F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on observation, interviews and record review, the facility failed to report an allegation of abuse to the
Department and other officials immediately, but not later than two hours for one of one sampled resident
(Resident 1) in accordance with the mandated Federal and State regulatory guidelines.
This deficient practice had the potential for the facility to under report allegations of abuse, which could lead
to failure to investigate alleged abuse in a timely manner.
Findings:
A review of Resident 1 ' s admission Record indicated an admission date on 4/3/2024 with diagnoses
including hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness on one side of
body) following cerebral infarction (stroke) affecting left non-dominant side.
A review of Resident 1 ' s History and Physical Examination dated 4/9/2024, indicated Resident 1 had the
capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 4/7/2024
indicated Resident 1 had moderately impaired cognition and needed some help with self-care, indoor
mobility (ambulation) and function cognition (the need for assistance with planning regular tasks).
A review of Resident 1 ' s Progress note dated 4/14/2024 timed at 2:13 PM indicated two (2) uniformed
local enforcement officers came to facility to speak with Resident 1. The progress note indicated Resident 1
had concerns about a suppository (a solid but readily meltable cone or cylinder of usually medicated
material for insertion into a bodily passage or cavity) not being given.
During an interview with Resident 1 on 4/19/2024 at 1:14 PM, Resident 1 stated he felt sexually and
verbally abused by the Administrator (ADM) because the ADM did not respect resident 1 ' s privacy when
discussing the use of a plastic applicator for the suppositoryand spoke about an applicator that was being
used for a suppository. Resident 1 stated the ADM verbalized to Resident 1 said in a common area within
the facility that you told staff you want the thing up and to twirl it around. Resident 1 stated he was upset
with the ADM.
During an interview with the Social Services Director (SSD) on 4/19/2024 at 1:38 PM, SSD stated she
attempted to speak with Resident 1 multiple times after the local enforcement came to the facility to speak
with Resident 1. SSD stated she did not document any follow up note after the local enforcement came
since the SSD did not speak with the resident.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055845
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
04/19/2024
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent interview and record review of Resident 1 ' s Progress notes with the Director of
Nursing (DON) on 4/19/2024 at 2:25 PM, the DON could not find documented evidence to indicate an
investigation was done after the local law enforcement was at the facility for Resident 1. The DON could not
find documented evidence that the SSD attempted to follow up with Resident 1 after local law enforcement
came to see resident. The DON stated the SSD should have documented that she attempted to follow up
with Resident 1. The DON stated there should be an investigation and follow up with Resident 1 to address
what the resident was feeling and make sure Resident 1 ' S psychosocial well-being is intact.
A review of the facility ' s policy and procedure titled Abuse, Neglect, Exploitation or MisappropriationReporting and Investigating, dated 4/2024 indicated all reports of resident abuse (including injuries of
unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local,
state and federal agencies (as required by current regulations) and thoroughly investigated by facility
management, findings of all investigations are documented and reported.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055845
If continuation sheet
Page 2 of 2
