Other·February 14, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one facility reported incident during an annual recertification visit. Facility reported incident number: 615625 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 33668, RN, HFEN Health Facilities Evaluator Nurse: 31331, RN, HFEN Health Facilities Evaluator Nurse: 33670, RN, HFEN Health Facilities Evaluator Nurse: 34178, RN, HFEN Health Facilities Evaluator Nurse: 36924, RN, HFEN Total Resident Population: 95 Total Resident Sample: 24 Closed Record: 3 Highest Scope and Severity: G No deficiencies were issued for facility reported incident number 615625.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 01/30/2019 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE by: Based on interview and record review, the facility failed to have the Physician's Orders for Life-Sustaining Treatment (POLST, form is a legal document for people with advanced illnesses that specifies the type of care a person would like in an emergency medical situation) signed by the physician for one of 24 sampled resident (Resident 151). This deficient practice had the potential for the facility staff to not know what to do in an emergency medical situation. Findings: A review of Resident 151's Resident Face Sheet indicated the resident was admitted to the facility on 12/21/18, with diagnoses that included history of falling, diabetes (a metabolism disorder that affects the body's ability to use blood sugar), and hypertension (high blood pressure). A review of Resident 151's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/27/18, indicated Resident 151 had clear speech and was able to make needs known. Resident 151 needed extensive assistance, staff providing weightbearing support, for transferring and dressing. During an interview and concurrent record review, of Resident 151's POLST, on 12/28/18, at 8:42 a.m., with the Director of Nurses (DON), the DON stated, the POLST was missing information and the primary physician had not signed it. The DON stated, it should have been done at admission. A review of the facility policy and procedure titled, "Advance Directives," dated 4/2008, 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/30/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop a resident centered plan of care for one of 24 sampled residents (Resident 201) to ensure the resident's caregiver was provided instructions to properly transfer or ambulate the resident who had right-sided weakness. This deficient practices had the potential to result in falls, accidents and injury that lead to pain and decline in the residents well-being. Findings: A review of the Resident Face Sheet indicated Resident 201 was admitted to the facility on 12/13/18, with diagnoses that included dementia (a progressive brain disorder that affects the thought process and memory loss) 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE and difficulty in walking. A review of the Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated 12/25/18, indicated Resident 201 had moderated cognitive (ability to think and reason) and memory impairment that required extensive assistance (resident involved in activity and staff provide weight bearing support) with one-person assist in bed mobility and transfers. A review of Resident 201's History and Physical Examination, dated 12/25/18, indicated Resident 201 had severe ataxia (loss of full control of body movement), progressive aphasia (a disorder caused by damage to the brain that makes it hard to read, write, and express needs) and with right upper extremity weakness. On 12/26/18, at 1:31 p.m., during an observation, Resident 201 was assisted by a caregiver to ambulate approximately six yards towards the bed. Resident 201 was observed with right-sided weakness and an unsteady gait, On 12/26/18, at 2:11 p.m., during an interview, the caregiver stated, she took care of Resident 201 at home and she always encourage Resident 201 to walk. The caregiver stated, she had not been instructed by the facility staff how to properly ambulate the resident. On 12/27/18, at 3:41 p.m., in an interview, the Director of Nursing (DON) stated, private caregivers are not trained by the facility to ambulate the residents they care for. They are supposed to call for assistance when needed. On 12/31/18, at 8:36 a.m., during a review of Resident 201's plan of care and concurrent 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE interview with the Director of Rehabilitation Services (DOR), the DOR stated, the resident caregiver was provided instructions about the mobility and transfer of Resident 201. A review of the rehabilitation progress notes, did not indicate who was given instructions. A review of Resident 201's plan of care, dated 12/14/18, titled, Has a decline in: In bed mobility, gait, balance and safety. Interventions included physical therapy evaluation, gait training, therapeutic activity and exercises. The plan of care did not include instructions and evaluation to the caregiver who provided assistance with ambulating the resident.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 01/30/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have a care plan for one of 24 sampled resident (Resident 81) for a medication (Eliquis a blood thinner) the resident was taking. This failure had the potential for the resident to receive inadequate care and services individualized to their needs. Findings: A review of Resident 81's Resident Face Sheet indicated the resident was admitted to the facility on 10/11/18, with diagnoses of renal renal dialysis (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) and diabetes (a metabolism disorder that affects the body's ability to use blood sugar). A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/23/18, indicated the resident had clear speech and was able to express needs and wants. According to the MDS, Resident 81 required extensive assistance, staff providing weight-bearing support, for transferring and dressing. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of Resident 81's physicians' orders dated 10/16/18, indicated Resident 81 was ordered Eliquis 2.5 milligrams (mg) twice a day. During an interview, on 12/28/18, at 7:31 a.m., the Director of Nurses (DON) stated, Resident 81 should have had a care plan for Eliquis since the resident was receiving the medication. The DON stated, the care plan should have an intervention to monitor for bleeding for this medication. A review of the facility policy and procedure titled, "Care Plan-Comprehensive," dated 10/2010, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of the residents are ongoing and care plans are revised as information about the resident's condition change.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 01/30/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: 2. A review of Resident 151's Resident Face Sheet indicated the resident was admitted to the facility on 12/21/18, with diagnoses that included history of falling, diabetes (a metabolism disorder that affects the body's ability to use blood sugar) and hypertension (high blood pressure). A review of Resident 151's MDS dated 12/27/18, indicated Resident 151 had clear speech and was able to make needs known. Resident 151 needed extensive assistance, staff providing weight-bearing support, for transferring and dressing. During an interview and concurrent record review, on 12/28/18, at 8:43 a.m., the DON stated, Resident 151 was admitted with a left heel DTI from the hospital on 12/21/18. The DON stated, the facility started the treatment on the wound on 12/22/18, but did not order the heel protectors until 12/27/18. The DON stated, they should have ordered the heel protectors on admission to prevent worsening of the wound. A review of Resident 151 admission skin assessment, the nurse documented there was a mid chest old surgical scar and bilateral foot edema (both feet swelling). There was no documentation on admission regarding the left heel DTI. The DON was unsure why the admitting nurse did not have any documentation of the left heel DTI. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the facility form titled, "Clinical Documentation-Skin Integrity," dated 12/21/18, indicated Resident 151 had a mid chest old surgical scar and bilateral foot edema. A review of Resident 151's physician's order dated 12/21/18, indicated to cleanse the left heel DTI with normal saline (salt water), paint with Betadine, wrap with Kerlix (gauze) daily. A review of Resident 151's physician's order dated 12/27/18, indicated may use floater on left heel every shift as tolerated for wound management. A review of the facility P&P titled, "Pressure Ulcer Treatment," dated 10/2010, indicated the pressure ulcer treatment program should focus on the following strategies: Assessing the resident and the pressure ulcer. Managing tissue loads. Pressure ulcer care. Managing bacterial colonization and infection. Operative repair of the pressure ulcer(s). Educating and quality improvement. 3. A review of the Resident Face Sheet indicated Resident 76 was admitted to the facility on 7/2/14 and was readmitted on 12/5/18, with diagnoses that included, heart failure (inability of the heart to meet the body's demand) and muscle wasting. A review of the MDS dated 12/17/18, indicated Resident 76 was usually able to understand others and express ideas and wants and required total dependence with one-person assistance for bed mobility. On 12/29/18, at 9:43 a.m., during an observation and concurrent interview, Resident 76 was observed with left foot wrapped with Kerlix dressing and was wearing a boot. LVN 2 stated, Resident 76 had a DTI on the left heel 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE and was being treated with Betadine. A review of the physician's order, dated 12/5/18, indicated to treat Resident 76's left heel DTI with normal saline, pat with Betadine and wrap with Kerlix daily for thirty days. On 12/31/18, at 2:10 p.m., in an interview, the DON stated, according to the facility protocol, Betadine was not the treatment of choice for DTI. A review of the facility P&P dated 10/2010, titled, "Pressure Ulcer Treatment," did not include Betadine for treatment of DTI. According to National Institute of Health, the care of pressure ulcer was to keep the wound clean and prevent infection and do not use iodine cleanser as it can damage the skin. Reviewed: 5/12/18 https://medlineplus.gov/ency/patientinstructions /000740.htm Based on observation, interview, and record review, the facility failed to prevent and have preventative measures in place to prevent worsening of pressure ulcers (injuries [PI]/areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) prominence as a result of pressure) for three of five sampled residents with pressure injuries (Resident 22, 76, and 151) in a total resident sample of 24. 1. For Resident 22, the resident had a facility acquired deep tissue injury (DTI an injury under the intact skin due to prolonged unrelieved pressure) PI to the left heel. The facility failed to: 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE a. Ensure weekly skin assessment were done on 12/17/18, and 12/24/18, in accordance with the facility's policy and procedures. b. Notify the physician of Resident 22's change in condition to the left foot PI. The left foot was swollen. c. Ensure Resident 22 was monitored on multiple days to relieve constant pressure on the left heel (offload the heel) as indicated in the plan of care. d. Notify the physician of the facility's policy and procedures regarding treatment for deep tissue injury (DTI/ are purple or maroon areas of intact skin caused by damage to the underlying soft tissues) and Resident 22's allergy to the current treatment order. 