Health inspection·February 20, 2026

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 ensure one of seven residents sampled for pressure injury prevention (Resident 1), who had multiple pressure injuries, received necessary treatment and services consistent with professional standards of practice when Resident 1's low air loss mattress (LAL- a medical support surface that uses a constant flow of air to reduce pressure, heat, and moisture on the skin to help prevent or treat pressure injuries) was set to an incorrect setting. Based on Resident 1's weight of 161 pounds (lbs- a unit of weight), the LAL setting should have been at level 3. During the survey observation, Resident 1's LAL setting was found to be set at level 4. This failure had the potential to cause further worsening of Resident 1's pressure injuries. A misconfigured mattresses that is not aligned with the resident's weight may also compromise the resident's stability while in bed, increasing the risk of accidents or injury. During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including a Stage 3 pressure injury (Full-thickness loss of skin. Dead and black tissue may be visible) of the right lower back and unstageable pressure injuries (a wound covered by slough [dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds] or eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off] that makes the depth impossible to determine) on his left heel and sacrum. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1 had severely impaired cognition (significant difficulty with memory and orientation) and required maximal assistance (helper does more than half the effort) for turning left and right, and dependent on staff (helper does all of the effort) for most cares such as toileting and bathing. The MDS also indicated Resident 1 was at risk of developing pressure injuries. During a review of Resident 1's untitled Care Plan (CP) initiated on 12/14/2025 and revised on 2/19/2026, the CP indicated Resident 1 was at risk of pressure injury development related to fragile skin, immobility, aging process, and disease process. The CP indicated interventions to use a low air loss mattress for wound management: Setting 3 (135 lbs - 170 lbs). During a review of Resident 1's Current Weights and Vitals dated 2/20/2026, the document indicated Resident 1's weight on 2/1/2026 was 161 lbs. During a review of the facility's undated low air loss manufacturer's guidelines titled, DermaFloat LAL (Low Air Loss) Model: Comfort Adjust Setting, the guidelines indicated to: Select the highest or most firm Comfort Adjust setting. For residents 135 lbs to 170 lbs, set to 3. Document comfort setting on pump label provided and re-evaluate comfort setting as needed. If a resident requests a comfort setting that falls outside the parameters provided, then provide education and document setting and rationale in plan of care. During an observation on 2/18/2026 at 10:48 AM, Resident 1's low air loss mattress was observed. A label to the top right corner of the LAL machine Residents Affected - Few Page 1 of 8 555609 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, Setting: 3. The Comfort Adjust settings indicated numbers 1, 2, 3', 4, and 5. The number 4 on the Comfort Adjust setting of the machine was lit up with a blue light. During an interview with the Director of nursing (DON) on 2/19/2026 at 10:38 AM, the DON stated the label at the top of the LAL machine indicated what setting the LAL should be set to. The DON further explained that Resident 1's LAL setting was set to 4 but should have been set to 3 per the resident's weight and the LAL manufacturer's guidelines. The DON stated that not setting the LAL appropriately can cause more harm than good and can cause further skin breakdown for the resident. The DON stated she usually checked the residents' LAL settings to ensure they were appropriate, however she did not do that today. During a review of the facility's Policy and Procedure (P&P) titled Support Surface Guidelines, revised 2/2024, the P&P indicated: Redistributing support surfaces were to promote comfort for all bed- or chairbound residents, promote circulation, and provide pressure relief reduction. Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface such as. air-loss. when lying in bed. 555609 Page 2 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications (unexpected problems that may arise during treatment) of enteral feedings (liquid nutrition through a flexible tube that goes in directly into the stomach) for two of three sampled residents ( Residents 36 and 25) who was observed receiving enteral feeding continuously with head of bed (HOB) less than 30 degrees in accordance with the facility's policy and procedure titled Enteral Feedings - Safety Precautions This deficient practice had the potential to result in vomiting and/or aspiration pneumonia (severe lung infection) that could negatively affect Resident 36 and 25 qualities of life. Findings: 1. During review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included attention to gastrostomy (G-tube-a surgically placed device used to give direct access to the stomach for supplemental