Health inspection·June 13, 2024

F 0550 A review of facility's policies and procedures titled, Dignity revised dated 02/2024, indicated residents are treated with dignity and respect at all time and residents are provided with a dignified dining experience. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 2 of 21 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 06/13/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 call light was within reach for one of eight sampled residents (Resident 11). Residents Affected - Few This deficient practice has the potential to delay necessary assistance, not meeting the needs of the resident promptly. Ensuring that the call light is always within reach is crucial for the safety and well- being of resident. The delay in in meeting the resident's needs for assistance can lead to frustration, falls and accidents. Finding: A review of Resident 11's admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included repeated falls and abnormalities of gait (walking pattern) and mobility. A review of Resident 11's Care Plan, dated 2/6/2023, indicated the resident was high risk for falls. Resident 11's care plan further indicated to strongly reinforce the use of call light for assistance. A review of Resident 11's Minimum set data (MDS - a comprehensive assessment and care screening tool) dated 1/30/ 2024, indicated Resident 11 had severely impaired cognitive skills and required extensive assistance for bed mobility, transfer, toilet use, personal hygiene, and bathing. During an observation on 6/10/2024 at 1:14 p.m., Resident 11 was observed in the room, sitting in the wheelchair with lunch tray positioned in front of her on the bedside table. Resident 11 was observed no staff present to assist the resident with the meal, nor call light in reach to for needed assistance. During a concurrent observation and interview on 6/10/2024 at 1:15 p.m. with CNA 4 in Resident 11's room, CNA 4 verified the call light was not within reach of Resident 11. CNA 4 stated the importance of having a call light within reach is important in case of emergencies like choking while a resident is eating and to receive help quickly. A Review of the facility's policy and procedure Revised on 10/2010, and titled, Answering the Call light, indicated the purpose of this procedure is to respond to the resident's requests and needs. General guidelines when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 3 of 21 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 06/13/2024 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 46), was informed of where to find the facility's monthly and alternative, breakfast, lunch, and dinner menu. This deficient practice denied the resident the right to choose and participate in food choices, leading to feelings of helplessness and loss of autonomy, which can have negative impacts on their overall wellbeing. Findings: A review of the admission Record indicated Resident 46 was admitted to facility on 05/08/2024, with the diagnoses of right femur fracture (hip fracture or break), abnormality of gait (walking abnormality) and mobility. A review of the History and Physical dated 05/17/2024, indicated Resident 46 had the capacity to understand and make decisions. A review of Resident 46's care plan dated 05/09/2024, indicated Resident 46 had nutritional risk for weight changes and risk for variable intake of nutrition due to poor appetite. The care plan interventions indicated for dietary service to assess likes and dislikes, food preferences, and to offer alternatives. A review of the Minimum Date Set (MDS - a standardized assessment and care planning tool) dated 05/12/2024, indicated Resident 46 required partial assistance to complete any activities such as walking with or without a crutch. During a concurrent observation and interview on 06/10/2024 at 11:43AM with Resident 46, observed no visible food menu posted in the resident's room. Resident 46 stated if he did not like what is being served, the resident notifies the dietitian. Resident 46 stated if he asked for an alternative meal, it sometimes takes as long a one - two hours before resident can eat. Resident 46 stated he had never been informed by staff that he could choose from an alternative menu. During an interview on 06/11/2024 at 01:07 PM with LVN 4, LVN 4 stated the weekly food menu is kept in the residents' rooms. During an interview on 06/11/2024 at 02:15 PM with the RD, the RD stated we keep a regular menu in the resident's room. During an interview on 06/11/2024 at 02:28 PM with the DS, the DS stated if a resident does not like the meal that is being served, the facility have prepared alternative meals ready for exchange. During a concurrent observation and interview on 06/12/2024 at 08:38 AM with LVN 1, observed no menu posted in a resident's room. LVN 1 stated not seeing a menu in the resident's room. LVN 1 stated the facility keep the menu in the hallway and in front of the kitchen. LVN 1 stated the resident would need to go to hallway or in front of the kitchen to view the menu. LVN 1 stated the resident would not know what is being served until the meal has been served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 4 of 21 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 06/13/2024 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/12/2024 at 09:43 AM with DS, stated we only make alternative meals per request. Stated we have no meals ready to go. Stated alternative