess the resident for falls and start care planning upon admission/re-admission if they have a history of falls or range moderate to high in fall risk. The DON stated the fall risk identifiers were a red mark on the door upon entry to the resident's room. The DON stated that, Every fall risk resident has a fall risk armband, especially those who have fallen in the past and are high risk. During a concurrent interview and record review, on 11/16/2021 at 11:05 AM , the DON stated that she could not locate a fall risk care plan completed (for admission period from 5/9/2021 to 10/13/2021). During a concurrent interview and record review on 11/16/2021 at 11:10 AM, the Administrator (ADM) stated that Resident 17 did not have a care plan for the resident's risk for falls from the admission period 5/9/2021 to 10/13/2021 in the resident's active care plans. A review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, revised December 2016, indicated that a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated the comprehensive, person-centered care plan would include measurable objectives and timeframes, and were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated the comprehensive, person-centered care plan would reflect treatment goals, timetables, and objectives in measurable outcomes. A review of the facility's P&P titled, Care Planning-Interdisciplinary Team (IDT), revised December 2008, indicated that the care planning/IDT was responsible for the development of an individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 10 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0656 comprehensive care plan for each resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 11 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to revise the care plans for two of two sampled residents (Residents 63 and 76). Resident 63 and Resident 76, who were receiving Hemodialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy), had care plans for risk of infection at the dialysis access site that were not updated to include the residents had a Permacath catheter (a long, flexible tube that is inserted into a vein most commonly in the neck vein) as the access site for treatment. This failure had the potential for the residents to not receive the appropriate care and services individualized to their needs. Findings: 1. A review of Resident 63's Face Sheet (a record of admission) indicated the resident readmitted to the facility on [DATE], with a diagnosis that included end stage renal disease (ESRD, a medical condition in which a person's kidneys stop functioning on a permanent basis) needing hemodialysis treatment, cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), and pneumonia (an infection of the lungs). A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/30/2021, indicated the resident was cognitively impaired and required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, personal hygiene, and toileting. On 11/16/2021 at 11:30 AM, during an interview, a Licensed Vocational Nurse 3 (LVN 3) stated Resident 63's hemodialysis access site was in the resident's right upper chest and the resident had a Permacath. LVN 3 stated Resident 63 also has an arteriovenous (AV, an abnormal connection between an artery and a vein, surgically created to help with hemodialysis treatment) fistula/shunt on the left upper arm that was not being used for dialysis treatment for the past three (3) months because Resident 63's left arm got swollen and developed cellulitis (a skin infection). On 11/17/2021 at 10:40 AM, during an interview and record review, Registered Nurse Supervisor (RN 1) stated Resident 63 had a Permacath catheter on the right upper chest used as the dialysis treatment access site and had not used the AV shunt on the left upper arm for months. RN 1 stated Resident 63's care plan titled, ESRD with Renal Dialysis. Resident at risk for infection at the dialysis access site - AV shunt LUA (left upper arm), dated 10/30/2021, was not revised to reflect that the resident had a Permacath catheter as the access site for dialysis treatment. 2. A review of Resident 76's Face Sheet indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included ESRD needing hemodialysis treatment and hypertension (high blood pressure). A review of Resident 76's MDS, dated [DATE], indicated the resident had no impairment in cognitive skills intact and total dependence (full staff performance every time) from staff for transferring, personal hygiene, toileting, and bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 12 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/16/2021 at 11:25 AM, during a concurrent observation and interview, Resident 76 was observed awake in bed and had a Permacath on the right upper chest with clean, dry dressing. Resident 76 stated she had the catheter for dialysis treatment for the past two (2) years and her AV shunt on the left upper arm was not working anymore. On 11/16/2021 at 11:35 AM, during an interview, LVN 3 stated Resident 76's hemodialysis access site was in her right upper chest with a Permacath. LVN 3 stated Resident 76 had an AV shunt on the left upper arm that it was not working and was not being used for dialysis for the past 2 years. On 11/17/2021 at 10:40 AM, during an interview and record review, RN 1 stated Resident 76 had a Permacath dialysis catheter on the right upper chest used as the dialysis treatment access site and had not used the AV fistula/shunt on the left upper arm for months. RN 1 stated Resident 76's care plan titled, ESRD with Renal Dialysis. Resident at risk for infection at the dialysis access site - Left arm fistula, dated 11/13/2021, was not revised to reflect that the resident had a Permacath dialysis catheter as the access site for dialysis treatment. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated assessments of residents were ongoing and care plans were revised as information about the residents and the resident's condition changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 13 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 professional standards of nursing care were followed. Residents Affected - Some 1. During a treatment observation for Resident 14's pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure), a Licensed Vocational Nurse 2 (LVN 2) left treatment medication (Calcium Alginate, a highly absorbent, biodegradable dressing derived from seaweed and Medi-Honey, a treatment used on wounds for non-draining to moderately draining wounds) and treatment supplies unsupervised. 2. LVN 1 did not give Resident 30's 2 Cal (nutritional drink supplement) during medication pass as ordered. LVN 1 signed and documented in Resident 30's eMAR (electronic Medication Administration Record) that it was given when the resident refused the 2 Cal nutritional drink. LVN 1 did not document that it was refused. This deficient practice had the potential for accidental application, consumption, and/or contamination of the treatment medications for medication and supplies left at the bedside unattended. This deficient practice also had the potential for an inaccurate account of the resident's nutritional status from the refusal of nutritional supplements, which could lead to unplanned weight loss. Findings: A review of Resident 14's Face Sheet indicated the resident admitted to the facility on [DATE] with diagnoses that included diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high), history of transient ischemic attack (TIA, a temporary blockage of blood flow to the brain), and hypertension (high blood pressure). A review of Resident 14's History and Physical, dated 8/30/2021, indicated Resident 14 did not have the capacity to understand and make decisions. A review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/25/2021, indicated Resident 14 required extensive assistance (staff provide weight bearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 14's monthly physician's order for November 2021, indicated the following treatment order, Medi-honey paste 100% to the left ischium (lower and back part of hip bone) unstageable (full thickness tissue loss covered by extensive necrotic/dead tissue). The order indicated to cleanse with normal saline (NS, a mixture of salt and water similar to the body's fluids), pat dry, apply Medi-honey, apply Calcium Alginate, and cover with a dry dressing daily for fourteen (14) days. During