Other·April 26, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an investigation of one complaint and one Entity Reported Incident (ERI) during an abbreviated survey. Complaint number: CA00566726 ERI number: CA00566437 Representing the Department: HFEN 36904 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of complaint: CA00566726 and ERI: CA00566437.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 03/28/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to correctly code the "Minimum Data Set (MDS) Version 3.0 Resident Assessment and Care Screening" (an assessment tool used to complete the residents' comprehensive assessments) forms accurately for four of 1 of 2 sampled residents (Resident 1). For Resident 1, the facility failed LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to code the MDS assessment accurately for the history of a fall before the resident was admitted to the facility. This failure had the potential for plan of cares not to be developed in accordance with the residents' current status and functional limitations. Findings: A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on 10/26/17 with diagnosis of difficulty in walking and history of falling. A review of Resident 1's Client Diagnosis Report indicated the resident had diagnosis of Parkinson's disease (progressive disorder of the nervous system that affects movement), and displaced intertrochanteric fracture (hip fracture) of the left femur (the long bone of the thigh). A review of Resident 1's MDS, dated 11/7/17, indicated the resident needed an interpreter, had clear speech, was moderately impaired in cognitively skills (when a person has trouble remembering, learning new things, concentrating, or making decisions). The MDS indicated Resident 1 was totally dependent on staff for bed mobility (how resident moves to and from lying position, turns side to side, positions body while in bed), transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), locomotion on and off unit (how resident moves between locations), toileting, and personal hygiene. The MDS indicated Resident 1 did not have a fall before the resident was admitted to the facility. On 2/28/18, at 1:29 p.m., during a review of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's MDS and a concurrent interview with the facility's director of nursing (DON), she stated that she was not familiar with Resident 1's MDS. the DON stated Resident 1 was admitted to the facility with history of falls and a left hip fracture. The DON stated she did not know the reason Resident 1's MDS Fall History on Admission dated 11/7/17 was coded as Resident 1 had no previous falls and fractures. The DON stated that she did not "deal with the MDS." During an interview with LVN 3/MDS nurse, on 2/28/18, at 2:32 p.m., she stated that Resident 1's MDS Fall History on Admission dated 11/7/17 was coded wrong and that Resident 1's MDS required to indicate that Resident 1 had previous falls and fractures. LVN 3/MDS stated that Resident 1's MDS was inaccurate A review of the facility's undated policy and procedure, titled "Falls-Clinical Protocol," indicated as part of the initial assessment, the licensed nurse will help identify individuals with a history of falls and risk factors for subsequent failing.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 04/14/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure that each resident received appropriate supervision to prevent falls and injuries of two sampled residents (Residents 1 and 2) including: 1. Failure to ensure, Resident 1, who was assessed as at risk for fall and injury, with history of falls, impaired cognitive skills (when a person has trouble remembering, learning new things, concentrating, or making decisions), and required total assistance from staff in transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), and locomotion on and off the unit (how resident moves between locations) and locomotion, was provided supervision and assistance to prevent Resident 1 from falling twice from his wheelchair on 11/26/17 and on 12/24/17. 2. Failure to ensure Resident 2, who was assessed as at risk for fall, with impaired cognitive skills, and required extensive to total assistance from staff for transfers and locomotion, was provided supervision and assistance to prevent Resident 2 from falling from her wheelchair on 11/22/17. This deficient practice resulted in Resident 1 sustaining a re-fracture (the breaking of a bone that has united after a previous fracture) of his left hip, lacerations (deep cut or tear in skin or flesh) of the left forehead, face, and left arm. Resident 1 was transferred to a general acute care hospital (GACH) for treatment, and had a left hip arthroplasty (surgical procedure used to replace all or part of a patient's hip joint with a prosthetic hip) under general anesthesia (a medically induced coma), and had the potential for Resident 2 to sustain injuries. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/7/17 at 5:57 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding residents sustaining falls in the facility. 