Skip to main content

Inspection visit

Health inspection

DREIER'S NURSING CARE CENTERCMS #5558391 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged resident to resident altercation within two (2) hours for one of three sampled residents (Resident 1 ) to the California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating. This deficient practice resulted in the facility underreporting alleged abuse and had the potential for the facility to not report future allegations of abuse.Findings: A review of Resident 1's admission Record (AR), indicated that Resident 1 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses including, Fracture of Right patella ( a break in the knee cap) and acute (sudden ) respiratory failure with hypoxia (the lungs cannot get enough oxygen into the blood). A review of Resident 1's History and Physical (H&P) dated 6/13/2025, indicated that Resident 1has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/15/2025, indicated Resident 1 was cognitively intact ( normal thinking and memory). A review of Resident 1's Change in Condition Evaluation (COC) dated 1/09/2026, the COC indicated Resident 1 had behavioral changes: false allegations toward staff. A review of Resident 1's Progress Notes dated 1/07/2026 at 2:49 PM and written by Social Service Director (SSD) indicated, SSD received a call from Resident 1's Resident Representative (RP 1) who stated she received a call from the Dialysis Center explaining Resident 1 made the following claims: the walking ladies hit her to force her to walk. The Note indicated after the facility notified RP 1, RP 1 stated I know it's not true, she is losing her mind, I asked them to disregard it. RP 1 stated she explained to them that family sees my mom on a daily basis and have never seen any signs of that. The Note indicated Interdisciplinary Team (IDT) was made aware. A review of Resident 1's Progress Notes dated 1/07/2026 at 8:30 PM and written by Registered Nurse (RN 1), RN 1 indicated, At 8:30 PM the Police department arrived at the facility. Police officer explained to RN 1 that they had received a report from Adult protective services (APS) that Resident 1 reported to the Dialysis center that three female members of the facility physical therapy department were forcing her to walk. During an interview on 1/08/2026 at 9:45 AM with Director of Nursing (DON), the DON stated, the facilities Social Services Director (SSD) had reported that Resident 1's RP 1 had notified RP 1 that the Dialysis center had called RP 1 and stated Resident 1 had stated she was forced to walk and was hit by facility staff. The DON stated she was also notified last night (1/07/26) by RN 1 that the police department came to the facility to investigate an abuse report they had received from Adult protective services. The DON stated the facility had began to conduct an internal investigation. During an interview with 1/08/2026 at 10:54 AM with SSD, SSD stated yesterday 1/7/2026 she received a call from Resident 1's RP who notified SSD that she received a call from the Dialysis center stating Resident 1 told them while she was in Dialysis that the walking ladies at the facility hit her and had forced her to walk. The SSD stated the (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: 555839 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 555839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201 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 call was made yesterday (1/6/26) a little before 3 pm and Resident 1 was not in the facility so she did not get a chance to interview Resident 1. SSD stated she informed the DON regarding the incident of Resident 1 stating she was forced to walk and hit by facility staff. A review of the facility's P&P, titled Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating dated September,2022, indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) . The policy further states that 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials according to state lad immediately as defined as a. within two hours of an allegation involving abuse or result in serious bodily injury During an interview and record review on 1/08/2026 at 12:47 PM of the facility's P&P for Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating with DON, the DON stated the facility's P&P was not followed because the incident was not reported to CDPH within 2 hours because Resident 1 was not at the facility at the time they received the allegation. The DON stated it was important to follow the policy to ensure the resident was safe and to remain free from abuse. Event ID: Facility ID: 555839 If continuation sheet Page 2 of 2

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Back to top

Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

FAQ · About this visit

Common questions about this visit

What happened during the January 8, 2026 survey of DREIER'S NURSING CARE CENTER?

This was a inspection survey of DREIER'S NURSING CARE CENTER on January 8, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at DREIER'S NURSING CARE CENTER on January 8, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Share this reportEmail

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.