Health inspection·November 30, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure privacy and dignity to 1 of 4 sampled residents (Resident 25) when Certified Nurse Assistant (CNA 6) did not cover the Resident 25's naked body and did not close door while transporting Resident 25 from bedside commode to bed. This deficient practice had the potential for others to see Resident 25's naked body which may cause psychosocial harm to the resident. Findings: During an observation on 11/27/2023, observed CNA 6, use a mechanical lift to transport Resident 25 from the bedside commode to Resident 25's bed. Resident 25's naked body was exposed resulting in the potential for visitors to see Resident 25's naked body. The bathroom and bed are in Resident 25's room. The door was open to the hallway where persons were walking during the transfer. During an interview on 11/30/23 at 9:10 AM, with CNA 6, CNA 6 stated, I do not close the door to the room because I am inside the room. During an interview on 11/30/23 at 9:23 AM, with Charge Nurse (16-another identifier?) stated, When a resident is moved from bathroom or commode inside a room and is nude I would cover the resident and close the door. During an interview on 11/30/23 at 9:36 AM, with Director of Nursing (DON), DON stated, When transferring a resident from the bathroom to bed a resident is to be covered; if the resident is uncovered the door is to be closed to the room. A review of Resident 25's Physician Progress Note, dated September 26, 2023, the Progress Note indicated, Resident 25 does not have the mental capacity to request for Resident 25's naked body to be covered or the door to Resident's 25 room to be closed due to Resident 25 a medical history of advanced Alzheimer's dementia (define) with aphasia (difficulty speaking). And Resident 25 is nonverbal and has poor memory. A review of the facility's policy and procedure (P&P) titled, Resident Dignity & Personal Privacy, dated December 2016, states indicated, Examine and treat residents in a manner that maintains their privacy. Use a closed door, drawn curtain, or both, to shield the resident during all personal care and treatment procedures. Page 1 of 20 555605 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to obtain an informed consent from the responsible party for one of two sampled residents (Resident 28) who was prescribed Lorazepam (medication used to treat anxiety [a mental disorder that result in having the fear of the unknown]); Zyprexa (a medication used to treat psychotic conditions such as schizophrenia [a serious mental illness that affects how a person thinks, feels, and behave] and bipolar disorder [mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration], Depakene (medication used to treat seizure disorders [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements] that stabilizes mood, and Clozapine (a medication to treat medication for treatment-resistant schizophrenia). Residents Affected - Few This failure violated Resident 28's rights to be informed about the side effects (undesired effect of medication) and when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred. Findings: A review of Resident 28's face sheet (an admission record) indicated the facility readmitted the resident on 8/23/2023 with diagnosis of that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behave), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety (having severe feeling of the unknown), and Parkinson's disease (unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of a Minimum Data Set (MDS, an assessment and care screening tool), dated 10/9/2023, indicated Resident 28 had severe cognitive skills (ability to think, understand, and reason) impairment. The MDS also indicated Resident 28 was dependent (Resident does none of the effort to complete the activity and the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, dressing and personal hygiene care. A review of Resident 28's Physician Orders for the month of 11/2023, indicated to administer the following psychotropic drugs (medications that affects mood and behavior): 1. Lorazepam 0.5 milligrams (mg, unit of measurement) tablet, give 1 tablet by gastro-tube (G-Tube) every 6 hours as needed for recurrent outburst of anger related to anxiety disorder. 2. Zyprexa 5 mg tablet, give 1 tablet via G-Tube ( atube inserted into the stoamch used to deliver liquids and medications) at bedtime for yelling and screaming during care for no apparent reason related to schizophrenia. 3. Clozapine 25 mg tablet, give 1 tablet via G-Tube at bedtime for schizophrenia m/b auditory hallucinations (hearing voices that aren't present). 4. Depakene Solution 250 mg/5 milliliter (ml), give 5 ml via G-Tube three times a day for mood disorder 5 ml= 250 mg, poor impulse control. 