Health inspection·January 29, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and interventions to prevent pressure injury (PI-damage to an area of the skin caused by constant pressure on the area for a long time) for one (1) of three (3) sampled residents (Resident 1) by failing to turn, reposition and to off-offload (release pressure) from an area of the body every two hours while in bed, keep clean and dry after a bowel movement or wetness from urine due to incontinence (unwanted passage of urine or stool that you can ' t control). Residents Affected - Few These deficient practices resulted in: 1. Resident 1 developed a facility-acquired Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on sacrococcyx (tailbone) area on 10/15/24, and proceeded to Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) with drainage on 10/22/24. 2. A sacrococcyx PI reopened on 12/18/24 after MASD (Moisture Associated Skin Damage) developed on 12/8/24, and on 12/26/24 Sacrococcyx PI proceeded to Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), spondylosis (degeneration of the bones and disks), dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Sheet (MDS- a Federal mandated resident assessment tool) dated 9/19/24, indicated Resident 1 ' s was assessed to be dependent and required helper does all of the effort in Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) which included bed mobility, roll to left and right, transfer, dressing, and personal hygiene. toilet hygiene with two or more helper to perform activity. During a record review and concurrent interview with the Treatment Nurse (TN) on 1/29/25 at 10:15 am of Resident 1 ' s clinical record indicated the following: - Resident 1 ' s Braden Score Assessment (a tool to evaluate a patient's risk for developing pressure injuries) dated 9/19/24, indicated Resident 1 was at high risk for developing PI due to skin often moist, very limited mobility, makes occasional slight changes in body or extremity position and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555605 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 555605 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenhaven Healthcare 212 West Chevy Chase Drive Glendale, CA 91204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)