Health inspection·September 9, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure medical records are accurately documented for one of three sampled residents (Resident 1), the time of incident and vital signs recorded on Resident 1 ' s progress note (a type of documentation that is used to track and document patient's progress throughout treatment) and vital signs sheet (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) were not accurately documented per facility ' s policy. This deficient practice had the potential in miscommunication, provided inaccurate information affect to delivery of care and possible leading to the cause of death. Findings: A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing), heart failure (condition in which the heart is unable to pump enough blood to meet the body's needs), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs.) gastrostomy ( a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), dementia ( the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities.) and epilepsy (a common condition that affects the brain and causes frequent seizures). A review of Resident 1 ' s History and Physical Examination, dated 8/12/2024, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/30/2024, indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, bathing, toileting, personal hygiene, rolling left and right and lying to sitting. A review of Resident 1 ' s facility document titled Progress Notes, dated 8/30/2024 timed at 3:51 AM indicated at 1:00 AM RN 1 noted Resident 1 was having grunting sound, difficulty breathing, and oxygen saturation (the amount of oxygen you have circulating in your blood) was low at 85 percent with 2L of oxygen supplied via nasal cannula. The progress notes indicated, 911 emergency paramedics was called, evaluated Resident 1, and took Resident to GACH 1 for further evaluation. A review of Resident 1 ' s paramedic run report (means the response of an ambulance vehicle 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 2 Event ID: 555609 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 555609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendale Healthcare Center 1208 S. Central Ave 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)