Health inspection·August 6, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need by ensuring the call light was within reach as indicated on the facility's policy and procedure, titled Answering of Call Lights and resident's Care Plan for one of one sampled resident (Resident 135) who was at risk for fall. Residents Affected - Few This deficient practice had the potential for the resident not to receive or received delayed care to meet the necessary care and services that could result in fall and accident. Findings: During a review of Resident 135's admission Record indicated, the facility admitted Resident 135 on 7/29/2023. During a review of Resident 135's History and Physical (H&P), dated 7/30/2023, the record indicated, Resident 135's was alert, awake and oriented with diagnoses that included hypertension (high blood pressure), Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) and congestive heart failure (CHF, heart disease that affects pumping action of the heart muscle) and left upper extremity (arm) weakness. During a review of Resident 135's Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 7/29/2023, indicated Resident 135 was assessed as at high risk for fall. During a review of Resident 135's Care Plan titled, Falls Care Plan, initiated on 7/29/2023, the care plan indicated Resident 135 was high risk for fall. The interventions indicated the nursing staff will provide safety device such as keeping the call light within reach. During a review of Resident 135's Nurses Progress Notes, dated 8/4/2023, indicated, Resident 135 was able to make her needs known. During a concurrent observation and interview on 8/4/2023 at 2:40 p.m. with Registered Nurse (RN) 1, Resident 135 observed lying in bed with the call light located on the upper left side of the resident, hiding between the side rails and mattress that resident could not reach. RN 1 stated, Resident 135's call light should be within reach so that the staff could attend to the resident's needs in a timely manner. During an interview on 8/6/2023 at 12:15 p.m. with Director of Nursing (DON), DON stated, The call light should be in reach to maintain residents' safety at all times. Page 1 of 16 555911 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0558 Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's policy and procedure (P&P) titled, Answering of Call Lights, revised on February 2023, the P&P indicated, the facility will ensure the resident's call light is placed within the resident's reach. Residents Affected - Few 555911 Page 2 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a resident specific plan of care to prevent development and/or worsening Stage 2 pressure ulcer (a skin injury or ulcer resulting in partial-thickness skin loss with exposed open skin due to prolonged pressure or being in one position for prolong period) in accordance with the facility's policy and procedure for one of two sampled residents (Resident 89). Resident 89's plan of care did not indicate interventions on how often the resident will be repositioned and turned while in bed, how to keep resident clean and dry. This deficient practice resulted in Resident 89 not to receive the necessary care and services to prevent the worsening of pressure ulcer that could result in pain, discomfort, and wound infection. Cross reference to F686. Findings: A review of Resident 89's admission Record, indicated the facility admitted the resident on 6/29/2023. During a review of Resident 89's of H&P assessment, dated 6/26/2023, indicated the resident had diagnoses that included diabetes (high blood sugar), colon cancer (an abnormal cell growth). During a review Resident 89 MDS, dated [DATE], indicated the resident had moderate cognitive impairment. The MDS indicated Resident 89 was totally dependent with transfers, toilet use and personal hygiene and required extensive (resident involved in activity; staff provide weight-bearing support) with oneperson physical assistance in bed mobility. During a review of Resident 89's care plan, dated 7/18/23, for non-compliance with turning and repositioning and refusing care indicated, the facility staffs will explain to resident and responsible party the information regarding risk and complications resulting from non-compliance, and the resident will be monitored for untoward manifestations due to non-compliance. During a review of Resident 89's clinical records for July 2023 to August 2023 and the plan of care had no documented evidence for the reason of refusal of care was assessed or specific interventions and/or alternative measures were offered to the resident for refusing to turn and reposition. During a concurrent review of Resident 89's care plan, titled Pressure Ulcer Care Plan, dated 7/27/2023, and an interview with the Minimum Date Set Nurse 1 (MDSN 1) on 8/6/2023 at 5:15 pm, the MDSN 1 stated, Resident 89 had Stage 2 pressure ulcer on the sacrum (the lower back of the body), the plan of care included to reposition Resident 89 as indicated. The MDSN 1 stated, the care plan did not specify how often Resident 89 should be turned or repositioned in bed. During a review of Resident 89's Clinical Notes from 7/22/2023 to 8/6/2023 indicated the resident was compliant with care, turning and repositioning. The clinical record did not indicate how often Resident 89 was turned and repositioned. 