meals are not premade, the resident must wait until the meal is prepared. During an interview on 06/12/2024 at 02:03PM with Resident 46 stated, I do not know where the food menu is posted. Stated I do not get out of bed myself and my vision is poor. During an interview on 06/12/2024 at 02:19 PM with family member of Resident 46 stated, I do not believe my mother was told of where the menu was posted. Family member stated I was not informed of an alternative menu being available, nor was I aware of location of food menu. A Review of the facility's Policy and Procedure titled, Resident Food Preferences revised December 2008, indicated the Dietitian and nursing staff will accommodate resident preferences and Food Services Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 5 of 21 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 06/13/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of an Advance Health Care Directives form (AHCD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) readily available for review in the medical record of one (1) of 3 sampled residents (Resident 162). This deficient practice had the potential to cause conflict in carrying out the resident's wishes regarding health care. Findings: A review of the admission record indicated Resident 162 was admitted on [DATE], with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and major depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act). A review of the History and Physical Examination (H&P) dated 5/30/24, indicated Resident 162 has fluctuating capacity to understand and make decision. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 6/2/24, indicated Resident 162 indicated the resident's cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated that Resident 162 required setup or clean-up assistance (helper assists only prior to or following the activity) with eating and oral care and Resident 162 required partial/moderate (helper does less than half the effort) assistance with eating, toileting hygiene, and shower/bathe self. A review of Resident 162's Physician Orders for Life-Sustaining Treatment (POLST-a form that gives seriously ill patients more control over their end-of-life care) dated 6/1/24, indicated Resident 162 had an Advance Health Care Directive. During a concurrent record review and interview with Licensed vocational Nurse (LVN) 2 on 6/10/24 at 1:13 PM. The LVN 2 stated there was no AHCD filing in the Resident 162's medical chart. The LVN 2 stated it is important to have the AHCD in the residents' charts to know what his wishes. During a concurrent record review and interview with the Director of Nursing (DON) on 6/13/24 at 2:28 PM, the DON stated that Resident 162's AHCD Acknowledgement form, dated 6/1/24, indicated that Resident 162 has an Advance Directive. The DON stated if resident already had Advance Directive, the staff should obtain a copy of the Advance Directive and place it in the resident's medical record. The DON stated The AHCD let the staff know what the residents' wishes were. During a concurrent record review and interview with the Social Service Director (SSD) on 6/13/24 at 4:23 PM, The SSD stated Family (FAM) 1 has the the original copy of Resident162's AHCD and she was supposed to give a copy to facility. The SSD stated there was no documentation that follow-up was done to obtain a copy of the Advance Directive from Resident 162's FAM 1. A review of the facility's policy and the procedure titled Advance Healthcare Directives, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 6 of 21 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 06/13/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm dated December 2021, indicated that upon admission, social service director (SSD) or the admission staff or designee will inform the resident of his/her right to execute an AHCD. If the resident has an AHCD, the SSD, admission staff or designee will place a copy of the AHCD in the resident ' s medical record and will notify the IDT of the existence of the document. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 7 of 21 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 06/13/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 formulate a care plan for one out of 22 total sample residents (Resident 35) who did not understand the formal language in the facility and did not have a care plan to address the resident's communication needs. This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35. Findings: A review of Resident 35's admission record indicated Resident 35 was originally admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood), and muscle weakness. A review of Resident 35's History and Physical (H&P), dated 5/15/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 5/18/2024, indicated the resident has moderate cognitive impairment. The MDS also indicated the resident requires supervision (helper provides verbal cues and/or touching/steadying assistance as resident completes activity) for activities such as eating (the ability to use utensils to eat). A review of Resident 35's IDT (Interdisciplinary Team- team of staff that work together to develop the plan of care for the residents in the facility) Care Conference Notes, dated 5/15/2024, indicated the resident was able to verbalize needs in a foreign language. A review of Resident 35's Social Services admission Assessment, dated 5/15/2024, timed at 10:58 AM, indicated the Resident 35's spoken