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 during an abbreviated survey. Complaint number: CA 00563101 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. One deficiency was written as a result of complaint CA 00563101. This CMS-2567 is an amendment to the CMS-2567 issued on 4/17/18.

F744 SS=G Treatment/Service for Dementia CFR(s): 483.40(b)(3)

F744 05/17/2018 §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 2) who was admitted to the facility with diagnosis of Alzheimer's disease (a progressive brain disorder that impacts memory, thinking and 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: QX9Y11 Facility ID: CA970000081 If continuation sheet 1 of 8 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 04/17/2018 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 language skills) and dementia (a term used to describe symptoms such as loss of memory, loss of judgment and other intellectual functions), received necessary services, including: 1. Failure to assess Resident 2's behavior of hitting a table with her hands and fingers, and identify, address, and resolve the cause of the behavior. 2. Failure to notify the physician of Resident 2's behavior of hitting the table. 3. Failure to follow the physician order dated 11/10/17, to schedule Resident 2 for a consultation appointment with psychiatry (the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders). 4. Failure to provide redirection and diversional activities in a language that Resident 2 understands in accordance with the care plan for mood, behavior, and psychosocial health, dated 11/10/17. 5. Failure to implement the care plan for cognition and communication, dated 11/10/17, to provide a safe and secure environment. These deficient practices resulted for Resident 2 to sustain a fourth right finger displaced fracture (the two ends of the broken bone are separated from one another) on 11/19/17, when the resident repeatedly hit a table with her hands and fingers, that required a splint (a firm material used for supporting and immobilizing a broken bone); administration of Tramadol (pain relief medication) 50 milligrams (mgs) every eight hours; and the separation of the spouses (Resident 1 and 2) when Resident 2 had a lateral transfer (movement to the same FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 2 of 8 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 04/17/2018 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 type of facility) to another skilled nursing facility. The separation of Resident 2 from Resident 1 (Resident 2's spouse) caused emotional distress to Resident 1. Findings: During an observation on 12/7/17 at 6:14 a.m., Resident 1 (Resident 2's spouse) was awake and lying in bed. During an interview with the assistance of Certified Nursing Assistant 1(CNA 1) who translated for Resident 1, Resident 1 stated he missed Resident 2 not being in the facility and he was concerned about Resident 2 because Resident 2 was transferred to a different facility. 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 (the ability to think, read, learn, remember, reason, and pay attention), and was totally dependent on staff for bed mobility, transfers, and locomotion on and off unit (how resident moves between locations). A review of Resident 2's Record of Admission indicated that the resident was admitted to the facility on 11/10/17 with diagnoses that included Alzheimer's disease, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), epilepsy (seizure or convulsion), and difficulty walking. A review of Resident 2's Physician Admission Orders, dated 11/10/17, indicated to schedule a consultation appointment with psychiatry for the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 3 of 8 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 04/17/2018 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 2's Psychosocial Assessment, dated 11/15/17, indicated the resident was to sit close to the nursing station to be monitored by staff. A review of Resident 2's Minimum Data Set, dated 11/16/17, indicated that the resident needed an interpreter, had unclear speech, and that sometimes understood others. The MDS indicated that Resident 2 was severely impaired in cognitively skills, required extensive assistance (resident involved in activity; staff provide weight bearing support) for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair) requiring two persons to assist, and was totally dependent on staff locomotion on and off unit. The MDS indicated the resident exhibited a behavioral symptom not directed toward others, for example, physical symptoms such as hitting or scratching self or verbal/vocal symptoms like screaming and disruptive sounds. A review of Resident 2's care plan titled, "Mood/Behavior/Psychosocial Wellbeing," dated 11/10/17, indicated that the resident had alteration in mood, behaviors and psychosocial well-being related to anxiety agitation. The interventions included redirecting behavior as needed, attempting to determine cause of upset and try to resolve, providing diversional activities as needed to redirect behavior, and psych consult and follow up as needed. A review of Resident 2's care plan titled, "Cognition/Communication," dated 11/10/17, indicated that Resident 2 had altered cognition related to diagnosis of dementia, Alzheimer's disease, psychosis and that resident had altered communication related to language barrier. The interventions included providing a safe and secure environment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 4 of 8 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 04/17/2018 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 2's SBAR (Situation, Background, Assessment