feeding), gastroesophageal reflux disease (GERD) (a chronic condition where stomach acid frequently flows back up into the esophagus (the tube connecting the mouth and stomach), causing regular heartburn, irritation, and damage), dysphagia (swallowing difficulties) and generalized muscle weakness. During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2026, Resident 36 cognitive skills (ability to make decisions) was severely impaired. The MDS indicated Resident 36 was dependent (helper does all the effort) to all activities of daily living (ADLs). During a review of Resident 36's care plan (CP) Resident requires tube feeding related to dysphagia dated 2/6/2026, intervention include elevate HOB 30 to 45 degrees during feeding with the goal to be free of complications related to tube feeding. During a review of Resident 36's order summary report (OSR), dated 2/18/2026 indicated; Resident 36 to receive feeding formula via G-tube at a rate of 60 cc/hour times 20 hours a day, and elevate HOB 30 to 45 degrees during feeding. 2. During review of Resident 25's admission Record indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included attention to gastrostomy tube (G-tube), dysphagia, and hemiplegia and hemiparesis (weakness or inability to move one side of the body). During a review of a Minimum Data Set, dated [DATE], Resident 25 cognitive skills was severely impaired. The MDS indicated Resident 25 was dependent to all activities of daily living. During a review of Resident 25's care plan Resident requires tube feeding related to dysphagia dated 2/11/2022, intervention include elevate HOB 30 to 45 degrees during feeding with the goal to be free of complications related to tube feeding. During a review of Resident 25's order summary report, dated 2/18/2026 indicated; Resident to receive feeding formula via G-tube at a rate of 65 cc/hour times 20 hours a day, and elevate HOB 30 to 45 degrees during feeding. During a concurrent observation and interview on 2/18/2025 at 9:42 AM with Licensed Vocational Nurse (LVN) 1, both Residents 36 and 25 were receiving continuous enteral feedings with their head-of-bed (HOB) elevated less than 30 degrees and receiving continuous enteral feeding. LVN 1 stated, Residents HOB should be elevated at least 30 degrees during enteral feeding but there were no guidelines posted on the bed to ensure the HOB was at least 30 degrees. LVN 1 stated, not ensuring Resident 36 and 25's HOB at least 30 degrees had the potential to result in vomiting and/or aspiration pneumonia. During a concurrent observation and interview on 2/18/2025 at 9:50 AM with the Nurse Consultant (NC) in Residents 36 and 25's shared room, both residents were receiving continuous enteral feedings with their head?of?bed (HOB) minimally elevated. Using an angle measuring device, the NC confirmed Resident 36's HOB was at 19 degrees and Resident 25's was at 22 degrees, both below the required minimum of 30 degrees. The NC stated that residents on enteral feeding must have their HOB elevated at least 30 degrees to 555609 Page 3 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reduce the risk of vomiting, fluid entering the lungs, and aspiration pneumonia. During an interview on 2/19/2026 at 8:52 AM, the Director of Nursing (DON) stated it was unacceptable for Residents 36 and 25, who were receiving continuous enteral feedings, to have their head?of?bed (HOB) elevated less than 30 degrees. The DON explained that inadequate HOB elevation increases the risk of vomiting and aspiration pneumonia, which could negatively affect the residents' overall health. A review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions dated 11/2018, indicated; in preventing aspiration, elevate the HOB at least 30 degrees during tube feeding and at least 1 hour after feeding. 555609 Page 4 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure annual skills competency assessments for four of seven sampled nursing staff (Licensed Vocational Nurse [LVN] 2, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) as required in their Facility Assessment (a yearly review that identifies the staff, equipment, and resources the facility needs to safely and effectively care of its residents). This deficient practice had the potential to place residents at risk for unmet care needs and care errors related to activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), hand hygiene (the practice of cleaning one's hands-either by washing with soap and water or using an alcohol-based hand sanitizer-to remove dirt, germs, and pathogens, thereby preventing the spread of infections), and measuring vital signs (VS) and intake / output (I/O). Findings: During a review of LVN 2's employee file, the file indicated LVN 2's last competency evaluation was done on 4/16/2024. During a review of CNA 4's employee file, the file indicated CNA 4's last competency evaluation was done on 8/16/2024. During a review of CNA 3's employee file, the file indicated CNA 3's last competency evaluation was done on 11/4/2024. During a review of CNA 2's employee file, the file indicated CNA 2's last competency evaluation was done on 12/14/2024. During a review of the Facility Assessment