an observation in Resident 14's room, on 11/17/2021 at 9:29 AM, Licensed Vocational Nurse 2 (LVN 2) was observed providing treatment for Resident 14's pressure injury with Certified Nursing Assistant 5 (CNA 5). LVN 2 was observed discarding Resident 14's previous (soiled) dressing and went around Resident 14's curtain to wash LVN 2's hands. LVN 2 told CNA 5 to watch Resident 14's supplies and treatment medication while LVN 2 left them unattended at Resident 14's bedside. LVN 2 returned to Resident 14's bedside and continued with the dressing change treatment. LVN 2 was observed leaving treatment supplies unattended again to wash her hands. CNA 5 was on the opposite side of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 14 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prepared treatment medications. LVN 2's treatment medication and supplies were not within sight of LVN 2 since Resident 14's curtains were drawn while she was washing her hands the second time. During an interview, on 11/17/2021 at 9:45 AM, LVN 2 stated treatment medications and supplies should be within sight of LVN 2, and that LVN 2 should not have CNA 5 watch the prepared medication since CNA 5 was not a licensed staff. LVN 2 stated treatment medications and supplies were prepared by licensed staff, therefore, it was the licensed staff's responsibility to oversee the medications, and that when the medications were not within sight, accidental spillage or consumption might occur. During an interview, on 11/17/2021 at 11:05 AM, Registered Nurse 1 (RN 1) stated Medi-honey and calcium alginate were considered medications, therefore, must be kept within sight of the licensed nurse, and not a CNA. RN 1 stated it was the accountability of the licensed nurse to ensure medications, including treatment medications, were safeguarded and given appropriately. During an interview, on 11/18/2021 at 11:16 AM, the Director of Nursing (DON) stated treatment medications must stay within the sight of the licensed nurse administering the medication/treatment. The DON stated when the licensed nurses stepped away, the treatment medication must stay within sight. The DON stated CNA's could not supervise unattended medications since they were not licensed nurses. The DON stated when medications were left unattended it was possible for residents to spill, grab, or another resident could ingest the medications. The DON stated to prevent that from occurring, medications must be protected by always keeping the medications within sight. A review of the facility' undated policy and procedure titled, Administering Medications, indicated medications were administered in a safe and timely manner, and as prescribed. 2. A review of Resident 30's Face Sheet indicated the resident admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) and chronic kidney disease (kidney failure in which there is a gradual loss in the body's ability filter waste and excess fluid from the body). A review of Resident 30's History and Physical, dated 4/25/2021, indicated Resident 30 had the capacity to understand and make decisions. A review of Resident 30's MDS, dated [DATE], indicated the resident required extensive assistance from staff for transferring, dressing, and personal hygiene. A review of Resident 30's monthly Physician's Order Report for November 2021, indicated an order dated on 7/9/21 for the resident to receive 2 CAL 120 milliliter (ml, unit of measurement) orally three times a day with medication pass (at 9 AM, 1 PM, and 5 PM). A review of Resident 30's care plan titled, Nutritional Status, dated 5/1/2021, indicated Resident 30 had experienced weight loss with an intervention (updated on 8/6/21) to increase 2 CAL to 120 ml orally three times a day with medication. A review of Resident 30's, Progress Notes: Registered Dietician (RD) Weight Review, dated on 10/4/2021 and 11/2/2021, the RD documented that Resident 30 was at risk for weight loss due to poor oral intake. The notes on both 10/4/2021 and 11/2/2021 indicated the resident was currently receiving nutritional supplement 2 CAL three times a day with medication pass. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 15 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a medication administration pass observation, on 11/16/2021 at 10:08 AM, LVN 1 did not provide Resident 30 the nutritional supplement 2 CAL. During an interview, on 11/16/2021 at 1:56 PM, LVN 1 stated that she did not give Resident 30's 2 CAL during the medication pass observation. LVN 1 stated after checking Resident 30's physician order that she should have given Resident 30 her 2 CAL during medication pass. LVN 1 stated that the resident's physician ordered a nutritional supplement because it was recommended by the RD because the resident was losing weight and the nutritional supplement (2 CAL) would provide more nutrients and calories to the resident. During an interview, on 11/18/2021 at 9:50 AM, Resident 30 (with a Registered Nurse 1 for interpretation) stated she never received her nutritional drink supplement when she received her medications. Resident 30 stated she did not like the taste of the nutritional supplement, and she has been refusing it and returning it to the nurses. On 11/18/2021 at 9:50 AM, during the same interview and record review, LVN 1 stated Resident 30 refused 2 CAL yesterday as well. LVN 1 stated that Resident 30's eMAR indicated 2 CAL was given everyday from the month of October 2021 to present (11/18/2021). LVN 1 stated licensed nurses including her should be documenting that Resident 30 has been refusing 2 CAL. LVN 1 stated it was important to document that the supplement was given accurately so that the RD could review and evaluate Resident 30's dietary and nutritional needs. A review of Resident 30's Progress Notes from October 2021 to November 2021, there was no documentation that the resident has been refusing her 2 CAL. During an interview with RD and Dietary Supervisor (DS), on 11/18/2021 at 11:40 AM, RD stated she usually recommended giving supplements like 2 CAL during medication pass since it helped residents to drink and consume it well. RD stated 2 CAL was usually recommended and prescribed to residents at risk of weight loss due it having high calories and high protein contents. DS and RD stated that they were not aware that Resident 30 was refusing her 2 CAL. RD stated licensed nurses should document and report to her and to the DS whenever residents refused any supplements. During an interview, on 11/18/2021 at 1:34 PM, the DON stated supplements should be given as ordered by the physician. The DON stated licensed nurses should document in the eMAR if residents refused any medication or supplements. The DON stated that if residents refused for 3 days or more, licensed nurses should document and report to the family, RD, and resident's physician. The DON stated if the resident did not want the supplement, the resident's physician could have changed the order to something else. A review of facility's policy and procedure titled, Documentation of Medication Administration, revised on April 2007, indicated documentation must include reason(s) why medication was withheld, not administered, or refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 16 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free of accidental hazards for three of three sampled residents (Residents 31, 63, and 17), who were assessed at risk for falls. Residents 31, 63, and 17 were not observed in bed in the lowest position. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. Findings: 1. A review of Resident 31's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE], with diagnoses that included heart failure (a condition when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and generalized muscle weakness. A review of Resident 31's Fall Risk Assessment Tool, dated 9/14/2021, indicated Resident 31 was at risk for falls. A review of Resident 31's care plan titled, At risk for falls due to dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning) ., initiated on 9/14/2021, indicated for Resident 31 to be free of falls and/or serious injuries. The care plan included an intervention to keep the bed in the lowest possible position. A review of Resident 31's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/18/2021, indicated the resident was cognitively impaired and required extensive assistance (resident involved in activity, staff provided weight bearing support) from staff for transferring, dressing, and personal hygiene. On 11/16/2021 at 9:35 AM, during an observation Resident 31 was observed lying in bed with the bed not on a low position. On 11/17/2021 at 10:31 AM, during a concurrent observation and interview, a Licensed Vocational Nurse 1 (LVN 1) stated that Resident 31's bed was not in the lowest position. LVN 1 stated Resident 31 was at risk for falls, and it was important for the resident's bed to be in the lowest position for the resident's safety and to prevent injury in the event of a fall incident. 