555605 Page 2 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent record review and interview with Director of Nursing (DON) on 11/28/23 at 12:16 PM, the DON stated there was no documented evidence in Resident 28's clinical that indicated the physician obtained a consent signed by the resident's representative and the physician prior to receiving administer Lorazepam 0.5 mg tablet, Zyprexa 5 mg tablet, Clozapine 25 mg tablet, and Depakene Solution. The DON stated, a signed consent should had been obtained from Resident 28's representative before the administration of antipsychotic medications and ensure to keep the consent in Resident 28's clinical records. A review of the facility's policy and procedure, titled Psychoactive Medication Informed Consent dated July 2017, indicated it was the policy of the facility to ensure that an informed consent was obtained for each residents who receives psychoactive medication that was authorized in writing by a physician for specified time period, and when necessary to protect the resident from self-injury or injury to other. The purpose of the policy is to ensure that informed consent has been obtained and verified prior to initiation of psychotropic medication use. 555605 Page 3 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 interview and record review, the facility failed to accurately assess, reflective of the resident's status at the time of the assessment for one of four residents (Resident 41). The Social Service Designee (SSD) did not assess Resident 41's communication needs due to the resident being asleep during the assessment and documented Resident 41 was not interview able. Residents Affected - Few As a result of this deficient practice, Resident 41 did not receive the communication tools needed to communicate needs which had the potential for the resident not to receive the care and services needed to maintain the highest well-being. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra) and chronic heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 41's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/13/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated that resident was rarely/never understood. The MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 41's History and Physical, dated 11/2/2023, indicated that the resident was alert and had fluctuating (changing) capacity to make decisions. A review of Resident 41's Care plan initiated on 11/6/2023, indicated that the resident has a communication problem r/t language barrier. The record also indicated an intervention included to provide translator as necessary to communicate Resident 41 who preferred to communicate in a foreign language. During an interview on 11/29/2023 at 10:02 AM, the Activities Director (AD) stated she interviewed Resident 41 when the resident's daughter (FAM1) was present to help with the language barrier. The AD stated she learned that Resident 41's preferences for music and to have her phone close and charged for communication with her family. The AD stated Resident needs a foreign language speaker that she understands for more than basic things. During an interview on 11/29/2023 at 11:03 AM, Director of Nursing (DON) stated that Resident 41 had intermittent confusion but was able to communicate. The DON stated Resident 41's primary language was a foreign language. The DON stated that she speaks the foreign language that Resident 41 spoke but was never asked by the staff to help interpret during the MDS assessment for Resident 41. During an interview on 11/29/2023 at 11:18 AM, the MDS Nurse stated the Social Services Designee (SSD) was responsible for section C (what is sections C means?) of the MDS. During an interview on 11/29/2023 at 11:25 AM, the SSD stated Resident 41 was able to communicate 555605 Page 4 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but that she spoke another language. The SSD stated that during the MDS assessment Resident 41 was asleep and she did not wake up Resident 41 to interview and complete the MDS assessment. The SSD stated she does not remember the guidance on how to do the cognitive assessment. The SSD stated normally she would interview a resident to complete the MDS assessment. During an interview on 11/29/2023 at 12:37 PM, The MDS Nurse stated when completing the cognitive assessment section C of the MDS, sleeping does not qualify as the resident was not interview able. A review of Centers for Medicare and Medicaid Services (CMS) document titled, CMS RAI version 3.0 Manual, dated 2019 indicated that, assessment of a resident's mental state provides a direct understanding of resident function that may enhance future communications and assistance, direct nursing interventions to facilitate greater independence, as well as indicate at residents cognitive status which can bring awareness of possible impairment and may be important for maintain a safe environment and providing safe discharge planning. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf A review of Centers for Medicare and Medicaid Services (CMS) document titled, CMS RAI version 3.0 Manual, dated 2019 indicated that when completing the cognitive assessment section, attempt to conduct the interview with ALL residents, and to interact with the resident using his or her preferred language. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf 555605 Page 5 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 3's face sheet (an admission record) indicated the facility initially admitted Resident 3 on 2/3/21 with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behave), dementia (a progressive disease resulting in loss of intellectual functioning, impairment of memory, thinking, with personality changes) and anxiety (severe feeling nervousness and fear of the unknown), and was readmitted on [DATE] with the same diagnoses. Residents Affected - Few A review of a Minimum Data Set (MDS, an assessment and care screening tool), dated 11/11/2023, indicated Resident 3 had severe impairment in cognitive skills (ability to think, understand, and reason). The MDS also indicated Resident 3 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, dressing and personal hygiene care. A review of the Resident 3's letter PASARR Level 1 Screening from Department of Health Care Services (DHCS), dated 7/21/23, indicated Resident 3 was screened with a Positive for PASARR Level I with serious mental illness and required a PASSAR Level II Mental Health Evaluation. A review of Resident 3's History and Physical Examination, dated 7/24/2023, indicated Resident 3 can does not have the capacity to understand and make medical decisions. During a concurrent interview and record review on 11/29/2023 at 9:35 AM, the Medical Record Director (MRD) stated there was no documented evidence that Resident 3 was evaluated to PASSAR level II. A review of the facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASSR), release date 12/2017, indicated: a) If the Level I screening results indicate that the applicant should receive the Level II screening, the Facility shall contact the appropriate state agency for additional screening. b) The state agency will arrange for Level II screening and determine whether the individual should be admitted to the Facility, and if so, what services the individual will need. The Level II screening must be completed prior to admission. c) The state is responsible for providing specialized services to residents with MD/ID residing in Medicaid-certified facilities. d) Recommendations from the Level II screening will be incorporated into the residents' care plan. Based on observation, interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASARR - a federally required screening for mental health; PASARR Level I identifies suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of two sampled residents (Resident 22 and 3). This failure had the potential to result in Resident 22 and Resident 3 not to receive necessary mental health services which can negatively affect their quality of life. 555605 Page 6 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0645 Findings: Level of Harm - Minimal harm or potential for actual harm 1. A review of Resident 22s facesheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should ) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Residents Affected - Few A review of Resident 22s History and Physical Examination, dated 12/8/2022, indicated Resident 22 had fluctuating (changing) capacity to understand and make decisions. A review of Resident 22s Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/19/2023, indicated Resident 22s had moderately impaired cognitive status (ability to think, remember, and reason) that required set up or clean-up assistance (the helper sets up or clean up resident; resident completes activity. The helper assists only prior to or following the activity) with eating, oral hygiene, personal hygiene, and dependent (helper does all the effort) with toileting, bathing, dressing, and chair/bed-to-chair transfer. A review of the Resident 22s letter from Department of Health Care Services (DHCS) - PASARR Section, dated 12/17/2021, indicated, Resident 22 had positive PASRR Level 1 screening and required a PASARR Level II mental health evaluation. A review of Resident 22s Order Summary Report (OSR), dated 11/29/2023, to indicated to give Lexapro (medication used to treat depression and anxiety) 5 mg (a unit of mass measurement) by mouth for depressive disorder. The OSR indicated to give Zyprexa (an antipsychotic medication that affects chemicals in the brain) 5 mg for schizophrenia. During a concurrent observation and interview on 11/28/2023 at 8:20 AM, Resident 22 was observed in the room watching television by herself, with a sad looking facial expression. Resident 22 stated, I am fine, I prefer to eat here in the room. During an interview on 11/29/2023 at 8:09 AM, the DON stated, she was responsible to complete the PASARR when the residents were admitted to the facility and sends the information to DHCS (Department of Health Care Services) and waits for the call on when the DHCS will show up for the assessment. The DON stated, she did not keep a log or documentation to indicate that the facility followed up with DHCS or DHCS showed up to evaluate Resident 22 (the requirement for PASRR Level II was dated 12/17/2021). During a concurrent interview and record review, on 11/29/2023, at 8:52 AM, with the DON, Resident did not have documented evidence that the facility notified DHCS for the PASARR level II requirement. There were also no logs that the facility followed up about the PASARR level II requirement. 555605 Page 7 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 interview and record review, the facility failed to develop a person- centered care plan addressing resident specific interventions for one of four sampled residents (Resident 16). This deficient practice had the potential to negatively affect the delivery of care and services related to the residents' health conditions and needs. Findings: A review of Resident 16's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, hemiplegia (paralysis that affects one side of the body), dysphagia (difficulty swallowing), and epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 16's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/7/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was substantially dependent (helper does more than half the effort) on staff for oral hygiene, showering/bathing, dressing, and