Health inspection·January 8, 2026

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 Page 1 of 2 555839 555839 01/08/2026 Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 555839 Page 2 of 2