2. A review of Resident 63's Face Sheet indicated the resident readmitted to the facility on [DATE], with diagnoses that included end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis), cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), and pneumonia (an infection of the lungs). A review of Resident 63's Fall Risk Assessment Tool, dated 10/10/2021, indicated Resident 63 was a high fall risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 17 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 63's care plan titled, Safety/Fall Risk, initiated on 10/30/2021, indicated Resident 63 was at risk for falls due to history of falls. The care plan indicated a goal for Resident 63 to have reduced risk of complications from safety devices daily and would have reduced risk of falls or injuries daily for 3 months. The care plan indicated the resident to be on a low bed. A review of Resident 63's MDS, dated [DATE], indicated the resident was cognitively impaired and required extensive assistance from staff for transferring, dressing, personal hygiene, and toileting. On 11/16/2021 at 10:12 AM, during an observation Resident 63 was observed sleeping in bed not in the lowest position. On 11/17/2021 at 10:20 AM, during a concurrent observation and interview, LVN 3 stated Resident 63's bed was not in the lowest position and bed position should always be in the lowest position for her own safety. LVN 3 pressed the button of the resident's bed control and lowered the bed to the lowest possible position. On 11/18/2021 at 10:35 AM, during an interview, the Director of Nursing (DON) stated if the resident was at risk for falls according to the Fall Risk Assessment tool, interventions should be implemented which included placing the resident on a low bed. DON stated if the resident's bed was not on the lowest setting, it could lead to a possible injury to the resident in the event of a fall. A review of the facility's policy and procedure titled, Managing Falls and Fall Risk, revised March 2018, indicated the facility staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Factors that could contribute to the risk of falls included incorrect bed height or width. 3. A review of Resident 17's Face Sheet indicated the resident initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, unspecified (A chronic condition in which the heart doesn't pump blood as well as it should) and muscle weakness. A review of Resident 17's Physical Therapy Evaluation, dated 5/10/2021, indicated Resident 17 had impaired strength, impaired aerobic capacity and impaired balance. The patient is at risk for falls, decreased ability to return to prior living environment, decreased participation in functional tasks and increased dependency on caregivers. A review of Resident 17's History and Physical, dated 7/20/2021, indicated Resident 17 had a medical history of advanced dementia and complete blindness of the right eye. A review of Resident 17's John Hopkins Fall Risk Assessment Tool (a screening tool to measure an individual's fall risk), dated 9/4/2021, indicated Resident 17 had a score of 15 which indicated at high fall risk (greater than score of 13 was high fall risk). A review of Resident 17's care plan titled, Cognitive Loss/Dementia, revised on 9/10/2021, indicated to provide a safe and secure environment. A review of Resident 17's care plan titled, Falls, initiated on 11/10/2021, indicated to offer two floor mats for safety. The care plan indicated the resident refused and the facility would continue to offer (the floor mats). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 18 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/15/2021 at 9:10 AM, Resident 17 was observed seated in her wheelchair by the foot of her bed falling asleep without any supervision. Resident 17's call light was not within reach. During the same observation, there were no fall identifiers in place (for example, armband, sticker, star, etcetera). During an observation and interview, on 11/16/2021 at 8:10 AM, a Certified Nursing Assistant 1 (CNA 1) stated that Resident 17's bed was not positioned at the lowest position and that the bed was positioned about four (4) feet (ft, a unit of measurement) from the floor. During a concurrent observation and interview, on 11/16/2021 at 8:15 AM, CNA 1 stated the resident always does that. She gets the bed remote and puts her bed in a high position because she wants to be closer to the bedside table. CNA 1 stated the fall risk identifier for the residents were a red sticker next to their name upon entry to the room. There was no identifier (red sticker) next to Resident 17's name outside the resident's room. Resident 17 had one fall mat that on the left side of the resident's bed (between the resident and her roommate). Resident 17's body was observed to be leaning on the right side, grabbing onto the right-side rail located on the head of the bed. During an interview on 11/16/2021 at 10:58 AM, the DON stated some interventions that were applied to prevent a fall included: placing the bed in the lowest position with fall mats in place. The DON stated the fall risk identifiers were a red mark on the door upon entry to the resident's room. The DON stated that, Every fall risk resident has a fall risk armband, especially those who have fallen in the past and are high risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 19 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0692 Provide enough food/fluids to maintain a resident's health. 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 Residents Affected - Few ensure one of three sampled residents (Resident 70), who was at risk for weight loss and/or decline in nutritional status, was monitored. The facility failed to complete the following: 1. Monitor and accurately document Resident 70's meal percentage intake. 2. Monitor and record Resident 70's weights as ordered by the physician. 3. Implement the resident's care plan interventions for the resident's altered nutritional status. These deficient practices had the potential for the resident to have unplanned weight loss that could adversely affect the resident's health and safety. Findings: A review of Resident 70's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood) and aortic aneurysm (balloon-like bulge in an artery [blood vessels that carry blood from heart to organs]). A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/24/21, indicated Resident 70 had moderate impairment in cognitive skills (ability to make daily decision). The MDS indicated Resident 70 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene and limited assistance (supervision and cueing) from staff with one person assistance for eating. During a dining observation in Resident 70's room, on 11/15/21 at 12:39 PM, Resident 70's lunch tray was served by a CNA 5. CNA 5 placed the resident's lunch tray on the overbed table in front of Resident 70. CNA 5 set up the meal tray for Resident 70 while he was lying on his bed, in a semi-Fowlers position (resident positioned on their back with the head and trunk raised to between 15 to 45 degrees). CNA 5 left Resident 70 in the room after setting up the tray and Resident 70 started eating. During an observation, on 11/15/2021 at 12:52 PM, Resident 70 was observed sleeping with the lunch tray in front of him. Resident 70's lunch tray observed with 10% of the meal eaten. After approximately four minutes, Resident 70 remained sleeping with his lunch meal tray in front of him. No staff returned to check on Resident 70 with his meal. During an observation outside Resident 70's room and interview with CNA 5, on 11/15/2021 at 12:58 PM, CNA 5 removed Resident 70's meal tray from Resident's 70's table and placed it inside the meal cart while Resident 70 was still sleeping. CNA 