personal hygiene. The MDS also indicated that Resident 16 required supervision or touching assistance for eating. A review of Resident 16's History and Physical dated 1/3/2023 indicated that the resident did not have the capacity to understand or make decisions. A record review of Resident 16's care plan dated 5/23/2023 indicated that the resident was at risk for nutritional problem related to hemiplegia. The care plan stated that the facility was to monitor/document/report any signs of dysphagia such as choking, coughing, or drooling. During a concurrent observation and interview on 11/29/2023 at 7:36 AM with certified nurse assistant 2 (CNA2), CNA2 was observed setting up breakfast for Resident 16. CNA2 stated that Resident 16 required assistant for meal set up (take off lids, uncover food, mix food or drinks) but that Resident 16 was independent with feeding. CNA2 stated that he check on Resident 16 from time to time. During a concurrent interview and concurrent record review on 11/29/23 at 9:03 AM with the Director of Nursing (DON), Resident 16's care plan was reviewed. The DON stated Resident 16 required supervision during mealtimes for choking but was able to feed himself. The DON stated Resident 16's care plan did not indicate interventions including meal set up and meal supervision. During a concurrent interview and record review on 11/29/23 at 9:05 am with the DON, Resident 16's CNA flow sheet (a task sheet where certified nursing assistants chart on their assigned tasks for residents) for November 2023 was reviewed. The DON stated that CNAs charted 9 frequently for Resident eating. The DON stated that 9 indicated, not applicable according to the key on the CNA flow sheet. The DON stated that '6' indicated independent with eating. The flow sheet indicated '6' 31 times on the CNA flowsheet for Resident 16. and The DON stated Resident 16 was likely not supervised or meals were not set up during mealtime on days indicated by '9' on the flowsheet. 555605 Page 8 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/23 at 9:22 AM, the DON daily huddles were conducted to discuss the needs of the residents which included residents requiring feeding assistance and residents who were at risk for choking. The DON stated that the interventions for Resident 16 were not written on his care plan and that the care plan was important since the care plan ensures staff were implementing the specific needs of all residents. Residents Affected - Few A review of the facility's policy titled, Person Centered Plan of Care dated 12/2016, indicated that, the policy of the facility is to provide each resident with a person-centered plan of care developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, needs identified during the comprehensive assessment. It also indicated that the purpose of the care plan is to, attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing. 555605 Page 9 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 interview and record review, the facility failed to revise the care plan for one of four sampled residents (Resident 29) to indicate diet modifications. These deficient practices had the potential to result in Resident 29 not receiving the proper diet. Findings: A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), encephalopathy (A broad term for any brain disease that alters brain function or structure), and diabetes (A group of diseases that result in too much sugar in the blood). A review of Resident 29's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/1/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities), including eating, dressing, personal hygiene, and bed mobility. A review of Resident 29's History and Physical dated 5/29/2023 indicated Resident 29 had fluctuating capacity to make decisions. A review of Resident 29's care plan dated 5/31/2023, indicated that Resident 29 required tube feeding related to dysphagia. The plan of care did not indicate a diet change to solid foods by mouth During an interview on 11/29/2023 at 7:39 AM, certified nurse assistant (CNA2) stated that Resident 29 attempts to independently feed himself, but Resident 29 requires assistance since Resident 29 was at risk for choking. During an interview on 11/29/2023 at 9:22 AM, the DON stated that Resident 29's diet was changed to solid food by mouth. The DON stated Resident 29's care plan was not revised since the care plan did not indicate diet change to solid food for Resident 29. The DON stated the care plan should be revised to indicate Resident 29 current, specific needs. A review of the facility's policy titled, Person Centered Care Plan,' dated 12/2016, indicated that the facility would, re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly and with change in status assessment. A review of the facility's policy titled, Person Centered Care Plan,' dated 12/2016, also indicated that the facility would provide each resident with a person-centered plan of care in order to, meet their (the residents) medical, nursing, mental needs identified during comprehensive assessment. 