555911 Page 3 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0656 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure titled Pressure Ulcer & Skin Care Management dated 2/8/2023, indicated the skin care team observes care delivery to determine if the interventions identified in the care plan have been implemented in accordance with professional standards of practice, such as incontinence care with frequency to keep the resident clean and the skin dry, repositioning and evaluation, and nutritional interventions. Residents Affected - Few A review of the facility's undated Policy and Procedure (P&P) titled Comprehensive Care Plan dated 2/8/2023, indicated the facility will develop goals and approaches for each problem and/or condition that are realistic, specific, measurable, and include interventions/approaches that relate to each stated long or short-term goal. The P&P indicated the facility will ensure that interventions specify the frequency of service provided. 555911 Page 4 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

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 provide care and services consistent with facility's policy and procedure to prevent the development or worsening of pressure ulcer/injury (a skin injury due to friction or shear and for prolonged pressure by being in one position of a long period of time) for two of four residents (Resident 86 and 89) by failing to: Residents Affected - Few 1. Ensure Resident 86 who was using a Low Air Loss Mattress (LAL - mattress composed of multiple inflatable air tubes that alternately inflate and deflate designed to prevent and treat pressure ulcers) was set in a correct setting based on the manufacturer's recommendation. 2. Ensure Resident 89 who had a Stage 2 pressure ulcer (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer.) was turned and repositioned, not left in supine (lying in on the back) for a long period while in bed. This deficient practice had the potential for Resident 86 to develop pressure ulcers, and for Resident 89 to have a worsened pressure ulcer that developed at the facility (28 days after admission) and could result in pain, discomfort, and wound infection. Findings: a. A review of an admission Record indicated the facility admitted Resident 86 on 7/26/2023. A review of Resident 86's History & Physical (H&P) assessment, dated 7/28/2023, indicated the resident's diagnoses included obstructive hydronephrosis (swelling of the kidney from urine build up due to blockage or obstruction) with a nephrostomy tube placement (a tube is inserted through the skin into the kidney to drain urine from the body). A review of Resident 86's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 7/30/2023, indicated the resident was cognitively (thought process or ability to think and reason) intact. The MDS indicated Resident 86 required supervision with all activities of daily living. The MDS indicated Resident 86's weight 104 pound on admission to the facility. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 8/4/2023 at 3:40 pm, Resident 86 was asleep and positioned on the right side lying on a LAL mattress set at number 4 with corresponding labeled 170 pounds (lbs.). LVN 1 stated Resident 86 weight approximately 100 lbs., the LAL mattress should be set at number 2 and not at number 4. LVN 1 explained the LAL mattress setting was based on the resident's weight, and the setting of number 4 would make the mattress too firm. LVN 1 explained, if the mattress was too firm, Resident 86 would not benefit from the LAL mattress and would not serve its purpose in preventing the development of pressure ulcer. A review of the facility's Policy and Procedure, dated 2/8/2023, titled Low Air-Loss Therapy Bed indicated, the low air loss therapy inflates to specific pressures based on the height and weight of the resident. The segmented air cushions, covered by a low-friction fabric inflate and rest on a bed frame, reducing pressure on skin surfaces and diminishing shearing forces when repositioning the resident. The pressure redistribution devices are helpful for preventing and managing pressure ulcer, they shouldn't replace repositioning protocols. 