5 stated that Resident 70 consumed approximately 10% of the meal served. CNA 5 stated Resident 70 did not want to be fed and did not like to finish his lunch. CNA 5 stated she would report it to her Charge Nurse. During an interview, on 11/17/2021 at 8:22 AM, Resident 70 stated nurses usually helped the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 20 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident set up the lunch tray, but he would eat by himself. Resident 70 stated that recently the facility nurses started feeding him. During an interview and record review, on 11/17/2021 at 8:30 PM, the MDS Nurse (MDSN) stated Resident 70 was discharged from Hospice (a special kind of care that focused on the quality of life for people and their caregivers who were experiencing advanced, life limiting illnesses) on July 2021 because the resident's condition improved and got better. MDSN stated Resident 70 needed limited assistance with one person when eating. MDSN stated someone needed to stay with the resident to help set up his tray, cue, and encourage Resident 70 to eat. MDSN stated that Resident 70' physician ordered on 10/29/2021 and 11/3/2021 indicated to check and record Resident 70's weight weekly for four weeks. During an interview and record review, on 11/17/21 at 8:47 AM, a Restorative Nurse Assistant 1 (RNA 1) stated the facility had weekly weight variance meetings with RNA, Registered Dietitian (RD), the Director of Nursing (DON), Activity Director (AD), and Social Services Director (SSD) in attendance. RNA 1 stated one of the agendas of the weight variance meeting was to discuss the resident's weights and which resident to weigh and how often. RNA 1 stated the LVNs also received a communication form with the name of residents who needed to be weighed so they could discuss any concerns and could call the resident's physician if there was any change in condition, such as significant weight loss and/or gain. RNA 1 stated that Resident 70's order for weekly weights was missed and not done. RNA 1 stated that the facility's monthly and weekly weights list for the month of November 2021 indicated Resident 70 was missing two consecutive weeks (11/6/2021 and 11/13/2021). RNA 1 stated Resident 70's name was not included in the weekly weights list. During an interview, on 11/18/2021 at 9:15 AM, LVN 5 stated Resident 70 sometimes ate by himself and usually ate well during breakfast but sometimes the resident did not eat very much at lunch. LVN 5 stated Resident 70 needed cueing and encouragement from time to time. LVN 5 stated nurses did not need to feed Resident 70 but someone needed to stay or check on the resident often when during meals. LVN 5 stated CNAs needed to accurately document resident's meal percentage intake so the facility could track if residents were eating well or not and then notify resident's physician if needed. During a follow up interview and record review, on 11/18/2021 at 9:27 AM, CNA 5 stated she documented on Resident 70's meal percentage intake record for 11/15/2021 for the lunch meal as the resident ate 25 to 50%, when the resident ate 10% on 11/15/2021 (during the lunch observation). CNA 5 stated Resident 70 would eat good when someone was sitting beside him, cueing, and encouraging him. CNA 5 stated Resident 70 did not want to be fed sometimes. CNA 5 also stated that she needed to check Resident 70 from to time to time to check if he was eating or not. CNA 5 stated she was supposed to give residents enough time to finish their food and not rush the resident by removing Resident 70's meal tray if he was not done yet. CNA 5 stated it was important to accurately document resident's meal percentage intake so that licensed nurses and the dietitian could monitor the resident's meal intake to prevent weight loss and so that the facility staff could notify the resident's physician timely if needed. During an interview with RD and Dietary Supervisor (DS), on 11/18/2021 at 11:40 AM, RD stated she was the one who recommended for Resident 70 to be weighed weekly for four weeks to monitor his nutritional status and check how if the additional supplement was helping Resident 70's weight. RD stated Resident 70's physician ordered to weigh Resident 70 but it was not done. RD stated it was important for nurses to document meal percentage intake accurately so the facility knew what interventions to make. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 21 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 11/18/2021 at 1:34 PM, the DON stated nurses should document meal percentage intake accurately so the facility would know what interventions to change or make. The DON stated they do weekly weight meetings and IDT meetings, communicate with nursing including RNAs about dietary recommendations and lists of residents to weigh and how often. The DON stated Resident 70 required limited assistance with one person assistance with eating, meaning someone needed to stay and assist, cue, and/or encourage Resident 70. The DON stated care plans should be reviewed by licensed nurses and interventions should be updated if needed. The DON stated if residents were non-compliant or refusing treatments or interventions, it should be documented, or care planned. A review of Resident 70's care plan titled, Potential for altered nutrition, dated 7/24/2021, indicated a goal for the resident to consume at least 75% of meals. The care plan included interventions such as monitoring the resident's weekly weight and the certified nursing assistants (CNAs)/rehabilitative nursing assistants (RNAs) to assist during mealtimes. A review of facility's policy and procedure titled, Activities of Daily Living (ADL), Supporting, revised in 3/2018, indicated appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks). A review of facility's policy and procedure titled, Weight Assessment and Interventions, revised in 9/2008, indicated weights would be recorded in each unit's weight record chart or notebook and in the individual's medical record. A review of facility's policy and procedure titled, Nutritional Assessment, revised in 12/2011, indicated the nutritional assessment would be conducted by the multidisciplinary team and shall identify at least the following components: a. current height and weight, b. a description of the resident's usual intake and appetite, c. usual meal and snack patterns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 22 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide readily accessible language communication boards (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for three of four sampled residents (Residents 23, and 79) who were not fluent in English and had difficulty making needs known due to the language barrier and/or medical diagnoses. Residents Affected - Few 1. Resident 23, who spoke Armenian, did not have a communication board present in the resident room. 2. Resident 79, who spoke Armenian, did not have a communication board in the resident's room. This deficient practice had the potential for a delay in the residents' needs not being met and/or provided. Findings: 1. A review of Resident 23's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (a group of thinking and social symptoms that interferes with daily functioning), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). The Face Sheet also indicated Armenian as the resident's preferred language. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/13/21, indicated the resident mild impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 23 made self-understood and understood others. A review of Resident 23's care plan titled, Altered Cognition related to dementia, dated 9/13/21, indicated the resident had a problem due to language barrier. The care plan indicated the facility provide an interpreter as needed and use of a communication device. During an initial observation of Resident 23's room, on 11/15/21 at 10:44 AM, Resident 23 was observed lying in bed and speaking in Armenian with no language communication board in the resident's room. During a concurrent observation and interview with a Certified Nursing Assistant 1 (CNA 1) in Resident 23's room, on 11/16/21 at 8:40 AM, Resident 23 was observed speaking in Armenian and pointing at Resident 23's bed. CNA 1 stated that Resident 23 did not speak any English. CNA 1 stated she knew very little Armenian to communicate with Resident 23. CNA 1 could not translate what Resident 23 was saying. CNA 1 stated she was permanently assigned to Resident 23. CNA 1 stated there was no language communication board in Resident 23's room to aid staff in interacting with Resident 23. CNA 1 stated the communication board should be placed at the head of the bed to help staff understand Resident 23 since Resident 23 did not speak English and the communication board could help identify the resident's needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 23 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview, on 11/16/21 at 9:54 AM, a Licensed Vocational Nurse 5 (LVN 5) stated she could not speak or understand Armenian. LVN 5 stated when providing care for Resident 23 she would find staff who were available to translate for the resident. LVN 5 stated if no one was available, LVN 5 would use the communication board. LVN 5 stated there was no communication board at Resident 23's bedside. LVN 5 stated it was important for a communication board to be present so care could be understood between both the staff and residents. During an interview, on 11/18/21 at 1:33 PM, the Director of Nursing (DON) stated a communication board was necessary and must be located in all residents' rooms who were unable to speak English. The DON stated it was the responsibility of the social services to follow up once the language barrier was identified. The DON stated it was important for communication boards to be accessible in residents' rooms to ensure that medical needs were met. 2. A review of Resident 79's Face Sheet (a record of admission) indicated the resident initially admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), peripheral autonomic neuropathy (condition caused by damage to person's nerves), and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 79's History and Physical, dated 9/21/2021, indicated Resident 79 had the capacity to understand and make decisions. A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/2021, indicated the resident required total dependence (full staff performance every time) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 79's care plan titled, Had a language barrier problem, dated 9/21/2021, indicated the following interventions for the resident: use a communication device and place a communication board as needed on designated areas. A review of Resident 79's Interdisciplinary team (IDT) Care Plan Summary Note, dated on 6/22/2021 and 9/23/2021, the Social Services Director (SSD) documented that Resident 79 spoke Armenian and that a communication board was provided. During observations from 11/15/2021 to 11/17/2021, Resident 79 did not have a communication board at the resident bedside. During an interview, on 11/15/21 at 10:23 AM, Resident 79 stated she spoke and understood Armenian language only. During an observation and interview, on 11/17/21 at 8:06 AM, a Registered Nurse 1 (RN 1) stated Resident 79 needed an Armenian communication board and there was none currently in the resident's room. RN 1 stated she would put an Armenian communication board at Resident 79's bedside right away. During an interview, on 11/18/21 at 8:53 AM, a Certified Nurse Assistant 3 (CNA 3) stated she did not speak Armenian and would communicate with Resident 79 by calling other staff who spoke the resident's language. CNA 3 stated if there were no staff available who spoke the same language as the residents, she would use the communication board. CNA 3 stated it was important to have a communication board at the resident's bedside since it helped her and other staff to communicate with residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 24 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0745 who spoke other languages other than English. Level of Harm - Minimal harm or potential for actual harm During an interview, on 11/18/21 at 1:34 PM, the Director of Nursing (DON) stated communication boards in different languages should be available at the resident's bedside for all residents who did not speak or understood English. The DON stated it was the SSD's responsibility to make sure communication boards were provided to the residents and accessible to all staff. Residents Affected - Few A review of the facility's undated document titled, Language Preference, indicated the facility complied/adhered to all state and federal regulations that required the promotion of care for residents in a manner in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. The document indicated, when engaging in caring for or speaking to a resident, employees will use the residents native or normal language, a language board would be utilized if an interpreter is not available to speak their normal language or speak through an interpreter. A review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised May 2017, indicated the assurance that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The P&P indicated that it was understood that providing meaningful access to services provided by the facility required that the LEP residents' needs and questions were accurately communicated to the staff. A review of the facility's P&P titled, Social Services, revised October 2021, indicated medically related social services was provided to maintain or improve each resident's ability to control everyday physical needs, and mental and psychosocial needs. The P&P indicated to arrange for social and emotional support, and develop supportive services for residents according to their individual needs and interest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 25 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 accurately account for the use of one controlled substance (medications with a high potential for abuse), Pregabalin (a medication used to treat nerve and muscle pain) for one sampled resident (Resident 79) in one of three medication carts inspected (Unit 300). This deficient practice increased the risk that Resident 79 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an inspection and record review of the medication cart in Unit 300 with a Licensed Vocational Nurse 5 (LVN 5), on 11/16/21 at 2:36 PM, the facility's Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance was given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) for Resident 79's for Pregabalin 25 milligram (mg, a unit of measurement) did not match. Resident 79's Controlled Drug Record for Pregabalin indicated that there was 17 capsules left. Resident 79's medication card contained 16 pills. During an interview, on 11/16/21 at 2:38 PM, LVN 5 stated she administered one dose of Pregabalin medication to Resident 79 this morning (11/16/2021) but did not sign on the narcotic record (Controlled Drug Record) after administration. LVN 5 stated it was important to sign on the Controlled Drug Record for all doses administered to ensure that there was a record that the resident received it. LVN 5 stated she must log, document, and sign the Controlled Drug Record as soon as she took the medication out of the medication card. LVN 5 stated it was important to sign the Controlled Drug Record to ensure accountability for controlled substances was maintained and to make sure that residents or staff do not steal them or accidentally take them. During an interview on 11/18/21 at 9:40 AM, Registered Nurse (RN 1) stated licensed nurses must sign the Controlled Drug Record sheet as soon as they took it out from the medication card to show who gave the controlled drug and to which resident it was given. RN 1 stated documenting both in on the electronic Medication Administration Record (eMAR) and Controlled Drug Record were important when giving a controlled medication. During an interview, on 11/18/21 at 1:34 PM, the Director of Nursing (DON) stated licensed nurses must sign the Controlled Drug Record sheet as soon as they took the controlled medication out of the medication card to ensure accountability of controlled substances. A review of Resident 79's Face Sheet (a record of admission) indicated the resident initially admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), peripheral autonomic neuropathy (condition caused by damage to person's nerves), and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 79's History and Physical, dated 9/21/2021, indicated Resident 79 had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 26 