555605 Page 10 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 maintain good personal hygiene and activities of daily living (ADL) by ensuring the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for 2 of 2 sampled residents (Resident 38 and Resident 18) who needed assistance with ADLs as indicated in the facility's policy and procedure, titled Answering the Call Light and the resident's care plan. Residents Affected - Few This deficient practice had the potential for Resident 38 and 18 not to receive needed assistance to achieve their highest potential and wellbeing. Findings: 1. A review of Resident 38s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), abnormalities of gait and mobility (weakness of the hip and lower extremity muscles), and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/23/2023, indicated Resident 38s cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 38 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, required partial/moderate assistance (the ability to use suitable items to clean teeth) with oral hygiene, and dependent (helper does all the effort) with toileting, dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer. A review of the Progress Notes (PN) dated 11/8/2023, timed at 4:14 AM, indicated Resident 38 was witnessed by a staff deliberately slid of the bed on the floor mat on the side of his bed and stated 'I want to go Kaka (bowel movement). A review of Resident 38s Care Plan (CP) initiated on 11/8/23, indicated Resident 38 had an actual fall and slid off the bed. The CP indicated goal included reduce risk of falls and/or injury thru appropriate interventions daily. The interventions included to attach the call light to the bed within access of resident. During a concurrent observation and interview on 11/27/2023 at 2:40 PM with Licensed Vocational Nurse (LVN) 2 in Resident 38s room, Resident 38 was calling for help and pointing at his call light. In an observation Resident 38s call light was on the floor, not within reach of Resident 38. In a concurrent interview LVN 2 stated, Resident 38s call light should had been within reach so he can call for help. LVN 2 stated, Resident 38 was at risk for fall and should have access to the call light all the time. 2. A review of an admission record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), 555605 Page 11 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and dementia (a syndrome [a group of related symptoms] associated with an ongoing decline of the brain and its abilities). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/27/2023, indicated the Resident18s cognitive skills was severely impaired. The MDS indicated Resident 18 required partial/moderate assistance (helper does less than half the effort) with eating, dressing, and required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting, and personal hygiene. A review of Resident 18s care plan, initiated on 10/17/2023 indicated, Resident 18 had alteration in cognitive function related to short-term and long-term memory problem. The CP interventions included to keep Resident 18's call light within reach. During a concurrent observation and concurrent interview on 11/27/2023 at 2:40 PM with Certified Nurse Assistant (CNA) 1 in Resident 18s room, Resident 18 was sitting in bed with food and drinks on the side table. Resident 18's call light was on the floor and was not within reach of Resident 18. CNA1 stated, Resident 18s call light should be with reach. CNA 1 stated, Resident 18 knows how to use the call light to get help. During an interview on 11/29/2023 at 10:30 AM the Director of Staff Development (DSD) stated, he had provided in-serviced to the staff on 11/8/23 and 11/27/23 and reminded the staffs about keeping the call light within the residents reach. The DSD stated, the call light needs to be answered immediately because residents may need help, especially residents who are high risk for fall and injury. During an interview on 11/29/2023 at 11:09 AM, the Director of Nurses (DON), DON stated, the call light should be within residents reach, and should be answered immediately. The DON stated the call light was used by residents to get help, and if call light was not answered it could affect residents 'quality of care or resident might try to get up and possibly injure themselves. During a review of the facility's policy and procedure (P&P) titled, Standards of Care Activities of Daily Living, dated 02/2017, the P&P indicated guidelines, dependence on others for ADL assistance can lead to feelings of helplessness, isolation, diminished self-worth, and loss of control over ones 'destiny. The P&P indicated, a) assist resident to keep clean, neat, and well-groomed including nail care and shaving. During a review of the facility's policy and procedure (P&P) titled, Answering Call Lights, dated 8/2017, the P&P indicated, the facility will respond to the resident's request and needs, and the steps will be taken to ensure resident's need and request was considered when request were made and when call lights were used to respond to needs at the time of use. The P&P indicated; the facility will ensure the call light was always plugged and when resident was in bed and confined to a chair, the call light will be placed within easy reach of the resident. The P&P indicated; resident's call lights will be answered as soon as possible. 