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
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