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/1/2021, indicated the resident required total dependence (full staff performance every time) from staff for transferring, dressing, toileting, and personal hygiene. Residents Affected - Few A review of Resident 79's monthly Physician Order Report for November 2021, indicated an order for Pregabalin 25 mg 1 capsule orally twice a day. A review of facility's policy and procedure titled, Controlled Substances, revised on 4/2019, indicated that upon administration of a controlled medication the administering nurse was responsible for recording the quantity of the medication remaining and sign for the medication administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 27 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to define and monitor specific target behaviors related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 43). Resident 43, who was receiving quetiapine (a medication used to treat schizophrenia) and escitalopram oxalate (a medication used to treat depression), did not have specific behaviors the resident exhibited to monitor the use of these psychotropic medications. This deficient practice increased the risk for the resident to have adverse effects (unwanted or dangerous medication side effects) of psychotropic medications and/or inability to monitor effectiveness of each medication. Findings: A review of Resident 43's Face Sheet (a record of admission) indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included schizophrenia (a brain disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities). A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/17/2021, indicated the resident was cognitively impaired and required extensive assistance (resident involved in activity, staff provided weight bearing support) from staff for transferring, dressing, bathing, and toileting. A review of Resident 43's physician order report, dated 9/28/21, indicated Resident 43 was ordered for the following medications: a. quetiapine 25 milligrams (mg, a unit of measurement) 1 tablet by mouth twice a day for psychotic disorder manifested by paranoia (the feeling that you're being threatened in some way, such as people watching you or acting against you, even though there's no proof). b. escitalopram oxalate 10 mg 1 tablet by mouth once a day for major depression manifested by isolated lack of motivation. A review of Resident 43's Medication Administration Record (MAR) for October 2021 to November 2021, indicated Resident 43 received quetiapine twice daily and escitalopram oxalate once daily as ordered. On 11/17/2021 at 1:38 PM, during an interview, Registered Nurse 2 (RN 2) stated that she documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 28 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on Resident 43's behavior monitoring for paranoia on 11/5/21 because the resident had increased agitation and was talking to himself that he wanted to leave, verbalizing that he did not belong in the facility. RN 2 stated the specific behavior she would document on Resident 43's behavior monitoring for lack of motivation was if the resident was not participating in activities and refusing activities of daily living (ADLs, such as feeding oneself, bathing, grooming, and dressing). RN 2 stated that the behavior monitoring of paranoia and lack of motivation were not specific behaviors for the resident. RN 2 stated resident's target behaviors should be specific to the resident to improve behavior monitoring and care planning. On 11/17/2021 at 2:52 PM, during an interview, LVN 4 stated the behaviors tied to the use of quetiapine and escitalopram oxalate for Resident 43 were not specific. LVN 4 stated the she would document under paranoia on the behavior monitoring log if the resident had increased agitation, verbalizing that someone wanted to hurt him, and wanting to leave. LVN 4 stated she would document under lack of motivation on the behavior monitoring log if Resident 43 did not take his medications and just wanted to sleep all the time. LVN 4 stated that without specific behaviors tied to the use of psychotropic medications, it would be difficult to assess the effectiveness of psychotropic medication therapy and care plan properly. On 11/18/2021 at 10:35 AM, during an interview, the DON stated Resident 43's behavior monitoring for the use of psychotropic medications were not specific and the facility addressed the issue. DON stated it was important to monitor specific behaviors of the resident because each resident had different manifestations and lack of motivation and paranoia differed from one resident to another. DON stated it was important for the facility to monitor and log specific behaviors to make sure the medicine worked and was not causing harm to the resident. A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated when medications were prescribed for behavioral symptoms, documentation would include specific target behaviors and expected outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 29 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 Symbicort HFA aerosol inhaler (a medication used to treat breathing problems) medication was administered to one of four sampled residents (Resident 44) in accordance with physician's order. Residents Affected - Few This deficient practice had the potential in complications that could lead to hospitalization and/or death. Findings: A review of Resident 44's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), essential hypertension (high blood pressure that doesn't have a known secondary cause), and glaucoma (group of eye conditions that can cause blindness). A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/17/2021, indicated the resident had no impairment in cognitive skills (ability to make daily decisions) and able to make needs known. The MDS indicated Resident 44 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from staff for transferring, dressing, toileting, personal hygiene. A review of Resident 44's monthly Physician Order Report for November 2021, indicated an order for Symbicort HFA aerosol inhaler to inhale two puffs orally twice a day. The order specified this to be a clinician administration (intended to be administered by a licensed nurse). During a medication pass observation, on 11/16/2021 at 9:43 AM, a Licensed Vocational Nurse 1 (LVN 1) handed the Symbicort inhaler to Resident 44. Resident 44 administered a dose of the inhaler to himself while LVN 1 watched. Resident 44 was observed improperly self-administering the inhaler by opening his mouth and talking to LVN 1 as soon as he administered one puff. Resident 44 did not listen to LVN 1 to hold his breath for at least 10 seconds. Resident 44 also observed administering a second puff less than a minute after the first puff. During an interview, on 11/16/2021 at 11:22 AM, Resident 44 stated he usually takes his Symbicort inhaler by himself everyday supervised by LVNs. Resident 44 stated he felt his medication Symbicort inhaler was not effective as compared to his previous inhaler medication. During an interview, on 11/16/2021 at 11:27 AM, LVN 1 stated she did not administer the Symbicort inhaler to Resident 44 as the physician orders. LVN 1 stated Resident 44 administered the inhaler medication to himself while she supervised. LVN 1 stated after verifying policy with her supervisor, she understands that for a resident to be able to self-administer medications, they first need an IDT assessment and physician approval even if they seem otherwise capable. LVN 1 stated that she understands the importance of administering the medications directly to the resident to ensure proper technique and medication. LVN 1 stated it is important for Resident 44 to receive correct inhaler medication dose to prevent Resident 44 from having respiratory (organs and other parts of the person's body involved in breathing) symptoms like shortness of breath and wheezing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 30 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 During an interview, on 11/16/2021 at 11:45 AM, Registered Nurse (RN 1) confirmed Resident 44 does not have an evaluation and physician order for self-administering medication. RN 1 stated RN supervisors must complete a self-administration medication evaluation first to determine if residents can safely self-administer medication. RN 1 stated it is important for residents to properly administer medication for the medication to work and to prevent worsening of resident's condition. Residents Affected - Few During an interview, on 11/18/2021 at 1:34 PM, the Director of Nursing (DON) stated residents must be evaluated first if able to self-administer medication safely, then RN supervisor must complete a self-administration of medication evaluation and the resident needs to sign it. RN 1 stated after completing the self-administration of medication evaluation, resident's physician needs to approve and give an order. RN 1 stated licensed nurses must still supervise and observe those residents self-administering their medications. A review of Resident 44's care plan titled, Impaired Respiratory Status ., revised on 9/18/2021, indicated a long term goal for the resident not to exhibit signs and symptoms of respiratory distress. The care plan indicated interventions breathing treatment as ordered (clinician administration not self-administration of medication). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 31 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to store, discard, and/or label medications in accordance with the facility's policy and procedure. The following were observed during inspection of the medications carts: 1. Medication cart in Unit 300 had expired Budesonide Inhalation Suspension (a medication used to prevent difficulty of breathing, chest tightness, wheezing and coughing; used to treat breathing problems) for Resident 69. 2. Medication cart in Unit 300 had Anoro Ellipta (a medication used to treat breathing problems) for Resident 53 that was opened and not labeled with when it was opened to ensure how long it was good to use. 3. Medication cart in Unit 200 had Ipratropium-Albuterol (a medication used to treat breathing problems) inhaler for Resident 11 that was opened and not labeled with when it was opened to ensure how long it was good for. These deficient practices had the potential for the residents to be at risk for ineffective medications and/or suffer from side effects of using expired medications. Findings: During an inspection of the medication cart in Unit 300 and interview, on 11/16/2021 at 2:36 PM, the following was observed with a Licensed Vocational Nurse 5 (LVN 5): 1. For Resident 69, one Budesonide Inhalation Suspension foil envelope was opened and dated 10/14/2021. According to the manufacturer's product label, it indicated that once the foil envelope was opened to use the ampules within two weeks (now 32 days after opening). 2. For Resident 53, one foil tray of Anoro Ellipta was opened and not labeled with an open date. According to the manufacturer's product label, it indicated that once removed from the protective foil pack, Anoro Ellipta inhalers must be used or discarded within six weeks. LVN 5 stated that the medications were not stored properly, one was expired (Budesonide) and one not labeled with an open date (Anoro Ellipta). LVN 5 stated that licensed nurses must check the cart for expired medications routinely, identify and remove medications that were in the cart longer than they should be based on their expiration dates. LVN 5 stated if a medication was expired and given to a resident, there was a chance it might not work as intended and could cause harm to the resident. 3. During an inspection of the medication cart in Unit 200 and interview, on 11/16/21 at 3:37 PM, the following medications were observed with LVN 4: a. For Resident 11, one Ipratropium-Albuterol (a medication used to treat breathing problems) inhaler was opened and not labeled with an open date. According to the manufacturer's product label, it indicated once the medication was removed from the protective foil pack, Ipratropium-Albuterol inhalers must be used or discarded within two weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 32 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN 4 stated that the inhaler for Resident 11 was not stored properly because it was not labeled with open date. LVN 4 stated licensed nurses must label the inhalers with an open date once it was opened and routinely check the cart for expired medications. LVN 4 stated if a medication was expired and given to a resident, there was a chance it might not work as intended and could cause harm to the resident. During an interview, on 11/18/21 at 1:34 PM, the Director of Nursing (DON) stated medications should be properly stored and labeled, making sure no expired medications were present in the medication carts and/or medication storage rooms. The DON stated it was important to follow the manufacturer's label instructions to make sure residents were given unexpired medications. The DON stated that expired medications could affect the efficacy (ability to produce the desired result) of the medications and could harm the residents. A review of facility's policy and procedure titled, Storage of Medications, dated 11/2020, indicated outdated or deteriorated drugs and biologicals were returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 33 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 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. Based on observation, interview, and record review, the facility failed to follow the menu and recipe on preparation of foods during a lunch tray line observation. The following were observed: Residents Affected - Few 1. [NAME] 1 did not follow the recipe to make southern green beans and served plain steamed green bean. 2. [NAME] 1 prepared the pureed southern green beans by using peas instead of pureed southern green beans and did not have a recipe to make pureed diet. This deficient practice had the potential for the nutritional value and/or tastes of the prepared foods to not be met. Findings: A review of the facility's lunch menu for 11/15/2021, indicated the following items would be served: 1. Meatball sandwich with sauce and shredded cheese (1 sandwich), 2. Southern [NAME] Beans ½ cup, 3. Creamy cucumber and celery salad ½ cup, and 4. Pudding with whipped Topping 1/3 cup. During a lunch tray line observation and interview, on 11/15/2021 at 10:40 AM, [NAME] 1 was blending peas and not southern green beans for the puree diet. [NAME] 1 stated the green beans for residents who were on a regular diet were steamed green beans (not southern green beans). During a test tray, on 11/15/32021 at 12:45 PM, the southern green beans of the regular diet the tasted like plain steamed green beans with no seasonings or onions. The pureed diet tray, the southern green beans tasted like peas and not like green beans. A review of the facility's undated record titled, Recipe: Southern [NAME] Beans, indicated the following ingredients: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 34 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 Frozen, cut green beans Level of Harm - Minimal harm or potential for actual harm 2. Onions, chopped Residents Affected - Few 3. Bacon fat or margarine 4. Salt and pepper Directions included to heat green beans and drain well. Sauté (fry onions) in margarine or bacon fat until tender, then combine green beans, onions, and the seasonings. The facility did not provide a recipe for preparing the pureed diet for southern green beans. During an interview, on 11/15/2021 at 1 PM, [NAME] 1 stated she had all the ingredients, but she forgot to follow the recipe to make the southern green beans. [NAME] 1 stated that the southern green beans should have had sautéed onions and cooked with margarine/bacon fat and seasonings (salt and pepper). [NAME] 1 stated that the taste between southern green beans and plain green beans) was different. During an interview with Dietary Supervisor (DS) and Registered Dietitian (RD), on 11/15/2021 at 1:20 PM, DS stated [NAME] 1 did not make the southern green beans as indicated on the menu. DS stated that the kitchen had all the ingredients for the recipe. During an interview, on 11/15/2021 at 1:20 PM, [NAME] 1 stated that she used peas to blend for the puree diet, because peas have a lot of starch and adding the peas would make the mixture thicker. [NAME] 1 stated that she did not follow a recipe to make the pureed diet for the beans. A review of facility's policy and procedure titled, Menu Planning, dated 2018, indicated that the menus were planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and in accordance with the most recent recommended dietary