Health inspection·February 10, 2026

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed in writing of the findings of the investigations and the corrective actions needed after grievances (a formal, written or verbal expression of dissatisfaction regarding the quality of care, services, or treatment from a provider or health plan) were received in accordance with facility's Policy and Procedures (P&P) titled Filing Grievances/Complaints. This deficient practice violated Resident 1's right to be informed of the outcome and actions required from the facility after a grievance was filed to address Resident 1's concerns and had the potential for needs to be unresolved. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with diagnoses including following (condition after a specific event or procedure) surgical amputation (surgical removal of the portion), acute osteomyelitis (sudden inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/6/2026, the MDS indicated that Resident 1's had intact cognitive function (thought process or decision consistent/reasonable). The MDS also indicated that Resident 1 did not exhibit any physical or verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). During a review of the nine (9) Grievance/ Complaint/ Theft and Loss (GCT) Forms filed by Resident 1, including stapled attachments dated from 8/25/2025 to 1/26/2026 each GCT form indicated documentation of grievance, investigation including recommended corrective action, and resolutions of grievance. The GCT form did not indicate the investigation findings, the date and documentation that Resident 1 was informed of the investigation findings as well as corrective actions that would be taken. The GCT form did not indicate a date when Resident 1 signed the form. During a concurrent interview and record review on 2/10/2026 at 2:45 PM with Resident 1, Resident 1 stated that he signed the GCT forms when social service director (SSD) 1 originally presented him with the forms. Resident 1 stated SSD no longer worked in the facility and the forms were provided to Resident 1 to sign. Resident 1 stated he was never informed of the investigation findings and actions taken. During a concurrent interview and record review on 2/10/2026 at 3:50 PM with Director of Nursing, Resident 1's GCT Forms and Social Service Progress Note (SSPN) were reviewed. DON stated there were no documented findings during the investigation written in the GCT forms, SSPN, and Resident 1's medical record that indicated Resident 1 was informed of the findings, and what the corrective actions were based on the investigation. DON stated SSD 1 should have dated the GCT form on the date the grievance was resolved and should have provided a copy of the written summary of the investigation to Resident 1 and document the resolution on Resident 1's medical record. The DON stated Resident 1 signed the form when the grievance was filed by Resident 1, Page 1 of 2 555839 555839 02/10/2026 Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few however signed in the wrong place that indicated resolution, therefore no follow up actions were relayed to Resident 1 regarding the filed grievance. During a review of the facility's Policy and procedure (P&P) revised in 11/2010, the P&P indicated that upon receipt of a grievance and/or complaint, the identified department will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The P&P also indicated that the resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will make such reports orally within 7 (seven) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the Social Service office. 555839 Page 2 of 2