language was a foreign language. A review of Resident 35's care plans did not have documented evidence for the presence for a care plan that addresses the resident's communication needs. During a concurrent observation and interview on 6/12/2024 at 10:57 AM inside Resident 35's room with Certified Nursing Assistant (CNA) 8, Resident 35 was observed speaking in a non-English language while CNA 8 was providing care to Resident 35. CNA 8 stated she does not speak Resident 35's language and Resident 35 does not speak English. During a concurrent interview and record review on 6/12/2024 at 10:59 AM with Licensed Vocational Nurse (LVN) 5, Resident 35's care plans were reviewed. LVN 5 stated Resident 35 does not have a care plan for the resident's communication needs. LVN 5 stated Resident 35 should have a care plan for communication needs because the resident does not understand and speak the formal language in the facility. LVN 5 stated the care plan will help staff in formulating ways to facilitate communication between staff and Resident 35. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 8 of 21 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 06/13/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 6/13/2024 at 9:48 AM with Director of Nursing (DON), DON stated Resident 35 only understands and communicates using foreign language. The DON stated there should be a care plan to address the resident ' s communication needs. DON stated there should be a plan for when the resident needs to speak with staff, especially during the delivery of care. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated the comprehensive, person-centered care plan will incorporate identified problem areas. The P&P also indicated the care plan will aid in preventing or reducing decline in the resident's functional status and/or functional levels. Event ID: Facility ID: 055845 If continuation sheet Page 9 of 21 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 06/13/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide a communication tool for one of 22 total sample residents (Resident 35) who did not understand the formal language, was not provided a communication board (a communication device, usually a whiteboard and a marker, used to facilitate communication between resident and staff). Residents Affected - Few This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35. Findings: A review of Resident 35's admission record indicated Resident 35 was originally admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood), and muscle weakness. A review of Resident 35's History and Physical (H&P), dated 5/15/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 5/18/2024, indicated the resident has moderate cognitive impairment. The MDS also indicated the resident requires supervision (helper provides verbal cues and/or touching/steadying assistance as resident completes activity) for activities such as eating (the ability to use utensils to eat). A review of Resident 35's IDT Care Conference Notes, dated 5/15/2024, indicated the resident was able to verbalize needs in a foreign language. A review of Resident 35's Social Services admission Assessment, dated 5/15/2024, timed at 10:58 AM, indicated the Resident 35's speaks a foreign language. During a concurrent observation and interview on 6/12/2024 at 10:57 AM inside Resident 35's room with Certified Nursing Assistant (CNA) 8, Resident 35 was observed speaking in a non-English language while CNA 8 was providing care to Resident 35. CNA 8 stated she does not speak Resident 35's language and Resident 35 does not speak the formal language in the facility. CNA 8 stated Resident 35 does not have a communication board. During an interview on 6/12/2024 at 10:59 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 35 does not speak English. LVN 5 stated Resident 35 should have a communication board to help the resident communicate with staff. During an interview on 6/13/2024 at 9:48 AM with Director of Nursing (DON), DON stated Resident 35 only understands and communicates in a foreign language. DON stated Resident 35 should have a communication board for when Resident 35 needs to communicate with staff, especially while Resident 35 is receiving care. DON stated using other ways to communicate, such as via a phone translator, will not be adequate to immediately address the resident ' s communication needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 10 of 21 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 06/13/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Communication with Persons with Limited English Proficiency, revised 6/2024, indicated language assistance will be provided through the use of interpreters and a communication board. The P&P indicated the communication board will be available in the resident ' s room that is easily accessible to the resident and staff. The P&P also indicated staff will utilize the communication board to meet the needs of the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 11 of 21 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 06/13/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 three sampled residents (Resident 106), received care and services for urine and bowel incontinence (no control) care promptly and after each incontinent episode as indicated in the resident's care plan and the facility's policy and procedure. Resident 106 waited one hour before she was assisted to be cleaned