555911 Page 5 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0686 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Low Air Loss Mattress Manufacturer's Guide, indicated to press the ADJUST SETTINGS up/down arrows to adjust the mattress pressure levels. The number selected 1 to 9 will be shown in the window. Use the weight settings guide as a reference/starting point. The quick reference guide indicated Number 2 setting for 105 pounds (lb.) weight and Number 4 setting for 170 lb. Residents Affected - Few b. A review of Resident 89's admission Record, indicated the facility admitted the resident on 6/29/2023. During a review of Resident 89's of H&P assessment, dated 6/26/2023, indicated the resident had diagnoses that included diabetes (high blood sugar), colon cancer (an abnormal cell growth in the colon). During a review of an MDS, dated [DATE], indicated Resident 89's had moderate cognitive impairment. The MDS indicated Resident 89 was totally dependent with one-person physical assistance for transfers, toilet use and personal hygiene and required extensive (resident involved in activity; staff provide weight-bearing support) with bed mobility. During multiple observations on 8/5/2023, at 9:15 am, 12:30 pm, 3:11 pm, 4:41 pm, 5:45 pm, and 8:24 pm, Resident 89 was lying supine, in the same position in bed, and was not observed being assisted to turn or reposition to relieve pressure from the bony areas of the body. During an observation on 8/5/23 at 3:23 pm, Certified Nursing Assistant 2 (CNA 2) went inside Resident 89's room to check Resident 89's blood pressure (BP - a measurement of the pressure of blood inside your arteries). CNA 2 did not reposition Resident 89 before or after the BP was checked. During an observation on 8/5/23 at 3:23 pm, at 5:49 pm, Licensed Vocational Nurse 2 (LVN 2) went inside Resident 89's room to administer a medication. LVN 2 did not offer Resident 89 to be turned or repositioned the resident. During a review of the Certified Nursing Assistant documentation, dated 8/5/2023, indicated Resident 89 was repositioned and turned to supine position on 8/5/23 at 12:27 am, and at 10:06 pm, (two times in a period 24 hours on 8/5/23). During a review of Resident 89's care plan, dated 7/18/23, for non-compliance with turning and repositioning and refusing care indicated, the facility staffs will explain to resident and responsible party the information regarding risk and complications resulting from non-compliance, and the resident will be monitored for untoward manifestations due to non-compliance. During a concurrent review of Resident 89's care plan, titled Pressure Ulcer Care Plan, dated 7/27/2023, and an interview with the Minimum Date Set Nurse 1 (MDSN 1), MDSN 1 stated, Resident 89 had Stage 2 pressure ulcer on the sacrum (the lower back of the body). The interventions of the plan of care included to reposition Resident 89 as indicated. The MDSN 1 stated, the care plan did not specify how often Resident 89 should be turned or repositioned in bed. During a concurrent review of Resident 89's care plan, titled Pressure Ulcer Care Plan, dated 7/27/2023, indicated Resident 89 had Stage 2 pressure ulcer. The care plan did not have an intervention on how to keep Resident 89 clean and dry in accordance with the facility's policy and procedure for residents with pressure ulcer. 555911 Page 6 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 89's Family 2 (FAM 2) on 8/6/2023 at 10:57 am at resident's bedside, using a phone interpreter. FAM 2 stated the facility should do whatever they need to take care of Resident 89 to prevent the development of pressure ulcer. During a review of Resident 89's Physician Progress Notes on the following dates indicated, Resident 89 was cooperative and had no refusal of care during the physician's assessment on 7/1/2023, 7/31/2023 and 8/3/2023. During a wound care observation with Treatment Nurse 2 (TXN 2) on 8/6/2023 at 3:18 pm, Resident 89 cooperated with the treatment during pressure ulcer wound care and did not refuse to be turned to the side with assistance. During a concurrent record review and interview on 8/6/2023 at 3:44 pm, TXN 2 stated, Resident 89 had no pressure ulcer when admitted to the facility on [DATE]. TXN 2 explained Resident 89 was first discovered with the Stage 2 pressure ulcer at the facility on 7/27/2023. During an interview with Certified Nursing Assistant 3 (CNA 3) on 8/6/2023 at 4:19 pm, CNA 3 stated he was assigned to Resident 89 when she was just admitted to the facility. CNA 3 stated at that time Resident 89 would refuse to be changed because of the pain on her leg. During a review of Resident 89's clinical notes from 7/26/2023 to 8/6/2023 indicated the resident was compliant with care, turning and repositioning was documented, but did not indicate how often Resident 89 was turned and repositioned, or if the resident refused to turn or reposition due to pain. A review of the facility's Policy and Procedure titled Pressure Ulcer & Skin Care Management dated 2/8/2023, indicated a resident having pressure ulcer will receive necessary treatment and services to promote healing, prevent infection and reduce the risk for new pressure ulcers development. The policy indicated the Skin Care Team will observe care delivery to determine if the interventions identified in the care plan have been implemented in accordance with professional standards of practice, such as incontinence care with frequency to keep the resident clean and the skin dry, repositioning and evaluation, and nutritional interventions. A review of the facility's Policy and Procedure titled Comprehensive Care Plan dated 2/8/2023, indicated to ensure that interventions specify the frequency of service provided. 