revised in 1/2026, the Assessment indicated the following facility resources needed to provide competent resident support and care daily and during emergencies: Competencies on Activities of Daily Living was required to be evaluated upon hire, annually, and as needed for CNAs and Licensed Nurses (LNs). Competencies on Infection Control - Hand Hygiene was required to be evaluated upon hire, annually, and as needed for all staff. Competencies on Measurements - Vital Signs (VS) and Intake and Output (I/O) was required to be evaluated upon hire, annually, and as needed for CNAs and LNs. During a review of the Director of Staff Development (DSD) and Infection Preventionist (IP) in-service (a training session provided by a facility to educate staff on specific skills, policies, or procedures they need to know to safely and correctly perform their jobs) binder, the in-services indicated the following: LVN 2's last competency evaluation on Hand Hygiene was last completed in 2024. CNA 2's last competency evaluation on ADL's, Hand Hygiene, and Measurements of VS and I/O was last completed in 2024. CNA 3's competency evaluation on Measurements of VS and I/O was last completed in 2024. CNA 4's competency evaluation on Measurements of VS and I/O was last completed in 2024. During an interview with the Director of Staff Development (DSD) on 2/19/2026 at 3:20 PM, the DSD stated skills competencies for nursing staff were done upon hire and once a year to ensure that all nursing staff were competent and able to perform their job duties correctly. The DSD stated it was important that staff's competency be regularly evaluated for the safety of the facility's residents. During another interview with the DSD on 2/19/2026 at 3:35 PM, the DSD stated she was not aware of the facility's Facility Assessment or the staff competency requirements outlined in it. During an interview with the Director of Nursing (DON) on 2/20/2026 at 8:12 AM, the DON stated the facility held an annual Skills Fair that assessed the nursing staff's competencies, but she was not aware that their Facility Assessment included the required topics of the nursing staff's annual competency assessment. During another interview with the DON on 8/20/2026 at 8:23 AM, the DON stated the previous Skills Fair was completed on 6/2026. The DON further stated that if any staff missed the Skills Fair, there should be a makeup day. However, the DON stated she was not sure if there was a makeup day completed for the previous Skills Fair. During an interview with the Administrator (ADM) on 8/20/2026 at 2:24 PM, the ADM stated that the Facility Assessment was revised annually as needed by the interdisciplinary team (IDT) which consisted of CNAs, LNs, DSD, and DON and was updated 555609 Page 5 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some based on resident care needs and resident population. The ADM stated there would be a concern if the staff's competency was not completed based on the Facility Assessment. During a review of the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing revised on 8/2022, the P&P indicated competency requirements and training for nursing staff were established and monitored by nursing leadership with input from the medical director to ensure that Gaps in education were identified and addressed Tracking or other mechanisms were in place to evaluate effectiveness of training 555609 Page 6 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 properly wash dishware when the water temperature was lower than manufacturer specifications. This deficient practice has the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all medically compromised residents.Findings: During an observation on 2/18/2026 at 8:51 AM, Dietary Aide 1 (DA1) was operating a low-temperature dishwasher (commercial ware washers that clean at 120 -140 degrees Fahrenheit (F) water temperature and rely on chemical sanitizers) to wash plate ware from breakfast service where the water reservoir thermometer read 98 F. During a concurrent interview with Dietary Services Supervisor (DSS) she stated that water temperature varies during usage and should be 120 F at the beginning of dishwashing. During a concurrent record review, a poster issued by the manufacturer of the dishwashing machine placed on the wall facing where DA1 was working indicated It is recommended that 140 F water be used. Report to your supervisor if it is lower than 120 F or higher than 160 F. During a concurrent observation and interview on 2/18/2026 at 11:22 AM with the Maintenance Supervisor (MS) stated that there is second thermometer installed in the hot water inlet pipe behind the dishwashing machine which indicates the temperature of incoming water which should be at minimum 140 F. He states that the water heater is located on the second floor and is far enough to cause variations in heat when initiating the machine. MS states that incoming maintenance requests are made verbally and that he has not received any requests regarding low temperatures during the use of the dishwashing machine. During an observation on 2/18/2026 at 11:45 AM the hot water inlet thermometer (instruments used to monitor water temperature) as