555605 Page 12 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 provide an assistive device, such as a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach for two of two sampled residents (Resident 38 and Resident 18) who were at high risk for fall. This deficient practice had the potential for Resident 38 and 18 not to be assisted when needed assistance with activities of daily living (ADL) or in an event of emergency and result in accidents and injury. Findings: 1. A review of Resident 38s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), abnormalities of gait and mobility (weakness of the hip and lower extremity muscles), and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/23/2023, indicated Resident 38s cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 38 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, required partial/moderate assistance (the ability to use suitable items to clean teeth) with oral hygiene, and dependent (helper does all the effort) with toileting, dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer. A review of the Progress Notes (PN) dated 11/8/2023, timed at 4:14 AM, indicated Resident 38 deliberately slid of the bed on the floor mat on the side of his bed. The PN indicated no injury was noted. The PN indicated Resident want to go Kaka. The PN indicated it was witnessed by staff. A review of Resident 38s Fall Risk Assessment, dated 11/08/2023 at 7:44 AM, indicated Resident 38 was a high risk for fall. A review of Resident 38s Care Plan (CP) initiated on 11/8/23, indicated Resident 38 had an actual fall and slid off the bed. The CP indicated goal included reduce risk of falls and/or injury thru appropriate interventions daily. The interventions included to attach the call light to the bed within access of resident. During a concurrent observation and interview on 11/27/2023 at 2:40 PM with Licensed Vocational Nurse (LVN) 2 in Resident 38s room, Resident 38 was calling for help and pointing at his call light. In an observation Resident 38s oxygen tube or nasal cannula was on the other side of the bed and the call light was on the floor, not within reach of Resident 38. In a concurrent interview LVN 2 stated, Resident 38s call light should had been within reach so he can call for help. LVN 2 stated, Resident 38 was at risk for fall and should have access to the call light all the time. 2. A review of an admission record indicated Resident 18 was admitted to the facility on [DATE] 555605 Page 13 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0689 Level of Harm - Minimal harm or potential for actual harm with diagnoses that included generalized muscle weakness, congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and dementia (a syndrome [a group of related symptoms] associated with an ongoing decline of the brain and its abilities). Residents Affected - Few A review of Resident 18s History and Physical Examination, dated 10/17/2023, indicated Resident 18 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/27/2023, indicated the Resident18s cognitive skills was severely impaired. The MDS indicated Resident 18 required partial/moderate assistance (helper does less than half the effort) with eating, dressing, and required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting, and personal hygiene. A review of Resident 18s care plan, initiated on 10/17/2023 (CP) indicated Resident 18 had alteration in cognitive function related to short-term and long-term memory problem. The CP interventions included to keep Resident 18's call light within reach. A review of Resident 18s Fall Risk Assessment, dated 10/17/2023, timed at 2:58 PM, the FRA indicated Resident 18 was at high risk for fall. During a concurrent observation and concurrent interview on 11/27/2023 at 2:40 PM with Certified Nurse Assistant (CNA) 1 in Resident 18s room, Resident 18 was sitting in bed with food and drinks on the side table. Resident 18's call light was on the floor and was not within reach of Resident 18. CNA1 stated, Resident 18s call light should be with reach. CNA 1 stated, Resident 18 knows how to use the call light to get help. During an interview on 11/29/2023 at 10:30 AM the Director of Staff Development (DSD) stated, he had provided in-serviced to the staff on 11/8/23 and 11/27/23 and reminded the staffs about keeping the call light within the residents reach. The DSD stated, the call light needs to be answered immediately because residents may need help, especially residents who are high risk for fall and injury. During an interview on 11/29/2023 at 11:09 AM, the Director of Nurses (DON), DON stated, the call light should be within residents reach, and should be answered immediately. The DON stated the call light was used by residents to get help, and if call light was not answered it could affect residents 'quality of care or resident might try to get up and possibly injure themselves. During a review of the facility's policy and procedure (P&P) titled, Answering Call Lights, dated 8/2017, the P&P indicated, the facility will respond to the resident's request and needs, and the steps will be taken to ensure resident's need and request was considered when request were made and when call lights were used to respond to needs at the time of use. The P&P indicated; the facility will ensure the call light was always plugged and when resident was in bed and confined to a chair, the call light will be placed within easy reach of the resident. The P&P indicated; resident's call lights will be answered as soon as possible. 