2. Resident 151, skin assessment was not properly assessed to reflect the resident's pressure injury on the left heel and the facility failed to start preventative measures on admission. 3. Resident 76, with a DTI on the right heel was treated with Betadine (or Povidine-iodine is solution used to eliminate bacteria to prevent infection) These deficient practices put the resident at risk for further skin breakdown that could have been prevented. Findings: 1. A review of Resident 22's record titled, "Resident Face Sheet," undated, indicated the resident was admitted to the facility on 3/26/18, with diagnoses that included dementia (gradual decrease in the ability to think and remember 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE that is great enough to affect a person's daily functioning), heart failure, and allergies to intravenous (IV) dye (contrast/solution containing iodine given through the veins). A review of Resident 22's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 10/1/18, indicated the resident was able to express ideas and wants. The MDS indicated Resident 22 required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) from staff with activities of daily living ([ADLs] such as toileting, personal hygiene, and bed mobility) and had a pressure reducing device while in bed and chair. A review of Resident 22's Treatment Administration History, dated 12/1/18 to 12/27/18, indicated a physician's order on 12/10/18, to cleanse the left heel DTI with normal saline (salt solution), pat dry, paint with Betadine, then cover with dry dressing every day. During an observation on 12/26/18, at 11:22 a.m., Resident 22 was in the room on a wheelchair with no footrest. Resident 22 was wearing non-skid socks and both feet were resting directly on the floor. During an observation on 12/27/18 at 10:46 a.m., Resident 22 was in the room on a wheelchair wearing non-skid socks with both feet resting directly on the floor. During an interview with the Director of Nursing (DON) at that time, the DON stated Resident 22 had a facility acquired DTI PI to the left heel. During an inspection of Resident 22's left heel, there was no dressing, the foot was swollen, and an area was observed with dark purple discoloration. The DON verified the wheelchair 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE had no footrest and Resident 22's feet were directly on the floor. The DON stated Resident 22 was mostly on the wheelchair and was able to self- propel using her feet and was unable to use her arms due to weakness. When asked about the interventions provided to residents with PI, the DON stated the feet needed to be offloaded to prevent pressure and worsening of the PI. During an interview on 12/27/18, at 10:55 a.m., with Certified Nursing Assistant 3 (CNA 3) in the presence of Resident 22, CNA 3 stated Resident 22 refused the foot rest. At the same time Resident 22, stated when she is on the wheelchair, it takes a long time to move and prefers to use her feet. On 12/27/18, at 10:57 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), when asked if she was aware Resident 22 refused the foot rest, LVN 1 stated the CNAs have not reported to her that Resident 22 did not like the footrest. LVN 1 stated a resident with PI to the feet when on a wheelchair should have their feet offloaded and not resting on the floor. A review of Resident 22's care plan, "Left Heel Deep Tissue Injury," dated 12/10/18, indicated the wound should heal within 30 days and the following interventions: 1. Assess skin every day and as needed. 2. Provide pressure relieving surfaces to bed and wheelchair. 3. Encourage weight shifting while in wheelchair. A review of Resident 22's care plan, "Allergic to IV Dye," dated 3/26/18, indicated resident will be free of any allergic reactions. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a review of Resident 22's care plan on 12/27/18, at 11 a.m., and concurrent interview, the DON verified the care plan for DTI of the heel indicated an intervention to provide pressure relieving device when on a wheelchair and should have heel protectors. The DON stated Resident 22 was not provided heel protectors and have her feet offloaded. During an interview on 12/27/18, at 11:05 a.m., LVN 2 (treatment nurse) verified Resident 22 had no dressing to the PI. LVN 2 stated there was no wound consult (a wound specialist that assess and provide treatment) obtained to evaluate Resident 22's facility acquired PI since 12/10/18. During an interview on 12/27/18, at 11:06 a.m., the DON stated the procedures for facility acquired PI were the following: 1. Facility staff should notify the physician for the change in condition (facility acquired PI). 2. Obtain a treatment order according to facility's policy. 3. Treatment nurse should monitor the wound every day and ensure the nursing interventions are provided according to the care plan. 4. Develop a care plan for PI. 5. Make an incident report regarding facility acquired PI. During the same interview, when asked when the facility staff obtains a wound consult, the DON stated a resident with acquired PI should have a wound consult. During a concurrent review of Resident 22's clinical record, the DON verified that Resident 22, who acquired a left heel DTI on 12/10/18, had no documentation that the physician was notified of the allergy to iodine, swelling and treatment order not according to facility policy. The DON stated there was no physician order obtained 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE for a Doppler (test done to assess blood circulation for healing) study or wound consult. The DON verified there were no weekly