1a. During an observation on 12/7/17, at 6:14 a.m., Resident 1 was lying in bed awake. During a concurrent interview in Armenian with Resident 1, in the present of Certified Nursing Assistant 1 (CNA 1), Resident 1 stated on 11/26/17 he called staff for assistance, but the staff did not come to help him. Resident 1 stated he fell from his wheelchair, inside his room, while he was trying to go back to his bed. During an interview on 12/7/17 from 6:26 a.m. to 6:32 a.m., CNA 1 stated Resident 1 spoke Armenian and that some of the staff did not speak Resident 1's language. CNA 1 stated Resident 1 was dependent on staff for transfers. CNA 1 stated when she arrived on duty; she would find Resident 1's and other residents' call lights (a device used by a patient to signal his or her need for assistance) not within the residents' reach. During a telephone interview on 3/22/18 at 8:52 a.m., CNA 3 stated it was hard to attend to Resident 1's needs due to the resident required supervision and that she had other residents who were totally dependent. 1b. During an observation on 2/28/18, at 11:12 a.m., six residents were sitting on wheelchairs in front of the nursing station (same area where Resident 1 fell on 12/24/17) with no activities conducted and no staff present. During an interview on 1/10/18, at 12:12 p.m., Registered Nurse 1 (RN 1) stated Resident 1 sustained a fall on 12/24/17 and was transferred to a GACH for further evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a telephone interview, on 3/21/18, at 2:51 p.m., CNA 2 stated that Resident 1 was "little alert," and did not follow instructions. CNA 2 stated on 12/24/17, at approximately 10:30 a.m., she placed Resident 1 sitting on a wheelchair in front of a nursing station. CNA 2 stated she left Resident 1 by the nursing station due to the residents, who were at risk for falls, needed to be placed near the nursing station so that any nurse at the nursing station or any staff that passing by the nursing station was responsible to supervise the residents. CNA 2 stated no particular staff was assigned to supervise the residents who were placed by the nursing station. During a telephone interview on 3/22/18, at 11:42 a.m., RN 2 stated on 12/24/17, at 10:50 a.m., she found Resident 1 face down on the floor by the nursing station. RN 2 stated residents who were at risk for falls such as Resident 1 was placed by the nursing station, and no particular staff was assigned to supervise the resident. RN 2 stated whoever was the nurse sitting by the nursing station or whoever passed by the hallway was responsible to supervise the resident. A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on 10/26/17 with diagnosis of difficulty in walking and history of falling. A review of Resident 1's Client Diagnosis Report indicated the resident had diagnosis of Parkinson's disease (progressive disorder of the nervous system that affects movement) and displaced intertrochanteric fracture (hip fracture) of the left femur (the long bone of the thigh). A review of Resident 1's History and Physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Examination, dated 10/27/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Clinical Health Status, dated 10/26/17, indicated that resident was at risk for falls. A review of Resident 1's Care Plan dated 10/26/17, indicated the resident was at risk for fall injury secondary to history of falls, recent fall with fracture, and Parkinson's disease. The nursing intervention was to reposition the resident every two hours or as needed (PRN). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/7/17, indicated the resident needed an interpreter, had clear speech, was moderately impaired in cognitively skills (when a person has trouble remembering, learning new things, concentrating, or making decisions). The MDS indicated Resident 1 was totally dependent on staff for bed mobility (how resident moves to and from lying position, turns side to side, positions body while in bed), transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), locomotion on and off unit (how resident moves between locations), toileting, and personal hygiene. A review of Resident 1's care plan, dated 10/26/17, indicated the resident was at risk for potential injury from tremors and involuntary movements due to Parkinson's disease. The goal was for Resident 1 to have no injuries within three months. The nursing interventions were to monitor environment for possible padding of side rails, and special chair needs if involuntary movements put resident at risk for injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Change of Condition Report, dated 11/26/17, and timed at 2 p.m., indicated Resident 1 was found lying face down on the floor mattress next to his bed, inside his room, and that the interventions after the fall were to provide the resident with frequent supervision. A review of Resident 1's Change of Condition Report, dated 12/24/17, and timed at 10:45 a.m., indicated Resident 1 was found face down on the floor in a hallway by the nursing station and that Resident 1 had localized pain, redness, bleeding, swelling, a bump on his forehead, and a skin tear to the left forearm. A review of Resident 1's Licensed Personnel Progress notes, dated 12/24/17, indicated that at 10:35 a.m., RN 2 saw Resident 1 sitting on his wheelchair at a nursing station, and at 10:50 a.m. (15 minutes after) RN 2 overheard a sound of a fall. The notes indicated Resident 