555911 Page 7 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of 2 sampled residents (Resident 21) with indwelling catheter (a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure, titled Care of Indwelling Catheter and the resident's Care Plan. This deficient practice had the potential for Resident 21 to receive no care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and/or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in). Findings: During a review of Resident 21's admission Record indicated, the facility admitted Resident 21 on 7/18/2023. During a review of Resident 21's History and Physical (H&P) assessment, dated July 2023, indicated Resident 21 was alert and oriented to name, place and time, and admitted with diagnoses that included hypertension (high blood pressure), diabetes (a condition of having high blood sugar) and cholecystitis (inflammation of the gallbladder). During a review of Resident 21's Care Plan titled, Indwelling Catheter Care Plan, initiated on 7/19/2023, indicated Resident 21 had acute urinary retention (inability to urinate and retains urine in the bladder). The plan of care indicated, to prevent UTI the nursing staff will observe for signs and symptoms of infection such as foul odor, blood in the urine, sediments. The plan of care indicated if the signs and symptom of UTI are present the resident will be referred to doctor accordingly. During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/24/2023, Resident 21 had severely impaired cognition (thought process or ability to think and reason), and required extensive assistance (resident involved in activity while staff provide weight bearing support) with one-person physical assistance for dressing and toilet use. During a review of Resident 21's Physicians Order Notes, dated 8/3/2023, indicated to insert foley catheter to Resident 21 for acute urinary retention. During a concurrent observation and interview on 8/5/2023 at 9:43 a.m. with Registered Nurse (RN) 3, Resident 21's indwelling catheter tubing contained white sediments. In an interview, RN 3 stated there should be no sediments in the catheter tubing. RN 3 also stated foley catheter should be monitored by nurses. RN 3 stated, sediments in the catheter tubing or in the urine can cause infection to the residents. During an interview on 8/5/2023 at 4:18 p.m. with Director of Nursing (DON), the DON stated, The nurses are monitoring the foley catheter daily to check for patency, drainage, and characteristics of the urine for presence of blood or sediments, cloudiness and signs and symptoms of UTI. The DON 555911 Page 8 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, there was no other clinical documentation in Resident 21's clinical records that indicated the resident's urine was monitored for presence of sediments. The DON stated, indwelling catheter should be monitored for signs and symptoms of UTI such as the sediments because it can cause infection to the resident. During a concurrent interview and record review on 8/5/2023 at 4:45 p.m. with the Treatment Nurse (TXN) 1, Resident 21's Treatment Administration Record (TAR), TXN 1 stated Resident 21's TAR did not have a documented evidence that Resident 21's urine was monitored on the following dates: 1. 8/2/2023 2. 8/3/2023 During a review of the facility's policy and procedure (P&P) titled, Care of Indwelling Catheter, revised February 2023, the P&P indicated, routine catheter care helps prevent infections and other complications and is usually performed daily. During a review of the facility's policy and procedure (P&P) titled, Urinary Catheters, revised on February 2023, the P&P indicated, preventive measures for controlling common infections are a critical component of the overall plan of care for residents with a urinary catheter. 555911 Page 9 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 235's admission Record indicated the facility admitted the resident on 8/1/2023. During a review of Resident 235's H&P, dated 8/2/2023, indicated the resident was confused and bedridden (confined to bed by sickness or old age), with diagnosis that included dementia and depression. During a concurrent observation and interview on 8/5/2023 at 1:47 pm, Resident 235 was lying in bed. Resident 235's Family 1 (FAM 1) stated, Resident 235 did not want to eat and would get angry when assisted to be fed. FAM 1 stated Resident 235 would usually eat homemade soup but refused to eat now. During a concurrent record review of Resident 235's Physician Orders and interview with MDSN 1 on 8/6/2023 at 10:17 am indicated, the physician ordered Resident 235 to receive Sertraline. The physician order for Resident 235 did not specify the indication for use, and the behavior and/or side effects to be monitored for the use of Sertraline. In an interview the MDSN 1 stated, there was no documented evidence Resident 235's behavior was monitored for depression while receiving Sertraline. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Assessment and Monitoring, revised on February 2023, the P&P indicated, the facility will monitor the residents for behavior and the side effect of psychotropic medications. Based on interview and record review, the facility failed to prevent the unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) by failing to specify the indication for use, and monitor the behavior and/or side effects (undesired effect) of the medications in accordance with the facility's policy and procedure and the resident's care plan for four of five sampled residents (Residents 136, 9, 5 and 235). 1. Resident 136 was receiving Buspirone (an antianxiety medication use to treat anxiety [emotion characterized by feelings of tension, worried thoughts and physical changes]) and Lorazepam (antianxiety). 2. Resident 9 was receiving Quetiapine (a psychotropic medication use to treat serious mental disorder in which people interpret reality abnormally]), Sertraline (a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning]) and Lorazepam. 3. Resident 5 was receiving Sertralin. 4. Resident 235 was receiving Sertraline. These deficient practices had the potential to result in the resident's unnecessary use of medication and/or develop undesired harmful effects to the medications, that could lead to psychosocial (the emotions, thoughts, attitudes, motivation, behavior, and the way a person relates to and interacts with their environment) and physical decline. 555911 Page 10 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0758 Findings: Level of Harm - Minimal harm or potential for actual harm 1. A review of Resident 136's admission Record indicated Resident 136 was admitted to the facility on [DATE]. Residents Affected - Some During a review of Resident 136's History and Physical (H&P), dated 7/30/2023, indicated, Resident 136's was alert, awake and oriented, with diagnosis that included hypertension (high blood pressure), Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) and congestive heart failure (CHF, heart disease that affects pumping action of the heart muscle). During a review of Resident 136's Care Plan titled, Psychotropic Antianxiety Care Plan, initiated on 8/3/2023, indicated, Resident 136 had a diagnosis of anxiety disorder. The Care Plan Indicated Resident 136 had emotional deficit due to anxiety disorder. The Care Plan interventions included, the nursing staff will monitor the resident's frequency of relentlessness. During a review of Resident 136's Physicians Order, dated 8/4/2023, it indicated to administer Buspirone tablet 5 milligrams (mg) one tablet via gastrostomy tube (GT, a tube inserted into the stomach to deliver nutritional formula, fluids and medications) two times a day and Lorazepam 1 mg via GT every eight hours as needed to Resident 136. The physician order did not specifically specify the indication for use and the behavior or side effects to be monitored for the use of Buspirone. During a concurrent interview and record review of Resident 136's clinical record on 8/5/2023 at 12:18 p.m. with the Director of Nurses (DON), the Behavior Monitoring Form, dated August 2023, did not specifically specify the indication for use, the behavior and the side effects that were monitored when Resident 136 was administered Buspirone and Lorazepam. The DON stated, he failed to check if the nurses monitored the proper indication for use and the behavior of Resident 136's when receiving psychotropic medications. The DON explained, it was important to monitor the behavior of residents while receiving psychotropic medications to determine if the dosage needed to be increased, tapered (to reduce) or if the medication was necessary to be used. 2. A review of Resident 9's admission Record, indicated, the facility admitted Resident 9 on 7/14/2023. During a review of Resident 9's H&P, dated July 2023, indicated Resident 9's was alert and oriented to name, place and time, and with diagnoses that included hypertension (high blood pressure), and anemia (lack of red blood cells to carry adequate oxygen to the body's tissues). During a review of Resident 9's care plan titled, Psychotropic Antipsychotic Care Plan, initiated on 7/17/2023 indicated, Resident 9 had manifestation of delusion (the fixed, false belief that one is being harmed or mistreated by a particular person or group of people). The care plan indicated Resident 9 will be monitored by the nursing staff for frequency of unacceptable behavior. The care plan did not specify what are unacceptable behavior to be monitored. During a review of Resident 9's care plan titled, Psychotropic Antidepressant Care Plan, initiated on 7/17/2023, the care plan indicated, Resident 9 had a diagnosis of depression manifested by expression of sadness. The care plan indicated the nursing staff will monitor Resident 9 for any decline in activities of daily living function and will inform physician and responsible party. 