555605 Page 14 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 interview and record review, the facility failed to provide medically related social services to one of four residents sampled (Resident 41). The Social Service Designee (SSD) failed to accurately assess and arrange Resident 41's communication needs through the resident's primary method of communication or in a language that the resident understood. Residents Affected - Few As a result of this deficient practice, Resident 41 had the potential not to receive the care and services especially during an emergency needed to maintain or achieve the highest practicable mental and psychosocial well-being. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra) and chronic heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 41's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/13/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated that resident was rarely/never understood. The MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 41's History and Physical, dated 11/2/2023, indicated that the resident was alert, had fluctuating (changing) capacity to make decisions. A review of Resident 41's Care plan initiated on 11/6/2023, indicated that the resident has a communication problem r/t language barrier. The record also indicated an intervention included to provide translator as necessary to communicate Resident 41 who preferred to communicate in a foreign language. During an interview on 11/29/2023 at 10:02 AM, the Activities Director (AD) stated she interviewed Resident 41 when Family 1 (FAM1) was present to help with the language barrier. The AD stated she learned that Resident 41's preferences for music and to have her phone close and charged for communication with her family. The AD stated Resident needs a foreign language speaker that she understands for more than basic things. AD stated the some of the options to communicate with Resident 41 included a language binder that was at bedside, a translation phone line that was always available, or family members, which were not provided to Resident 41. During an interview on 11/29/2023 at 11:03 AM, Director of Nursing (DON) stated that Resident 41 had intermittent confusion but was able to communicate. The DON stated Resident 41's primary language was a foreign language. The DON stated that she speaks a foreign language that Resident 41 speaks, but she had never been asked to interpret during the MDS assessment for Resident 41. During an interview on 11/29/2023 at 11:18 AM, the MDS Nurse stated the Social Services Designee 555605 Page 15 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0745 (SSD) was responsible for section C (refers to the communication assessment of the resident) of the MDS. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/2023 at 11:25 AM, the SSD stated Resident 41 was able to communicate but that she spoke another language. The SSD stated that during the MDS assessment Resident 41 was asleep and she did not wake up Resident 41 to interview and complete the MDS assessment. The SSD stated she does not remember the guidance on how to do the cognitive assessment. The SSD stated normally she would interview a resident to complete the MDS assessment. Residents Affected - Few During an interview on 11/29/2023 at 12:37 PM, the MDS Nurse stated when completing the cognitive assessment section C of the MDS, sleeping does not qualify as a resident is not interview able. The MDS Nurse stated that not interview able means that a resident is nonverbal or unable to communicate all. A review of the facility's undated policy titled, Job Description, Director of Social Services, indicated that the Social Services Designee will, keep abreast of current federal and state regulations, as well as professional standards. A review of Centers for Medicare and Medicaid Services (CMS) document titled, CMS RAI version 3.0 Manual, dated 2019 indicated that, assessment of a resident's mental state provides a direct understanding of resident function that may enhance future communications and assistance, direct nursing interventions to facilitate greater independence, as well as indicate at residents cognitive status which can bring awareness of possible impairment and may be important for maintain a safe environment and providing safe discharge planning. A review of Centers for Medicare and Medicaid Services (CMS) document titled, CMS RAI version 3.0 Manual, dated 2019 indicated that when completing the cognitive assessment section, attempt to conduct the interview with ALL residents, and to interact with the resident using his or her preferred language. 555605 Page 16 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

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 ensure safe and sanitary food preparation practices in the kitchen when one of two dietary staff, Dietary Staff (DS) did not perform hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) and/or change gloves in between preparing sandwiches for 40 residents, and also touching the coffee machine, and the menu, sheet during tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) observation for lunch. This deficient practice had the potential to result in a harmful bacteria cross contamination (transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (caused by consuming contaminated foods or beverages) that could negatively affect residents who received food from the kitchen. Findings: During a food preparation observation in the kitchen on 11/28/2023 at 11:50 PM, the DS touched the surface of the coffee machine and then touched the lunch menu sheet without performing hand hygiene or changed gloves while preparing sandwiches for the residents. In a concurrent interview the DS stated, she was