1 was found on the floor face down with the resident's legs between the wheelchair footrests. The notes indicated Resident 1 had a bump on the left forehead measuring 2.2 by 2.0 centimeters (cm), a skin tear to his left forehead measuring 1.2 by1 cm. and a small amount of blood, and a left skin tear on the left posterior forearm measuring 2 by 1 cm. A review of Resident 1's Licensed Personnel Progress Notes, dated 12/24/17, indicated at 11 a.m., Resident 1 complained of pain 5/10 (0 being no pain, 10 being the worst pain you can imagine, and 5 being moderately strong pain) to his forehead. The notes indicated at 11:30 a.m., Resident 1's Physician ordered for Resident 1 to be transferred to a GACH for further medical evaluation. A review of Resident 1's GACH Discharge Summary Notes, dated 1/22/18, and timed at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12:37 a.m., indicated the resident was diagnosed with a re-fracturing of the left hip with displacement of the rode, and lacerations of the left forehead and face. A review of Resident 1's GACH Surgery and Procedure Reports, dated 12/29/17, and timed at 5:07 p.m., indicated the resident was taken to the operating room and was placed under general anesthesia for a conversion to the left hip arthroplasty, bone graft (surgical procedure that replaces missing bone) of severe acetabular (the cup-shaped socket of the hip joint which is a key feature of the pelvis) defect, and resection (is the surgical removal of part or all of a damaged organ or structure) of heterotopic ossification (the presence of bone in soft tissue where bone normally does not exist). During an interview with LVN 3/MDS nurse, on 2/28/18, at 2:32 p.m., she stated Resident 1 was totally dependent on staff for transfers, and locomotion off unit. LVN 3 stated Resident 1 required one person to assist for propelling and repositioning while the resident was in the wheelchair. LVN 3 sated Resident 1 needed to be supervised to prevent falls. 2. During an interview on 12/7/17 at 6:26 a.m., CNA 1 stated Resident 2 was no longer at the facility. CNA 1 stated Resident 2 was confused and that "it was difficult to care for her." A review of Resident 2's Record of Admission indicated that resident was admitted to the facility on 11/10/17. A review of Resident 2's Client Diagnosis Report indicated the resident had diagnosis of Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE brain), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 2's History and Physical, dated 11/19/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated 11/16/17, indicated the resident had severe impairments in cognitively skills and required extensive assistance with two persons-assist for transfers, bed mobility, and was totally dependent on staff for locomotion on and off the unit. A review of Resident 2's Fall Injury Potential Care plan, dated 11/10/17, indicated the resident was at risk for fall or injury. The staff's interventions were to provide safe, secure environment and to transfer resident with two persons-assist. A review of Resident 2's Licensed Personnel Progress Notes, dated 11/22/17, and timed at 9 a.m., indicated the resident was found lying on the floor with a student holding the wheelchair. A review of Resident 2's Change in Condition Report-Post Fall Trauma, dated 11/22/17, and timed at 9 a.m., indicated that resident was sitting on the wheelchair at the nursing station at 8:30 a.m., at 9 a.m. the student reported he was with the resident when she fell. The report indicated that the student reported Resident 1 insisted to get up from the wheelchair. During an interview, on 2/28/18 at 2:13 p.m., RN 2 stated that on 11/22/17 at 9 a.m., a CNA student (unidentified) reported to RN 2 that Resident 2 fell by the nursing station (same station as Resident 1). RN 2 stated that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE licensed nurses were supposed to be supervising the residents not the students and that no other staff was with Resident 2 at the time of Resident 2's fall. A review of the facility's policy and procedure titled "Safety and Supervision of Residents," with a revised date of December 2007, indicated that the facility strived to make the environment as free from accident hazards as possible and that resident safety and supervision and assistance to prevent accidents were the facility's wide priorities. The policy indicated that the type and frequency of resident supervision could vary among residents and over time for the same resident and that staff should use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. A review of the facility's policy and procedure titled "Falls-Clinical Protocol," with a revised date of April 2013, indicated that as part of the initial assessment, the licensed nurse would help identify individuals with a history of falls and risk factors for subsequent falling. The policy indicated that if an individual continued to fall, the staff and the physician would reevaluate the situation and consider other possible reasons for the residents falling besides those that were already identified, and would re-evaluate the continued relevance of current interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z3YX11 Facility ID: CA970000081 If continuation sheet 11 of 11