555911 Page 11 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 9's Care Plan titled, Psychotropic Antianxiety Care Plan, initiated on 7/17/2023, indicated, Resident 9 had anxiety disorder. The care plan indicated the nursing staff will monitor Resident 9 for frequency of nervousness. During a review of Resident 9's Physician's Progress notes, dated 7/25/2023, indicated, Resident 9 was to receive Quetiapine 25 milligrams (mg) one tablet by mouth two times a day and Sertraline 100 mg one tablet by mouth at bedtime and Lorazepam 0.5mg one tablet by mouth every 6 hours as needed. The physician orders did not indicate the indication for use of the medications Quetiapine, Sertraline and Lorazepam and the behavior or side effects to be monitored while receiving the psychotropic medications. During a concurrent interview and record review on 8/5/2023 at 12:18 p.m. with the DON), of Resident 9's Behavior Monitoring Form, dated August 2023, indicated Resident 9 was not monitored for behavior for expression of sadness, anxiety when Resident 9 was administered Quetiapine, Sertraline and Lorazepam use. DON also stated, he failed to check if the nurses were monitoring Resident 9's behavior. DON stated it was important to monitor the behavior of residents while receiving psychotropic medications to determine if medication dosage needed to be increased or tapered. 3. A review of Resident 5's admission Order indicated the facility admitted the resident on 7/10/2023. During a review of Resident 5's H&P, dated 7/8/2023, indicated Resident 5 was admitted to the facility with a diagnoses that included, Parkinson's disease (an age-related degenerative brain condition that causes part of the brain to deteriorate causing slowed movements, tremors, balance problems and more) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a concurrent record review and interview with the Minimum Data Set Nurse 1 (MDSN 1) on 8/5/2023 at 5:15 pm, the Physician Order, dated 7/11/2023, indicated to administer Sertraline 25 milligrams (mg) daily to Resident 5. The physician order for Resident 5 did not specify the indication for use and the behavior and/or side effects to be monitored for the use of Sertraline. During an interview with the Minimum Data Set Nurse 1 (MDSN 1) on 8/5/2023 at 5:19 pm, the MDSN 1 stated Resident 5's behavior was not monitored while receiving Sertaline. The MDSN 1 stated monitoring Resident 5's behavior was important to determine if Resident 5 need to have an increase or decrease dosage of the psychotropic medication, or if the resident need the physician to visit due to worsening depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). 555911 Page 12 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

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** 4. During a review of Resident 5's admission record indicated the facility admitted Resident 5 on 7/10/2023. Residents Affected - Some During a review of Resident 5's History and Physical assessment, dated 7/7/2023, indicated the resident had a history of urinary tract infection, diabetes (high blood sugar). During a review of Resident 5's MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 5 was totally dependent with bed mobility, transfers, dressing, toilet use and personal hygiene and required extensive assistance with eating. During an observation on 8/4/2023 at 7:38 pm, there was a sign outside Resident 5's room indicating Modified Droplet/Contact Precautions, the two visitors inside Resident 5's room were not wearing PPE while interacting with the Resident 5. In a concurrent interview LVN 4 stated, Resident 5 was on Modified Droplet/Contact Precautions due to Vancomycin Resistant Enterococcus in the urine as of 7/29/2023. LVN 4 stated, the visitors needed to wear an isolation gown and gloves when they're inside Resident 5's room to prevent spread of infection. During a review of Resident 5's Infection Care Plan dated 7/29/2023, indicated Resident 5 was infected with Vancomycin Resistant Enterococcus in the urine, and was placed on contact isolation. The care plan interventions indicated the facility staffs will inform residents and responsible party the infectious process, management and isolation precautions to practice as per protocol. A review of the facility's undated Policy and Procedure titled Transmission Precautions-Contact indicated to wear a clean, non-sterile gown upon entering to the resident's room on Modified Droplet/Contact Precautions if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room, the staffs or visitors were indicated to wear clean, non-sterile gloves when entering the room. 5. During a review of Resident 85's admission record indicated Resident 85 the facility admitted Resident 85 on 7/26/2023. During a review of Resident 85's Physician's Progress Notes, dated 7/31/2023 with diagnoses that included osteomyelitis (bone infection), urinary tract infection (infection of the urinary tract which includes the bladder and