nervous, and she should have performed hand hygiene and changed gloves in between task to prevent cross contamination. During an interview on 11/28/2023 at 12:00 PM with Dietary Service Supervisor (DSS), the DSS stated, the DS should have performed hand hygiene and changed gloves in between preparing the sandwiches for the residents and touching other surfaces in the kitchen. The DSS stated, not changing gloves in between task could cause cross contamination that can negatively affect the residents. During an interview on 11/29/2023 at 9:54 AM with Infection Preventionist (IP), the IP stated, as a food preparer the DS should perform hand hygiene and change gloves in between task during food preparation, because bacteria from the surfaces had the potential to be transferred to the food of the residents.' During an interview on 11/29/2023 at 11:09 AM with Director of Nurses (DON), DON stated, during food preparation, hand hygiene and changing of gloves should be done when touching other surfaces in the kitchen, because it could cause cross contamination and spread bacteria that could cause food borne illnesses to the residents.' A review of the facility's policy and procedure (P&P) titled, Food: Preparation, revised 09/2017, indicated, all foods are prepared in accordance with the FDA food code. The P&P indicated, procedures included a) all staff will practice hand washing techniques and glove use, b) dinning service staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. A review of the Food Code 2022, indicated 2-301.12 Cleaning Procedure - Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE (Ready to Eat) food as well as other pathogens that can be transmitted from environmental sources. 2-301.14 When to Wash. The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after the 555605 Page 17 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0812 activities. 2-301.15 Where to Wash - effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle of cross contamination. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555605 Page 18 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, and record review, the facility failed to ensure 12 of 16 residents' bedrooms (Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 15) met the required 80 square feet (sq. ft. a unit of measurement) per resident area as indicated in the federal regulation or the CMS (Centers for Medicare and Medicaid Services). The rooms were occupied by residents and consisted of six resident beds in each room, a total of 38 residents occupied the 12 rooms. This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the resident. Findings: During an observation from 11/30/23 09:31 AM , the residents residing in the Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 15 were observed with sufficient space for the residents to move freely inside the rooms during the care delivery and daily activities. During an observation on 11/30/23 at 10:09 PM, of Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 15, each room was occupied by the residents and had resident beds, side tables with drawers. There were adequate room for the operation and use of wheelchairs, walkers, or canes etc. A record review of client accommodation analysis with room size measurement, indicated Rooms 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14 and 15, that did not meet the CMS requirement to ensure the residents had 80 sq. ft per resident areas. During an observation the room sizes did not affect the care and services provided to the residents when facility staff were providing care. During an interview with Resident 14 on 11/30/23 at 11:12 AM, Resident 14 stated, she had been staying in the same room for four and a half months. Resident 14 stated she likes her room and being in the facility because it was quiet, clean, the staffs were nice and the room had enough space for walking, going to bathroom and when going in and out to participate in activities. During an interview with Licensed Vocational Nurse (LVN2) on 11/30/23 at 9:44 AM, LVN 2 stated the rooms that had two beds, or 4 beds were big and have enough space for going inside and outside with the wheelchair, walker, shower chair. LVN 2 stated there had been no resident complaint about the room being small or having not enough space. During an interview on 11/30/23 at 9:31 AM and review of the facility's application letter for Room Waiver (room waivers exempt facilities from of penalties for certain federal regulations) the ADM stated, she submitted the application for a Room Waiver for the 12 rooms (2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 15, 16 and 17). The room variance letter indicated these rooms (2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 15, 16 and 17) did not meet the 80 square feet per resident care area requirement per Long Term Care (LTC) CMS requirement as each were roomed with two or four residents. The letter indicated the facility will review room assignments during the resident's admission process and will check frequently for appropriateness of room assignments. The Room Waiver request indicated the following: Room # Room Size 555605 Page 19 of 20 555605 11/30/2023 Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204

F 0912 2 Level of Harm - Potential for minimal harm 155.68 (sq ft) 3 Residents Affected - Some 292 4 155.68 5 292 7 292 8 285 9 292 10 288.99 11 291.99 12 288.99 14 291.99 15 291.99 555605 Page 20 of 20