and brief to be changed due to incontinent. Residents Affected - Few This deficient practice could result in discomfort and pain due to skin breakdown that could lead to skin infection. Findings: A review of Resident 106's admission Record indicated Resident 106 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included muscle wasting and atrophy (decrease in size of muscle tissue), generalized muscle weakness, diabetes mellitus (a condition that happens when the blood sugar is too high), osteoporosis (a condition with a decrease in the amount and thickness of bone tissue, which causes the bones to become weak and break more easily), and urinary tract infection (UTI, a condition in which bacteria invade and grow in the urinary tract which includes the organs that make urine and remove it from the body). A review of Resident 106's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 5/5/24 indicated, Resident 106 ' s cognitive skills for daily decision making was severely impaired (difficulty with or unable to make decisions, learn, remember things) and was dependent (helper does all of the effort with assistance of two or more helpers was required for the resident to complete the activity) in toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal) and personal hygiene (the ability to maintain personal hygiene, including combing hair, washing/drying face and hands). A review of Resident 106's History and Physical, dated 5/4/24, indicated Resident 106 did not have the capacity to understand and make decisions. A review of Resident 106's Weekly Summary, dated 6/12/24 at 8:10 PM, indicated from 6/5/24 to 6/12/24 that Resident 106's mental status was alert and confused. The record indicated Resident 106 needed substantial/maximal assistance (helper does more than half the effort, lifts or holds trunk or limbs) in toileting hygiene and personal hygiene. A review of Resident 106's Care Plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 5/5/24, indicated Resident 106 ' s was at risk for UTI, and skin breakdown due to total incontinence. The care plan goal was for Resident 106 to be kept clean, dry, odor free, and free from skin breakdown daily and without sign/symptoms of UTI. The interventions included to answer call light promptly and provided incontinence care after each incontinent episode. During a concurrent observation and interview on 6/10/24 at 11:15 AM in Resident 106's room, Resident 106 was observed lying in bed tapping on the right bed siderail multiple times, Resident 106 stated, she had urinated in her incontinent brief and needed somebody to help her with brief change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 12 of 21 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 06/13/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/10/24 at 11:27 AM in the hallway outside of Resident 106's room, two facility's staffs were observed walking by Resident 106 room while Resident 106 continued to tap on the side rails multiple times. During an observation on 6/10/24 at 11:45 AM in the hallway outside of Resident 106's room, three facility's staffs were observed walking by the resident ' s room while Resident 106 was calling out Help! Please, please, somebody helps! with multiple tapings on the siderails. During a concurrent observation and interview on 6/10/24 at 12:08 PM in Resident 106 ' s room, Certified Nurse Assistant (CNA) 1 was observed assisting Resident 106 with brief change. CNA 1 stated, she was busy with other tasks and was helping another resident in the room next door when she heard Resident 106 yelling for help. CNA 1 stated, she had to finish assisting the other resident first before she could assist Resident 106. CNA 1 stated, Resident 106's brief was wet and needed to be changed. CNA 1 stated, she should have asked other staff to assist Resident 106 right when she heard Resident 106 calling for help. During an interview on 6/12/24 at 11:5 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, brief change for incontinent residents should be immediately because sitting on a wet brief for an hour could damage the skin. LVN 1 stated, if the CNA was busy, and heard that a resident was calling for help, she expected the CNA to let her know right away so that she could help right away. LVN 1 stated, she did not receive any request for help from any CNA on 6/10/24. During an interview on 6/12/24 at 12:31 PM with CNA 2, CNA 2 stated, Resident 106 was known to tap on the side rails or her bedside table when she called for help aside from pressing the call light. During an interview on 6/13/24 at 3:07 PM with the Director of Staff Development (DSD), the DSD stated, incontinent resident had a high risk for skin breakdown. The DSD stated, she expected CNA 1 to come and assist Resident 106 right away. The DSD stated, if CNA 1 was busy, CNA 1 should have called for help, because it was not acceptable for the residents to wait for one hour before they receive the help they needed. The DSD stated, sitting on a wet diaper could increase the risk of skin breakdown and their health could decline. A review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), and elimination (toileting). A review of the facility's P&P titled Prevention of Pressure Injuries, revised April 2020, indicated preventions for pressure injuries including skin care by keeping the skin clean and hydrated, and cleaning promptly after episodes of incontinence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 