Health inspection·June 16, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm reality) and mood disorder symptoms, such as depression, mania), bipolar disorder (a mental health condition that causes extreme mood swings), and anxiety disorder. A review of Resident 2 ' s HPE, dated 3/6/2025, indicated Resident 2 does not have the capacity to understand and make decisions. Residents Affected - Few A review of Resident 2 ' s MDS, dated [DATE], indicated the Resident 2 ' s cognitively status was moderately impaired. The MDS indicated Resident 2 required Setup and clean-up assistance with eating, personal hygeine, bathing, dressing and required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with toileting. A review of Resident 3 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, psychotic disturbance (a condition where a person experiences a significant loss of contact with reality), and anxiety. A review of Resident 3 ' s HPE, dated 1/23/2025, indicated Resident 3 was cooperative, appropriate affect, and normal judgment. A review of Resident 3 ' s MDS, dated [DATE], indicated the Resident 3 ' s cognitively status was moderately impaired. The MDS indicated Resident 3 required supervision or touching assistance with eating, personal hygeine, required partial/moderate assistance (helper does less than half the effort) with toileting and dressing, and substantial/maximal assistance (helper does more than half the effort) with bathing. A review of an SBAR (Situation, Background, Assessment, and Recommendation, a communication framework used to structure conversations, especially in healthcare, to ensure clear and concise information exchange, particularly in urgent situations) Communication Form and progress note dated 6/2/2025 timed at 9:25 PM, indicated Resident 2 punched LVN 1 on her right jaw in Resident 2 ' s room prior to medication administration. A review of SBAR Communication Form and progress note dated 6/5/2025 timed at 10AM, indicated Resident 2 had a physical and verbal aggressiveness towards a Resident (Resident 3) and was noted to have kicked Resident 3 ' s (while in his wheelchair) wheelchair in the hallway. A review of Resident 2 ' s facility document titled, SBAR Communication Form and progress note dated 6/5/2025 timed at 2:50 PM, indicated while playing BINGO in the activity room Resident 2 punched the other Resident (Resident 1) on the right side of the face. A review of Resident 2 ' s care plan (CP) for diagnosis of schizophrenia manifested by outburst of anger, revised on 6/5/2025, indicated Resident 2 had episode physical aggression towards staff on 6/2/2025, kicking wheelchair of another resident on 6/5/2025, and hitting another resident unprovoked on 6/5/2025. The CP did not have any intervention how resiudent will be supervised and monitored for aggressive behavior. During an interview on 6/16/2025 at 9:45 AM with Activity Staff (AS) (Witness of Resident-to-Resident abuse between Resident 1and Resident 2). AS stated, on 6/5/2025 in the afternoon, while in the activity room during a game of BINGO, Resident 1 was reaching for Resident 2 ' s chips (small disc use as currency), Resident 2 then hit Resident 1 on the chin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555605 If continuation sheet Page 2 of 4 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 06/16/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/16/2025 at 9:50 AM with Activity Director (AD), AD stated the altercation between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM. AD stated, AS reported to her that Resident 2 hit Resident 1 on the chin during a BINGO game, and she reported it immediately to the DON (Director of Nurses). AD stated, Resident 2 was not on 1 to 1 monitoring ( one staff monitoring one resident) or on frequent monitoring prior to the incident. Residents Affected - Few During an interview on 6/16/2025 at 10:00 AM with the DON, DON stated the incident between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM, both residents were separated, and Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for evaluation. DON stated, Resident 2 was not placed on frequent monitoring, or 1 to 1 sitter prior to the abuse incident with Resident 1. During an interview on 6/16/2025 at 10:50 AM with the LVN 1 (LVN whom Resident 2 hit on the chin on 6/2/2025), LVN 1 stated, the incident happened on 6/2/2025 around 9 PM. LVN 1 stated, Resident 2 approached her for his medication while she was passing medications for another resident, she then told Resident 2 she could go to his room to give his medication. LVN 1 stated, when she went to Resident 2's room and about to turn on the overhead light to give him his medication, Resident 2 turned around and punched her on her right jaw. During a concurrent interview and record review on 6/16/2025 at 10:55 AM with the DON, facility document titled SBAR Communication Form and progress note (PN), dated 6/5/2025 timed at 10:00 AM was reviewed. The document indicated, Resident 2 was noted to have kicked a Residents wheelchair in the hallway. DON stated, the incident happened on 6/5/2025 before 10:00 AM, Resident 2 kicked Resident 3 ' s wheelchair and had a verbal altercation as they passed by each other in the hallway. During an interview on 6/16/2025 at 11 AM with the Director of Rehab (DOR), and MDS Nurse (MDSN) (Witnesses of alleged physical and verbal altercation between Resident 2 and Resident 3 on 6/5/2025 before 10 AM). DOR stated, the incident happened on 6/5/2025 before 10 AM. DOR stated, she was taking Resident 2 to the rehab room, Resident 2 was ahead of her in the hallway, when she turned around because MDSN called her, she heard a loud sound and observed Resident 2 and Resident 3 was having a loud verbal altercation. DOR stated, Resident 2 told her he kicked Resident 3 ' s wheelchair. MDSN stated, he with DOR intervened to prevent further altercation. DOR and MDSN both stated, they both reported the incident to the DON and ADM right away. DOR and MDSN both stated, the policy for alleged abuse was no report the incident immediately within 2 hours to the Ombudsman, Police, and California Department of Public Health (CDPH), MDSN stated, they should have followed up with the DON and the ADM, if it was reported to the proper agencies because they mandated reporter. During an interview on 6/16/2025 at 11:23 AM with LVN 2, LVN 2 stated she was the primary nurse for Resident 2 on 6/5/2025. LVN 2 stated, she learned about the incident between Resident 2 and Resident 3 ' s physical and verbal altercation from the DON, DOR and MDSN in the morning. LVN 2 stated, she was not aware that the incident was not reported timely within 2 hours to the proper agencies. LVN 2 stated, incident of alleged abuse allegation needs to be reported immediately to have an intervention and to prevent reoccurrence of aggression, its policy. During an interview on 6/16/2025 at 12:10 PM with the DON, DON stated, the physical and verbal altercation between Resident 2 and Resident 3 that happened on 6/5/2025 before 10 AM was reported to him. DON stated, there was no physical injury, that ' s why he did not report the incident to the appropriate agencies. DON stated, looking back he should have reported the incident to the proper agencies within two hours, to protect other residents and staff in the facility by more frequent monitoring of Resident 2 ' s behavior. DON stated, not reporting the physical and verbal altercation between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555605 If continuation sheet Page 3 of 4 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 06/16/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 2 and Resident 3 timely within 2 hours had the potential for reoccurrence of Resident 2 abusive behavior that could affect other residents ' and staff safety and potentially could have prevented the resident-to-resident abuse between Resident 2 and Resident 1. A review of the facility ' s policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 06/2022, the P&P indicated: a)the facillity policy prohibit abuse, mistreatment through; prevention of occurrence, identification of possible incidents or allegations, reporting of incidents and protection of residents, b) the facility staff are doing that is within their control to prevent occurrence of abuse and mistreatment, and c) under reporting of incidents; upon receiving information concerning a report of suspected or alleged abuse and mistreatment the administrator or designee will report all alleged violations -immediately but no later than 2 hours if alleged violation involves abuse. Event ID: Facility ID: 555605 If continuation sheet Page 4 of 4