skin assessments for Resident 22 and stated residents with a PI should have weekly skin assessments. During an interview on 12/27/18 at 11:32 a.m., and concurrent record review, the DON stated Resident 22 had an initial assessment on 12/10/18, that indicated Resident 22 developed a left heel DTI, measuring 3.5 centimeters (cm) in length by 4 cm in width, the depth was unable to determine. The DON verified there were no other assessments done on a weekly basis for 12/17/18, and 12/24/18. During an interview on 12/27/18, at 11:49 a.m., the DON and LVN 2 verified there were no weekly assessments done on 12/17/18, and 12/24/18, per facility policy. The DON stated that currently, LVN 2 was the only treatment nurse in the facility due to the other treatment nurse being on leave. Both LVN 2 and LVN 7 were the treatment nurse that would conduct the weekly assessments and treatments for residents with wounds during the week (Mondays-Fridays). During a concurrent review of Resident 22's Treatment Administration Record (TAR), dated 12/18, the DON and LVN 2 verified the TAR indicated Resident 22 had an allergy to IV dye. When LVN 2 was asked for the treatment bottle for Resident 22, LVN 2 removed an open bottle from the treatment cart labeled Povidine Iodine 10 percent (%) with no open date label. LVN 2 stated he had no knowledge of the possible allergic reaction to iodine and IV dye. The DON stated she would call the physician and notify him of Resident 22's allergy and swelling to the left foot. During an observation on 12/27/18, at 3:26 p.m., Resident 22 was in a side lying position in 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE bed. The DON and LVN 2 verified Resident 22 had a heel protector to the left heel and none to the right foot. Resident 22 had a pillow between the feet with the right heel on top of the pillow that was over the left heel wound. The DON was notified of the positioning of pillow on the left foot; pressure was applied to the left heel wound. The DON verified the position of the pillow was not on the calf to allow for the offloading of the feet. During an interview on 12/28/18, at 5:15 a.m., CNA 4 stated she was told to offload Resident 22's feet. During a concurrent observation, Resident 22 was lying on her back with one pillow under the resident's calves with both heels directly pressing on the mattress, not offloading. CNA 4 stated she will add another pillow to elevate the feet. During an interview on 12/31/18, at 1:31 p.m., the DON and LVN 4 stated Betadine was not a current treatment for PI and it was the role of the nurse to verify with the physician if the treatment order was not the current standard practice. The DON stated the residents that were being cared by the wound consult did not have Betadine as a wound treatment for a DTI. During an interview on 12/31/18 at 2:56 p.m., the DON stated according to the facility's nurse consultant, a DTI PI followed the protocol for a Stage 4 PI (full thickness tissue loss wound). A review of the facility policy and procedures titled, "Pressure Ulcer Treatment," dated 10/10, indicated the treatment for a Stage 4 wound was to cleanse with normal saline, apply alginate, foam or hydrogel dressing and cover with dry dressing. A review of the facility policy and procedures titled, "Pressure Ulcer Risk Assessment," dated 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 10/10, indicated the monitoring of the skin should have weekly assessments to identify any changes. According to National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and Treatment of Pressure Ulcer: A Quick Reference Guide, 2014, indicated, "Reevaluate the PI plan if the PI does not show signs of healing within two weeks and position the individual off the PI." In addition, NPUAP guidelines for PI care included a caution that iodine products should be avoided in individuals with iodine sensitivity due to the risk of systemic absorption.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/30/2019 §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: Based on interview and record review, the facility failed to ensure the resident's assessment was accurate to prevent further falls for one of 24 sampled resident (Resident 65). Resident 65's fall assessment did not indicate the resident had a history of a fall. This deficient practice had the potential for a further fall. Findings: 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of Resident 65's Resident Face Sheet indicated the resident was admitted to the facility on 6/5/17, with diagnoses included falls, hyperlipidemia (high fat levels in the blood), and diabetes (a metabolism disorder that affects the body's ability to use blood sugar). A review of Resident 65's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/2/18, indicated Resident 65 had clear speech and was able to make needs known. Resident 65 needed supervision with staff for transferring and eating. During an interview, on 12/28/18, at 8:57 a.m., the Director of Nurses (DON) stated, Resident 65's last fall was on 7/22/18. The DON stated, the last assessment for resident's fall was done on 11/30/18, indicated the resident did not have a fall in the last six months. The DON stated that assessment was wrong because she had a fall in July. A review of the facility Johns Hopkins Fall Risk Assessment Tool, dated 11/30/18, indicated Resident 65 had no falls within the previous six months. A review of the facility policy and procedure titled, "Falls and Fall Risk, Managing," dated 12/2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG

F692 Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 SS=D DEFICIENCY) COMPLETE DATE 01/30/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy and procedure for placing a resident on weight variance program to prevent further weight loss and for failing to have a resident who was receiving renal dialysis (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) placed on a fluid restriction for two of 24 sampled residents (Resident 75 and 81). 1. Resident 75 had a weight loss of 6% in a month period. 2. Resident 81, who was receiving dialysis, did 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE not have a fluid restriction on her diet to monitor her intake and output of fluids. This deficient practice had the potential for the resident to loss more weight and for the resident's increase of fluid intake can cause worsening of symptoms. Findings: 1. A review of Resident 75's Resident Face Sheet indicated the resident was readmitted to the facility on 10/29/18, with the admitting diagnoses of hypertension (high blood pressure), dehydration, and dysphagia (difficulty or discomfort in swallowing). A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/26/18, indicated the resident had unclear speech and was usually able to express needs and wants. According to the MDS, Resident 75 needed extensive assistance, staff providing weight-bearing support, for dressing and personal hygiene. During an interview, on 12/28/18, at 7:33 a.m., the Director of Nurses (DON) stated, on 11/18/18, Resident 75 was 98 pounds (lbs.) and on 12/22/18, she was 92 lbs., a 6% weight loss in one month. The DON stated, if there is a weight loss of more than 5% in one month it was significant and the resident should be a weight variance programs to prevent further weight loss. The DON stated, when residents are placed on the weight variance program they notify the physician, responsible party and get consultation from the registered dietitian. The DON was unable to find any documentation the resident was placed on a weight variance program. During an interview, on 12/28/18, at 7:49 a.m., 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Registered Nurse 1 (RN 1) stated, he did not catch the weight loss since she was just sent to the hospital in 10/2018. RN 1 stated, he would place her on a weight variance program now. During a record review of Resident 75's weights are as followed: 11/11/18- 98 lbs. 11/18/18- 98 lbs. 12/9/18- 95 lbs. 12/15/18- 95 lbs. 12/22/18- 92 lbs. A review of the facility policy and procedure titled, "Nutrition (impaired)/ Unplanned Weight Loss- Clinical Protocol," dated 12/2011, indicated the threshold for significant unplanned and undesired weight changes will be bases on the following criteria [where percentage of body weight change = (usual weigh-actual weight)/(usual weight) x 100]: a. One month- 5% weight loss is significant; greater than 5% is severe. 2. A review of Resident 81's Resident Face Sheet indicated the resident was admitted to the facility on 10/11/18, with diagnoses of renal dialysis and diabetes (a metabolism disorder that affects the body's ability to use blood sugar). A review of the MDS dated 10/23/18, indicated the resident had clear speech and was able to express needs and wants. According to the MDS, Resident 81 required extensive assistance, staff providing weight-bearing support, for transferring, and dressing. During an interview, on 12/28/18, at 9:30 a.m., the DON stated, she was unable to find a physician order or any care plan for Resident 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 81 being on a fluid restriction due to her dialysis. The DON stated, residents on dialysis are usually on fluid restrictions to prevent fluid overload. During a phone interview, on 12/31/18, at 8:56 a.m., the Registered Dietitian (RD) stated, most residents who are on dialysis are on fluid restrictions. The RD stated, she calculates the resident's daily fluid intake by multiplying the resident's body weight in kilograms by 15-20 cubic centimeters (cc). A review of the facility Nutritional Assessment, dated 10/25/18, indicated the RD's recommended total fluids required to meet the Resident 81's needs are 855-1140 cc of fluid a day. According to the National Kidney Foundation: When you are on dialysis, your kidneys are no longer able to keep the right balance of fluid in your body. They cannot remove enough. That's why it's so important to limit how much sodium (salt) and fluid you have between dialysis treatments. This helps your body maintain the right amount of fluid, and it makes it easier for your dialysis treatment to remove extra water. The excess fluids can lead to: Swelling, discomfort, high blood pressure, shortness of breath, and heart problems. https://www.kidney.org/atoz/content/fluidoverload-dialysis-patient 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG

F693 Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 SS=D DEFICIENCY) COMPLETE DATE 01/30/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that nutritional care and services were provided to one of two sampled residents (Resident 16) with gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding in a total resident sample of 24. For Resident 16, facility failed to provide G-tube feeding as ordered by the physician in order to meet the daily nutritional calories in 20 hours of infusion time. This deficient practice placed the resident at risk for aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE airway). Findings: A review of the Resident Face Sheet indicated Resident 16 was admitted to the facility on 10/6/17, with diagnoses that included dementia (is a general term for a decline in mental ability severe enough to interfere with daily life) and an artificial opening of the digestive tract. A review of the Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 10/7/18, indicated Resident 16 had cognitive (ability to think and reason) impairment and required total assistance with two-person assist for bed mobility. The MDS further indicated Resident 16 had a feeding