13 of 21 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 06/13/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 facility provided respiratory care as indicated in the facility's policy and procedure and plan of care for one out of 22 residents (Resident 24) with a physician order to receive continuous oxygen therapy was observed with an empty oxygen tank that required a refill. Residents Affected - Few This deficient practice had the potential to cause Resident 24 to suffer complications associated to inadequate oxygen intake such as shortness of breath. Findings: A review of Resident 24's admission record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included asthma (inflammation and muscle tightening around the airways, which makes it harder to breathe), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 24's history and physical (H&P), dated 6/3/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 5/8/2024, indicated Resident 24 has severe cognitive (ability to process information) impairment. The MDS also indicated Resident 24 was assessed to have shortness of breath when lying flat. A review of Resident 24's Order Summary Report, dated 6/12/2024, included an order of Oxygen at 2 L/min (Liters, unit of measure, per minute) via N/C (Nasal cannula, a thin plastic tube used to deliver oxygen from a source to a person ' s nares) continuously every shift. A review of Resident 24's care plan for oxygen, initiated on 7/18/2023, indicated the resident needs continuous oxygen therapy for shortness of breath. During an observation on 6/10/2024 at 12:43 PM inside Resident 24's room, Resident 24 was observed sitting on the wheelchair, eating. Resident 24 was observed using a nasal cannula that was connected to an oxygen tank. The oxygen tank ' s gauge dial was observed pointing at the word refill. During a concurrent observation and interview on 6/10/2024 at 1:14 PM inside Resident 24's room with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 24 ' s oxygen tank was empty because the dial pointed to refill and was on red. LVN 5 stated he was not sure when the oxygen tank was last checked and who connected the resident to the oxygen tank. LVN 5 stated Resident 24 could have had an episode of shortness of breath because the resident was not receiving any oxygen. During a concurrent interview and record review on 6/11/2024 at 3:11 PM with LVN 5 of Resident 24's medical records, LVN 5 stated there was no documented evidence that Resident 24's oxygen tank was assessed. LVN 5 stated there was also no documentation pertaining to Resident 24 getting set up to use the oxygen tank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 14 of 21 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 06/13/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/13/2024 at 9:48 PM with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, was reviewed. DON stated the P&P indicated nursing staff should document in the resident's medical records when residents are set up to use oxygen tanks. DON stated only licensed nursing staff, such as LVN or Registered Nurses, could assess and set up residents to use oxygen tanks. DON stated part of the assessment performed by licensed nurses included checking the level of the oxygen tank. DON stated if licensed staff only documented that Resident 24 was transitioned to an oxygen tank, the resident's oxygen tank would not have gone down to empty. A review of the facility ' s P&P titled, Oxygen Administration, revised 10/2010, indicated a step in the administration of oxygen included for staff to observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. The P&P also indicated after completing the oxygen setup, the following information should be recorded in the resident ' s medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for PRN (as-needed) administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 15 of 21 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 06/13/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to complete a performance review by completing the Annual Core Clinical Competencies (ACCC, an assessment and training on the Certified Nurse Assistant(s) (CNA) the ability to perform clinical nursing care). In addition, the facility did not have a system in place to keep track of the CNA's performance evaluation to ensure three of five CNAs (CNA 1, CNA 2 and CNA 3) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. Residents Affected - Some This failure had a potential to result in the facility's resident's population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) not to receive quality care services from CNAs with insufficient skills and competencies. Findings: A review of the facility's undated Tracking log, indicated there was no tracking for the facility's CNA's ACCC that indicated which CNA required the training. During an interview on 6/13/2024 at 2:08 PM with Registered Nurse (RN) 1, RN 1 stated, she used to assist the facility as the Director of Staff Development (DSD) and has been helping to train the new DSD. RN 1 stated, all CNAs were required to have yearly clinical skills competency check. RN 1 stated, she based on the CNAs month of hire for the CNA's ACCC due date. RN 1 stated, once completed, she would file the CNAs' ACCC to the Administrator (ADM)'s office for records. RN 1 stated, there was no tracking system available to know if any CNA's ACCC was not completed or up to date. During an observation and record review on 6/13/2024 at 2:22 PM in the ADM's office, the DSD, RN 1 and ADM were observed checking the records for five sampled CNAs. The records indicated: 1. CNA 1 was hired on 10/22/1996 and the last competency date was 9/1/2022. 