it enters a system has been marked with a thick black line at 140 F to indicate the appropriate temperature prior to filling the water reservoir in the dishwasher. During a concurrent interview, DSS reports that Diet Aides are supposed to drain and fill the machine once the inlet thermometer meets 140 F mark at minimum. During an observation on 2/19/2026 at 8:30 AM, Dietary Aide 2 (DA2) was operating the dishwashing machine while the sink reservoir thermometer showed a temperature of 98 F. DA2 notified the Dietary Services Supervisor (DSS), who performed a drain-and-fill, resulting in a temperature increase to 105 F. During a concurrent interview, the DSS stated the temperature should be at least 120 F to properly wash dishware and reduce the risk of cross?contamination. Maintenance Staff (MS) was alerted and performed another drain?and?fill, draining the reservoir longer until the inlet thermometer reached 140 F and the reservoir reached 133 F. DSS stated staff had been educated on this procedure; however, she was unable to provide any in?service records at the time of request. During a document review of the facility's Policies and Procedures titled Sanitation dated 11/2022 it states that dishwashing machines are operated according to manufacturer's instructions and indicates a wash temperature of 120 F. During a document review of the manufacturer's Parts Manual dated 9/2016 it states that failure to provide adequate water temperature to the machine will cause the machine to function improperly. During a document review of the manufacturer's Service Manual the operating procedures indicate that if water temperature gauge has not reached 120 F, drain water from the machine and continue to fill until proper temperature is attained. 555609 Page 7 of 8 555609 02/20/2026 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

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 ensure Certified Nursing Assistant (CNA) 1 don (put on) an isolation gown (designed to protect healthcare workers from blood, bodily fluids, and contaminants by covering the torso, arms, and back) when providing care for one of one sampled residents (Resident 7) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a Sacro coccyx (near the lower back and spine) wound. This deficient practice had the potential to result in Resident 7 acquiring MDROs and/or spreading MDROs to other residents in the facility which could result in wide spread infection in the facility affecting their health and quality of life. Findings: During review of Resident 7's admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted with diagnoses that included pressure ulcer (skin injury due to prolonged unrelieved pressure) of sacral region , anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and end stage renal disease (person's kidneys cease functioning on a permanent basis). During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 11/19/2025, Resident 7 cognitive skills (ability to make decisions) was moderately impaired. The MDS indicated Resident 7 required set-up or clean-up assistance (helper sets up and clean up) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and personal hygiene. During a review of Resident 7's order summary report, dated 11/16/2025 indicated, Resident to be placed on Enhanced Barrier Precautions due to Sacro coccyx wound. During a review of Resident 7's care plan (CP) Resident requires Enhanced Barrier Precautions related to unhealed wound, dated 11/24/2025, intervention includes use of gown during high contact care activities such as brief changes. During an observation on 2/18/2025 at 12:02 PM by Resident 7's doorway, was an EBP signage indicating to use gown when performing brief changes to the Resident. During a concurrent observation and interview on 2/18/2025 at 12:05 PM with Certified Nurse Assistant (CNA) 1, in Resident 7's room (Resident 7 agreed to be observed during brief changing), observed CNA 1 touched and positioned Resident 7 to the side and changed the incontinent brief without wearing an isolation gown. CNA 1 stated, she forgot to wear a gown during her care, though she knows Resident 7 was on EBP isolation. CNA 1 stated, it is important to wear a gown when changing Resident 7's brief to prevent infection in the facility. During an interview on 2/19/2026 at 11:58 AM with the Director of Nurses (DON), DON stated, she was aware CNA 1 touched and changed Resident 7 briefs without wearing an isolation gown. DON stated, Resident 7 was on EBP isolation because of her unhealed Sacro coccyx wound, so wearing a gown is important during close contact care such as changing briefs to protect Resident 7 and other residents in the facility to acquire MDRO's and negatively affect their overall health and quality of life. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2022, the P&P indicated: a) enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents, b) EBPs employ isolation gown use during high contact resident care activities, and c) examples of high contact resident care activities requiring the use of isolation gown for EBPs include: providing hygiene and changing briefs Residents Affected - Few 555609 Page 8 of 8