kidneys). During a review of Resident 85's Nursing Clinical Note, dated 7/26/2023, indicated the resident was alert, awake, oriented to person, place, and time. During a concurrent observation and interview on 8/4/2023 at 3:19 pm, inside Resident 85's room, Resident 85 had a peripheral IV access on the left forearm, dated 7/25/2023, on the IV site (the date prior to Resident 85's admission to the DP/SNF (Distinct Part/Skilled Nursing Facility). In an interview Licensed Vocational Nurse 1 (LVN 1) stated we need to change the IV access every three (3) days. We planned to insert a midline, but the resident refused. LVN 1 stated the peripheral IV access are supposed to be changed every three days to prevent infections of the IV site. During an interview with Resident 85 on 8/4/2023 at 3:25 pm, Resident 85 stated he did not refuse to have the IV access changed by the facility staffs. 555911 Page 13 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review of the Nursing Clinical Notes, dated 7/26/2023 to 8/4/2023, there was no documented evidence indicating Resident 85 refused for the IV access to be changed, or an attempt was made to change the IV site that is more than three days since insertion. A review of the facility's Policy and Procedure titled Peripheral Line Maintenance dated 2/8/2023, indicated to maintain the peripheral IV site and system to reduce the risk of complications, such as thrombophlebitis (blood clot in the vein causes pain and inflammation) and infection. Routine maintenance of IV sites and systems regular assessment and rotation of site and periodic changes of dressing, tubing, and solution to prevent complications. The policy indicated the site rotation will be performed every 48 to 72 hours. Based on observation, interview, and record review, the facility failed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of 5 sampled residents ( Residents 136, 17, 21, 5 and 85) by failing to: 1. For Resident 136, there was no posting of a Contact Isolation (precautions to prevent transmission of infectious agents, which are spread by direct contact with the patient or the patient's environment) sign outside of resident room to remind staff and visitors to wear proper PPE (Personal Protective Equipment used to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) before entering the resident's room. 2. For Resident # 17, the peripheral IV line (a thin, flexible tube was inserted though the skin into a small vein in the periphery to deliver fluid and medications ) were not labeled to indicate date the tube was first used. This deficient practice had the potential to develop infection in the peripheral IV site that could enter the blood stream and result in severe infection. 3. For Resident 21, the foley catheter bag (a tube inserted into the bladder and drains urine into a drainage bag from the bladder) was observed touching the floor. This deficient practice had the potential to lead to (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters). 4. For Resident 5, who was placed in Modified Droplet and Contact Precautions (precautions to prevent transmission of infectious agents through direct contact with the patient or the patient's environment or contact with respiratory secretions) due to Vancomycin Resistant Enterococcus (VRE -Vancomycin resistant enterococcus are bacterial strains that are resistant to antibiotics) had two visitors in the resident's room that were not wearing appropriate PPE. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and the staffs that could result in a widespread infection in the facility. 5. For Resident #85 the peripheral IV site were not labeled to indicate date of insertion. 555911 Page 14 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0880 This deficient practice had the potential to develop infection in the peripheral IV site that could enter the blood stream and result in severe infection. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. A review of Resident 136's admission record indicated the facility admitted Resident 136 on 8/3/2023. During a review of Resident 136's Doctor's Progress Notes, dated 8/2/2023, indicated, Resident 136 was alert and awake with diagnoses that included hypertension (high blood pressure) and pneumonia (severe lung infection.) During a review of a Physicians Order, dated 8/4/2023, it indicated Resident 136's was to remain on Contact Isolation for Extended Spectrum Beta-Lactamase (ESBL a bacteria that is not easily killed by antibiotics) from sputum (a mixture of saliva and mucus coughed up from the respiratory tract) culture (laboratory test that looks for germs that cause infection) until the Contact Isolation was discontinued. During a review of Resident 136's Care Plan titled, Infection Care Plan initiated on 8/4/2023, indicated Resident 136 was placed on Contact Isolation for ESBL. The care plan interventions included the nursing staff will practice isolation precautions as per protocol. During a concurrent observation and interview on 8/4/2023 at 3:35 