2. CNA 2 was hired on 8/9/2016 and the last competency date was 4/19/2021. 3. CNA 3 was hired on 8/19/20 and the last competency date was 8/23/2023. During an interview on 6/13/2024 at 2:57 PM with the DSD, the DSD stated, CNAs were supposed to have yearly clinical skills competency check based on the facility's CNA Core Clinical Competencies check list to assess for their competency and to refresh their knowledge on how to provide appropriate care to the residents. The DSD stated, she just started the DSD position about eleven weeks ago and she did not have a system to log and keep track of the CNAs' ACCC. The DSD stated, if the CNAs' skills were not checked annually, the CNAs could miss important details care that could affect the residents' overall health. During an interview on 6/13/2024 at 3:45 PM with the Infection Control Nurse (IPN), the IPN stated, she held an in-person lesson in July and August 2023, which was considered as an annual ACCC for all CNAs. The IPN stated, all facility's CNAs were required to attend and watch a video with post test given. The IPN stated, some CNAs but not all of them were called to demonstrate the skills after watching the video. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 16 of 21 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 06/13/2024 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 0730 Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interview on 6/19/24 at 4 PM with the IPN, the facility's record Lesson Plan, with the title of Certified Nursing Assistant IPC (Infection Prevention) Curriculum, undated, was reviewed. The IPN stated, the lesson plan was used for the in-person lesson in July and August 2023. The IPN stated, not all skills listed in the facility's CNA Core Clinical Competencies were included in the lesson plan. Residents Affected - Some A review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised May 2019, indicated the following: a. Licensed nurses and nursing assistants employed by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents. b. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. c. Facility and resident-specific competency evaluations will include lecture with return demonstration for physical activities; demonstrated ability to use tools, devices, or equipment used to care for residents; demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 17 of 21 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 06/13/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of food service safety for residents in the facility by failing to label, date and store food in the refrigerator and freezer. Facility failed to ensure [NAME] 1 change visible soiled gloves prior to plating the residents' food. This deficient practice had the potential to place residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 06/10/2024 at 8:50 AM, with Dietary Service Supervisor, observed multiple open items in the walk- in refrigerator without a use by date. Those items were: Chicken broth - open date 5/3/2024 - no use by date. Lemon Juice - open date 5/3/2024 - no use by date. Sweet sour sauce - open date 4/6/2024 - no use by date. Yogurt - open date 6/9/2024 - no use by date. Feta cheese- open date 6/9/2024 - no use by date. Half watermelon - dated 6/9/2024 - no use by date. Fruit cocktail - open date 6/10/2024 - no use by date. Bacon - open date 6/9/2024 - no use by date. Fish (tilapia / marinated) dated 6/10/2024 - no use by date. Milk- open date 6/10/2024- no use by date. Apple sauce in plastic container - open date 6/10/2024 - no use by date. Ready Care shakes - open date 6/6/2024 - no use by date During the same interview with the Dietary Supervisor on 6/10/2024 at 8:50 AM, the Dietary Service Supervisor (DSS) stated the opened food items do not have the use by date labels. The DSS stated the facility uses the manufactures expiration date. The DSS stated the reason for an expiration date is to know when food expires. During a concurrent observation and interview on 06/10/2024 at 9:00 AM, with the DSS, observed frozen food boxes on floor of freezer. The DSS stated the boxes are not to be on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 18 of 21 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 06/13/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with the DSS, on 06/10/2024 at 9:10 AM, the facility was observed with multiple dry items including canned, without use by date. The DSS stated the facility does not have to have a use by date. Tomato can date 5/30/2-23 - no use by date. Residents Affected - Some Fruit cocktail opened 5/30/2024 - no use by date. Lemon pepper - opened 9/2/2023 - no use by date. Mint - open date 11/23/2024 - no use by date. During a concurrent observation on 6/10/2024 at 11:15 AM with LVN 3, observed Med cart in hallway without use by date on apple sauce, juice, and water. LVN3 stated it has the date it was made but no use by date. During an interview on 6/10/2024 at 12:20PM with the Infection Preventionist (IP), the IP stated the apple sauce and juice on the medication cart must be changed every day and labeled with a use by date. The IP stated the facility indicates the date, so nurses are aware when to throw a food item away. During