Recommendation - a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) Communication Form, dated 11/19/17, and timed at 12 p.m., indicated that the resident was noted with swelling to her right fourth finger, with increased agitation, striking out, and hitting the table. A review of Resident 2's Final X-Ray Report, dated 11/19/17, indicated that the resident had moderate soft tissue swelling and had a minimally displaced fracture involving the shaft (central part of a long bone) of the proximal (nearest to a point of reference ) right fourth phalanx (a bone of the finger). A review of Resident 2's Physician's Telephone Orders, dated 11/19/17, and timed at 4:40 p.m., indicated to place a splint on Resident 2's fourth finger. A review of Resident 2's Interdisciplinary Progress Notes, dated 11/20/17, and timed at 10:45 a.m., indicated that the resident was "very agitated," and that the resident had a right fourth finger fracture, and that on 11/19/17, in the morning she (Resident 2) hits around the table, so it caused the fracture. The notes indicated that the "resident is very agitated and was not appropriate for this facility," and that the Social Worker would find an appropriate facility. A review of Resident 2's untimed Physician's Telephone Orders, dated 11/20/17, indicated for Resident 2 to receive Tramadol 50 mg by mouth every 8 hours for pain for seven days. A review of Resident 2's Licensed Personnel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 5 of 8 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 04/17/2018 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 Progress Notes, dated 11/28/17, and timed at 11:15 a.m., indicated that Resident 2 was transported to another facility. During an interview, on 12/7/17 at 6:26 a.m., CNA 1 stated that Resident 2 was very confused and would get agitated when staff did not talk to her in Armenian, a language she (Resident 2) could understand and that "it was difficult to care of her." During an interview, on 2/28/18 at 12:40 p.m., the Director of Nursing (DON) stated that Resident 2 was not evaluated by the psychiatrist as ordered on 11/10/17, by Resident 2's physician. During an interview on 2/28/18 at 1:14 p.m., the Social Services Director (SSD), stated that Resident 2 was transferred to another facility (same services offered as the facility) due to Resident 2's agitation that was "hard to control." The SSD stated the facility was not appropriate for Resident 2 and that the resident needed to be in a dementia unit. The SSD stated Resident 2 was transferred to the same type of facility because "We just could not care for her here." During an observation, on 2/28/18 at 11:12 a.m., six residents were sitting in wheelchairs in front of the nursing station with no facility staff present. This was the same area where Resident 2 sustained a fourth right finger displaced fracture on 11/19/17 and a fall on 11/22/17. During an interview, on 2/28/18 at 1:47 p.m., a Licensed Vocational Nurse (LVN 1) stated that Resident 2 was "always" sitting in a wheelchair "by the table in the nursing station and hit the table every day," prior to Resident 2 sustaining a fourth right finger displaced fracture. LVN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 6 of 8 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 04/17/2018 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 stated that Resident 2 had the tendency to hit her (Resident 2's) hands and fingers against the table. LVN 1 stated that the nurses were supposed to assess the resident behavior and create a care plan to prevent injury. LVN 1 stated that she did not notify Resident 2's physician regarding resident's behavior. During the interview, LVN 1 stated that on 11/19/17 prior to 12 p.m., she (LVN 1) saw Resident 2 hitting the table. LVN 1 stated that she did not remove Resident 2 from the table when she (LVN 1) saw the resident hitting the table. LVN 1 stated that at 12 p.m., she saw Resident 2 with swollen right fourth finger while she was passing medications. During an interview, on 2/28/18 at 2 p.m., LVN 2 stated that Resident 2 was very confused and was placed daily at the nursing station and that the resident would "bang on the table to get attention from people." LVN 2 stated that Resident 2 would be "bored or something." LVN 2 stated that she would speak to Resident 2 in the language (Armenian) the resident would understand and the resident would calm down. A review of the facility's policy and procedure titled, "Dementia," with a revised date of October 2010, indicated that the staff and physician would review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. The policy indicated that individuals with dementia could also have a personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior and as needed, the physician could obtain a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 7 of 8 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 04/17/2018 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 psychiatrist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. The policy indicated that the staff would monitor the individual with dementia for changes in condition and decline in function and would report these findings to the physician. A review of the facility's policy and procedure titled, "Behavior Assessment and Monitoring," with a revised date of April 2007, indicated that problematic behavior would be identified and managed appropriately and that the nursing staff would identify, document, and inform the physician about an individual's mental status, behavior, and cognition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QX9Y11 Facility ID: CA970000081 If continuation sheet 8 of 8