tube. A review of Resident 16's physician's order, dated 12/5/18, indicated Glucerna (type of liquid nourishment fed into the G-tube) 1.2 formula at 50 milliliters (mL) per hour (/hr) mL/hr for 20 hours (12 p.m. to 8 a.m.). To provide 1000 mL/1200 kilocalories (kcal), start feeding at 12 p.m., until dose was complete. During an observation on 12/27/18, at 3:20 p.m., Resident 16 was observed in bed with a G-tube feeding of Glucerna 1.2 at 50 mL/hr, with a total of 863 mL infused. On 12/28/18, at 7:25 a.m., Resident 16 was observed in bed sleeping with G-tube feeding running at 50 mL/hr with a total infused of 756 mL. During an interview and concurrent record review on 12/28/18, at 8:05 a.m., the Director of Nursing (DON) verified there was 208 mL to infused over the next four hours. The DON stated the physician order was to stop feeding 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE at 8 a.m. The DON stated, the G-tube feeding, may run over up to an hour due to stopping for medication administration and resident care. The DON did not know what caused the four hour delay in the G-tube feeding. The DON further stated, Resident 16 would not have a pause between current feeding and her next feeding as ordered by the physician. The DON explained a pause in feeding was necessary to prevent aspiration when lying flat.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 01/30/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 86) receiving oxygen in a total resident sample of 24, was monitored for respiratory care according to the physician order. For Resident 86 the facility failed to ensure that the physician's orders for oxygen saturation (amount of oxygen in the blood) monitoring was done. This deficient practice placed Resident 86 at risk for inappropriate oxygen therapy and chronic obstructive pulmonary disease (COPD 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE a chronic inflammatory lung disease that causes obstructed airflow from the lungs) exacerbation. Findings: A review of the Resident Face Sheet indicated Resident 86 was readmitted to the facility on 11/25/18, with diagnoses that included COPD with acute exacerbation. A review of the Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 12/7/18, indicated Resident 86 had no cognitive (ability to think and reason) impairment and required extensive to total assistance from staff for activities of daily living. A review of Resident 86's physician's order, dated 11/25/18, indicated to monitor oxygen saturations via a pulse oximeter (a medical device that indirectly monitors the oxygen saturation of the blood via a monitoring device which is attached to a part of the body) every shift. A review of Resident 86's care plan for oxygen continuously via nasal cannula (tubing which delivers the oxygen into the nostrils) dated 11/25/18, indicated to monitor the oxygen saturations using the pulse oximeter to maintain oxygen saturation greater than 93%. During an observation on 12/26/18, at 11:05 a.m., Licensed Vocational Nurse 4 (LVN 4) verified Resident 86 was receiving five liters (L) of oxygen via a nasal cannula. During an interview and concurrent record review on 12/28/18, at 6:50 a.m., LVN 1 verified the oxygen saturations were not documented on the electronic Medication 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Administration Record from 11/25/18 to 12/25/18. During an interview and concurrent record review, on 12/28/18, at 6:59 a.m., the Director of Nursing (DON) verified the oxygen saturations were not documented on Resident 86's medical record as being monitored from 11/25/18 to 12/25/18. A review of the facility policy and procedure titled, "Oxygen Administration," dated 10/2010, indicated while resident was receiving oxygen therapy the oxygen saturation should be assessed.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 01/30/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure their renal dialysis (is a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) form had the correct assessment of the dialysis site (where the dialysis fluid enters the body and the blood 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE exits and reenters the body after being filtered) and post weights for one of two sampled dialysis resident (Resident 81). This deficient practice had the potential for complications due to not properly assessing the dialysis site and not monitoring weights. Findings: A review of Resident 81's Resident Face Sheet indicated the resident was admitted to the facility on 10/11/18, with diagnoses of renal dialysis and diabetes (a metabolism disorder that affects the body's ability to use blood sugar). A review of a Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/23/18, indicated the resident had clear speech and was able to express needs and wants. According to the MDS, Resident 81 required extensive assistance, staff providing weight-bearing support, for transferring, and dressing. During a record review and concurrent interview, on 12/28/18, at 7:26 a.m., the Director of Nurses (DON) stated, Resident 81's dialysis site was on the left upper arm. A review of Resident 81's Dialysis Communication Form dated 12/3/18, 12/10/18, and 12/19/18, it indicated the resident's dialysis site was on the right chest and on 12/17/18, there was no post dialysis weight documented. The DON stated, that the form had an inaccurate assessment due to the documentation of the wrong dialysis site and there should be a post dialysis weight on the form. A review of the facility policy and procedure titled, "End-Stage Renal Disease, Care of a 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Resident with," dated 9/2010, indicated educating and training of staff includes, specifically: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift bases.