p.m. the Registered Nurse (RN) 1, RN 1 stated, Resident 136's entrance door or near the doorway did not have a Contact Isolation sign posted to alert staffs and visitors to wear appropriated PPE, and wash or sanitize their hands before entering the room due before and after contact with the resident. RN 1 also stated, the sign also cautions visitors to check with the licensed nurses before entering due to a highly infectious disease contained in the room. RN 1 stated, Resident 136 was not on any isolation and entered Resident 136 room without wearing any PPE. During concurrent observation and interview on 8/6/2023 at 9:04 a.m. with the Infection Prevention Nurse (IPN), the IPN confirmed there was no Contact Isolation sign posted upon Resident 136's entrance door or near the entry doorway. IPN stated, Resident 136 was placed on Contact Isolation by the physician on 8/3/2023, but the Contact Isolation sign was not posted on Resident 136's entrance door until on 8/7/2023. The IPN explained, the Contact Isolation sign should be posted immediately upon Resident 136's admission. The IPN stated, it was important to post the Contact Isolation sign at the entrance door of Resident 136's room to notify the employees and visitors what proper PPE to wear before entering the residents room. During a review of the facility's policy and procedure (P&P) titled, Initiating Isolation, revised on February 2023, indicated, the facility will post an isolation notice sign on the room entrance door instructing staff and visitors to report to the nursing station before entering the room. 2. A review of Resident 17's admission record indicated, the facility admitted Resident 17 on 7/21/2023. During a review of Resident 17's History and Physical (H&P), dated 7/22/2023, indicated Resident 17 was alert and oriented with diagnoses that included, Chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing-related problem 555911 Page 15 of 16 555911 08/06/2023 Glendale Adventist Medical Center Dp/Snf 1509 Wilson Ter Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 17's Care Plan titled, IV Therapy Care Plan, initiated on 7/21/2023 indicated, Resident 17 was on IV therapy for pneumonia. The plan of care indicated the nursing staff to change the peripheral site. During a review of Resident 17's Physicians Order, dated 7/21/2023, indicated to change Resident 17's change IV line every seven days. During a review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/25/2023, indicated Resident 17' had no cognitive impairment (thought process or ability to think and reason). The MDS indicated, Resident 17 required supervision with one-person physical assistance for bed mobility transfer dressing, eating, toilet use and personal hygiene. During a concurrent observation and interview on 8/4/2023 at 2:46 p.m. with Registered Nurse (RN) 1, RN 1 confirmed and stated Resident 17's peripheral IV line was not labeled with date, time and initial of the nurse who inserted the IV line. During a concurrent interview and record review on 8/5/2023 at 12:18 p.m. with the Director of Nurses (DON), the DON stated Resident 17's peripheral IV line should be labeled with the date and initial of the nurse who inserted the IV line. DON stated, infection can set in on the site if it was not dated. During a review of the facility's P&P titled, Inserting a Short Peripheral IV Catheter, revised on February 2023, indicated, the facility will secure the resident's IV catheter with the sterile tape and apply dressing that is labeled with date, time and initials. 3. A review of Resident 21's admission record indicated the facility admitted Resident 21 on 7/18/2023. During a review of Resident 21's H&P, dated 7/5/2023, indicated Resident 21 was alert and oriented with diagnoses that included, hypertension and cholecystitis (inflammation of the gallbladder). During a review of Resident 21's MDS, dated [DATE], indicated, Resident 21's had severely impaired cognition, and required extensive assistance with one-person physical assistance for bed mobility, transfer and personal hygiene. The MDS indicated, Resident 2 was dependent with one-person physical assistance for dressing and toilet use. During a concurrent observation and interview on 8/4/2023 at 4:23 p.m. with Registered Nurse (RN) 1, Resident 21's indwelling catheter tubing was observed touching the floor. RN 3 stated the foley catheter should not be touching the floor because the floor was dirty and can cause infection to the resident. During an interview on 8/6/2023 at 3:08 p.m. with Director of Nursing (DON), the DON stated, the foley catheter bag should not be touching the floor because this could spread the infection through cross-contamination (passing of bacteria, or other harmful substances indirectly from one patient to another) and could lead to urinary tract infection UTI. During a review of the facility's P&P titled, Urinary Catheters, revised on February 2023, the P&P indicated, Do not allow the catheter tubing, bag to touch the floor. 555911 Page 16 of 16