a concurrent observation and interview on 6/12/2024 at 12:00 pm with the [NAME] in the facility's kitchen. The following were observed: Breaded fish filet removed from tray with gloves to plate, then used of same gloves to grab clean plates. No change of gloves in-between. Lasagna pushed off serving spatula gloves becoming soiled with pasta and meat sauce, then proceeded to touch countertop, serving spoons, and clean plates. No change of gloves. The [NAME] stated when his gloves have pasta on them or become soiled, he need to change the gloves. The [NAME] stated he did not change his gloves. During a review of the facility's policy and procedure titled, Food Handling, dated 2023, indicated, Food will be prepared and served in a safe and sanitary manner. Gloves should be changed, and personnel shall use suitable utensils. During a review of the facility's policy and procedure titled, Labeling and Dating of foods, dated 2023, indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newley opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 19 of 21 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 06/13/2024 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 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 implement the facility's policy and procedure for standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for one of one resident (Resident 31) by ensuring the Permcath (a flexible tube inserted into the skin and into the blood vessels and used for hemodialysis [is a type of treatment that helps your body remove extra fluid and waste products from the blood when the kidneys]) dressing was not peeling off. Residents Affected - Few This deficient practice placed the resident at risk for infection and accidental dislodgement (removal) of the Permacath. Findings: A review of an admission Records indicated resident 31 was originally admitted to the facility on [DATE] and admitted on [DATE] with diagnoses including dependence on renal (kidneys) dialysis and type II type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level). A review of the History and Physical Examination (H&P) dated 02/01/2024, indicated Resident 31 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 09/20/2023, indicated Resident 3's cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated Resident 31 required substantial/maximal (helper does more than half the effort) assistance from staff for toileting hygiene and lower body dressing. A review of Resident 31's Order Summary Report (a summary of all currently active physician orders), dated 06/11/2024, indicated for Resident 31 who was on hemodialysis treatment the physician ordered as follows: a. Always keep dressing to dialysis access site (right chest Permacath) dry and intact. Dialysis line care and dressing changes to be done by dialysis center pre and post treatment. Facility staff may change dressing if accidental removal of transparent dressing has occurred, wet or dressing is no longer occlusive as needed. b. Monitor hemodialysis access site (right chest Permacath) for sign and symptoms of complications and infection such as bleeding, swelling, pain, drainage, odor, hardness, or redness at site. Notify the physician and dialysis center immediately with any urgent problems every shift. During an observation on 06/10/2024 at 10:20 AM, Resident 31 was observed in the room lying in bed with the Permacath on the right upper chest. The transparent gauze dressing on the Permacath was observed peeling off at three corners and the gauze dressing came loose. During a concurrent observation and interview on 06/10/2024 at 10:24 AM in resident 31 ' s room, a License Vocational Nurse, Treatment Nurse 1 (TXN) verified Resident 31 ' s transparent dressing for the Permacath peeled off, the gauze dressing came loose. TXN 1 stated that Resident 31 was scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 20 of 21 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 06/13/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to have dialysis treatment on every Tuesday, Thursday, and Saturday and the dressing should be changed each dialysis treatment by dialysis staff, to minimize the risk of infection and consequently reduce the potential for patient harm. During a concurrent observation and interview with Director of Nursing (DON) on 06/10/2024 at 10:26 AM, the DON stated it was importance to maintain dressing over the Permacath access in a clean, dry, and intact manner to prevent infection. The DON stated the facility ' s licensed nurse should perform dressing changed immediately if the integrity of the dressing has been compromised from getting wet, loose, or soiled. A review of the facility's policies and procedures titled, End Stage Renal Disease, Care of a Resident, revised dated on 11/08/2023 indicated, the Hemodialysis site dressing will be changed in accordance with attending physician's order. A review of the facility's policies and procedures titled, Hemodialysis Catheter dated 06/2018, indicated licensed nurses in the facility shall monitor the device and document: a. Any signs and symptoms of complications at the exit site; redness, drainage, bleeding, swelling, odor or skin irritation. b. That the dressing placed over the exit site is intact. Change the dressing PRN (as needed) if the integrity of the dressing has been compromised (wet, loose or soiled). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055845 If continuation sheet Page 21 of 21