F732 SS=B Posted Nurse Staffing Information CFR(s): 483.35(g)(1)-(4)

F732 01/30/2019 §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to post the current nurse staffing information at the beginning of each shift. This deficient practice had the potential for residents and visitors not being informed of the current census and staffing for the facility. Findings: During an observation, on 12/31/18, at 2 p.m., and concurrent interview, with the Director of Staff Development (DSD) the Report of Nursing Staff Directly Responsible for Resident Care (Form-list the staff providing care to the residents) dated 12/31/18, was posted only at Station 200. The Form, indicated there was two restorative nursing assistants (RNA) on the floor. A review of the staff sign-in schedule, indicated there was three RNAs on the floor. The DSD stated, they print out a projected form indicating how many licensed and unlicensed staff who are on the schedule and they do not update it. The DSD stated, he was unaware they were supposed to update the form at the beginning of each shift and they should be posted in different places. During another interview, on 12/31/18, at 2:20 p.m., the DSD stated, they would be posting 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the form at all three stations and updating them at the beginning of each shift to be more accurate. A review of the facility policy and procedure titled, "Posting Direct Care Daily Staffing Numbers," dated 8/2006, indicated within two hours of the beginnings of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator. The form may be typed or handwritten. If completed by typewriter or word professor, the recorded information shall be minimum font size of 12 points. Should the information be handwritten, it must be legibly printed in black ink and must be written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in or facility daily staffing information.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 01/30/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to properly assess the use of psychotropic medications (any drug 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE capable of affecting the mind, emotions, and behavior) for two of 24 sampled residents (Resident 28 and 47). 1. For Resident 28, no behavioral monthly monitoring tally for the months of 9/2018 to 11/2018 for use of Lexapro (medication used to treat depression and anxiety). 2. For Resident 47, the facility failed to ensure resident behavior and non-pharmacological interventions were provided prior to restarting Seroquel (medication use to treat mood and behavior). This deficient practice placed residents at risk for unnecessary medication administration that could result in harm and other adverse side effects associated with the medication's use. Findings: 1. A review of Resident 28's Resident Face Sheet indicated the resident was admitted to the facility on 4/23/18, with the admitting diagnoses including depression, hypertension (high blood pressure) and gastroesophageal reflux disease ([GERD] acid reflux). A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool MDS, dated 10/21/18, indicated the resident had clear speech and was able to express needs and wants. According to the MDS, Resident 28 needed extensive assistance, staff providing weight-bearing support, for transferring and dressing. A review of the physician order dated 4/23/18, indicated to administer Resident 28, Lexapro 10 milligram (mg) one tablet a day for depression manifested by verbalization of sadness. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an interview and concurrent record review, on 12/28/18, at 8:59 a.m., the Director of Nurses (DON) stated, Resident 28 was currently receiving Lexapro. The DON stated, the last monthly behavior summary in chart was done in 8/2018. The DON stated, they were three months behind on the behavior summaries for this resident. The DON stated, the summaries are done so the physicians are able to see how many behavioral episodes the resident had for that month. A review of the facility policy and procedure titled, "Behavior Management- Clinical Protocol," dated 2/2014, indicated nursing staff will identify and document the individual's mental status, behavior, and cognition, This will include details about any problematic behavior such as onset, frequency, and precipitating factors. 