allowances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 35 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food in manner that was flavorful and had a variety of food options. Two of 22 sampled residents (Residents 5 and 67), who were on mechanical diets (texture modified diet that restricts foods that are difficult to chew or swallow), complained that the food served lacked flavor and that the facility did not have many choices to choose from. Residents Affected - Few This deficient practice had the potential to affect the resident's satisfaction and decrease meal intake which could result in weight loss. Findings: During a test tray observation, on 11/15/2021 at 12:45 PM, a regular and pureed diet of meatball sandwiches and southern green beans were tested. The southern green beans tasted like plain steamed green beans with no seasonings (salt and pepper) or sauteed onions. The pureed southern green beans tasted like peas and not like green beans. The meatballs from the sandwich was dry and had no flavor. A review of the facility's undated record titled, Recipe: Southern [NAME] Beans, indicated to sauté onions in margarine or bacon fat until tender, combine green beans, onions and seasonings (salt and pepper), and heat to serving temperature. During an interview, on 11/15/2021 at 1 PM, [NAME] 1 stated I do have the ingredients but forgot to follow the recipe to make the southern green beans. [NAME] 1 stated that the southern green beans should have been prepared with sautéed onions with margarine or bacon fat and seasonings. [NAME] 1 stated that the taste was different from plain green beans and southern green beans. During an interview, on 11/15/2021 at 9:53 AM, Resident 5 stated she did not like the food at the facility. Resident 5 stated the food was lousy. Resident 5 stated that there was no menu to select from and/or options to choose from. Resident stated that she has been in the facility for five years. Resident 5 stated that she did not like the taste of the foods served at the facility. During an interview, on 11/16/2021 at 12:10 PM, Resident 67 stated that menus were not provided to the residents in the facility and that when meal trays arrive that it was a surprise and that they find out what was being served after the tray arrived. A review of facility's policy and procedure titled, Menu Planning, dated 2018, indicated that menus were planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and in accordance with the most recent recommended dietary allowances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 36 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Dish Washer (DW) did not wash hands when removing the clean and sanitized dishes from the dish machine. This failure had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) that could lead to foodborne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins) for 85 of 87 residents who eat meals prepared from the facility's kitchen. Findings: During an observation on 11/15/2021 at 8:45 AM in the dish washing area, Dish Washer (DW) was observed rinsing (no soap used) dirty dishes before loading the dirty dishes into the sanitization machine. After the sanitization machine finished sanitizing the dishes, DW rinsed (no soap used) his soiled hands under the faucet that was used to wash dirty dishes. The sink contained soiled dishes. DW then proceeded to remove the clean and sanitized dishes from the dish machine without performing proper hand-hygiene (washing hands with soap and water). During a concurrent observation and interview on 11/15/2021 at 9 AM, DW stated that he washed his hands using the faucet above the counter used to rinse soiled dishes. DW stated after he washed hands, he shook off the excess water and removed the clean dishes. During a concurrent interview, on 11/15/2021 at 9:15 AM, DS stated that hand washing should be in the hand washing sink. DS also stated that, It doesn't make sense for DW to leave the dishwashing area and go to the hand washing sink to wash hands then return. DS further stated it was best for DW to wash hands using the faucet on the counter next to dish machine that contained dirty dishes. During an interview, on 11/15/2021 at 1 PM, a Registered Dietitian (RD) stated that the faucet located in the dirty dishes area was not where staff should perform handwashing. The facility did not have a policy and procedure to provide guidance on where to conduct proper hand hygiene in the kitchen to ensure that cross contamination of service of foods did not occur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 37 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform hand hygiene before and after assisting two of two sampled residents (Residents 9 and 24). During an observation, a Certified Nursing Assistant 1 (CNA 1) was helping Resident 9 and went into Resident 24's room to assist Resident 24 without performing hand hygiene. Residents Affected - Some This deficient practice had the potential to increase the spread of infection and illnesses to other residents, staff, and the community. Findings: During an observation while in Resident 24's room, on 11/18/2021 at 7:49 AM, Resident 24 was observed eating breakfast while seated in bed. CNA 1 was observed in an adjacent (next door) room, seated in front of Resident 9, preparing Resident 9's breakfast tray. CNA 1 was then observed standing up and walking into Resident 24's room, and picked up Resident 24's spoon and began feeding Resident 24 a spoonful of oatmeal. CNA 1 did not perform hand hygiene prior to entering Resident 24's room or prior to touching Resident 24's spoon (after leaving Resident 9's room). During an interview, on 11/18/2021 at 7:50 AM, CNA 1 stated she was assisting Resident 9 for breakfast and that she came into Resident 24's room to check in on Resident 24. CNA 1 stated she had not performed hand hygiene before coming into Resident 24's room and touching Resident 24's spoon. CNA 1 stated staff must always perform hand hygiene before entering a resident's room and providing care. CNA 1 stated she should have washed her hands (after helping Resident 9 and before helping Resident 24) for safety and the prevention of the spread of infections. During an interview, on 11/18/2021 at 1:33 PM, the Director of Nursing (DON) stated the facility's staff were to sanitize hands before going in and again when staff were leaving residents' rooms. The DON stated hand hygiene was performed for infection control practices to limit the spread of infections. The DON stated not performing hand hygiene before staff was assisting a resident with care was not appropriate and strict hand hygiene should be followed. A review of Resident 9's Face Sheet (a record of admission) indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (heart doesn't pump enough blood for your body's needs., hypertension (high blood pressure) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients). A review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/16/2021, indicated Resident 9 had severe impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 9 required supervision (staff to provide cue) for eating. A review of Resident 24's Face Sheet indicated the resident admitted to the facility on [DATE] with diagnoses that included hypertension, dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), and contact with and (suspected) exposure to other viral communicable diseases. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 38 of 39 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 055845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm A review of Resident 24's History and Physical, dated 12/16/2020 indicated Resident 24 did not have the capacity to understand or make decisions. A review of Resident 24's MDS, dated [DATE], indicated Resident 24 required extensive assistance (resident involved in activity, staff provided weight bearing support) from staff for eating. Residents Affected - Some A review of the facility's policy and procedure (P&P) titled, Standard Precaution, revised October 2018, indicated hand hygiene referred to handwashing with soap (anti-microbial or non-antimicrobial) or the use of a alcohol based hand rub (ABHR), which did not require access to water. The P&P indicated hand hygiene was performed before and after contact with the resident and after contact with items in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 39 of 39