2. A review of the Resident Face Sheet indicated Resident 47 was admitted to the facility on 8/16/17 and readmitted on 9/6/17, with diagnoses that included dementia (a progressive brain disorder that affects the thought process and memory) with behavioral disturbances. A review of the MDS dated 11/6/18, indicated, Resident 47, had severe cognitive (ability to think and reason) and memory impairment, without delusions (false belief or misconception contrary to reality) or hallucinations (perceiving something not present) and was able to communicate her needs, wants, and was able to understand others. The MDS also indicated Resident 47 required extensive assistance (resident involved with care and staff provide weight bearing assist) with one-person assist for personal hygiene and toilet use. On 12/26/18, at 11:26 a.m., during an 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE observation and concurrent interview, Resident 47 was observed calm and cooperative, sitting up in the wheelchair. Resident 47 stated, she was "fine" and satisfied with the care provided by the facility. A review of Resident 47's record indicated Resident 47 had no previous history of psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of the Medication Administration Record for Resident 47 indicated the following: a. On 9/7/18, Seroquel 12.5 mg given by mouth every evening was discontinued b. On 9/11/18, Seroquel 12.5 mg given by mouth every evening was restarted for psychosis with delusional thought that she left the stove on. A review of "Physician Order Report" recapped on 9/29/18, indicated, Resident 47 was to receive Seroquel 12.5 mg given by mouth for psychosis for delusional thought manifested by resident behavior that she left the stove on. On 12/26/18, at 1:28 p.m., during a record review and concurrent interview, Registered Nurse 1 (RN 1) stated, Resident 47 had periods of confusion due to dementia. RN 1 also stated, Resident 47's had no documented evidence to indicate when and how Resident 47 failed the gradual dose reduction (GDR) or if non-pharmacological interventions were provided prior to restarting the administration of Seroquel.

F761 Label/Store Drugs and Biologicals

F761 01/30/2019 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG SS=D CFR(s): 483.45(g)(h)(1)(2) ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on interview, observation, and record review, the facility failed to ensure an expired medication was removed from the medication cart. This deficient practice put the residents' at risk being administered expired medications. Findings: 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an inspection of the Station 100 treatment cart, on 12/27/18, at 11:30 a.m., a bottle of hydrogen peroxide was observed with no open date and an expiration date of 10/2017. During an interview, on 12/27/18, at 11:49 a.m., Licensed Vocational Nurse 2 (LVN 2) stated, when a medication is expired it's no good. During an interview, on 12/28/18, at 11:31 a.m., the Director of Nursing (DON) stated, she frequently reminds her nurses to check expiration dates and has a lot of in-services for her nurses about checking expiration dates of medications in carts to make sure everything was okay and discard expired medications. The DON stated, they should put the date the medication was opened on each medication opened. The DON stated, she was aware the hydrogen peroxide was expired and it was immediately discarded. A review of the facility policy and procedure, revised 4/2017, titled, "Labeling of Medication Containers," indicated all medications maintained in the facility shall be properly labeled in accordance with state and federal regulations.

F808 SS=E Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 01/30/2019 §483.60(e) Therapeutic Diets §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the licensed staff verify the residents' are served their prescribed diets for one of three nursing stations (Station 200). This deficient practice had potential for residents not to receive their prescribed diets. Findings: On 12/28/18, at 7:29 a.m., during a tray line observation in Station 200 and concurrent interview, Licensed Vocational Nurse 2 (LVN 2), checked the residents' breakfast trays with the tray card print out on their breakfast trays. LVN 2 did not have the residents' prescribed diet list to verified the residents' breakfast trays. LVN 2 stated, he had just came in and did not have the prescribed diet list to verify with the meal trays. On 12/28/18, at 2:35 p.m., during an interview, the Director of Nursing (DON) stated, LVN 2 did not verified the meal trays with residents' prescribed diet list. The DON stated, they did not print out the residents' prescribed diet list. A review of the facility policy and procedure titled, "Resident Nutrition Services," dated 4/2010, indicated nursing personnel will ensure that residents are served the correct food tray. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=E DEFICIENCY) COMPLETE DATE 01/30/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with the professional standard for food service safety by ensuring the following: a. 20 loaves of brown bread were dated or labeled of the expiration date or when to "use by" and were not stored in the refrigerator per facility's policy and procedure. b. Three trays with twenty glasses of white fluid were stored in the refrigerator without a label to indicate the type of fluid contained in the 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE glasses. This deficient practice had the potential to result in an outbreak of foodborne illness (illness caused by the ingestion of contaminated food or beverages) and the resident to develop complications related to dietary restrictions. Findings: On 12/26/18, at 10:28 a.m. to 10:58 a.m., during an initial kitchen tour with the Dietary Supervisor (DS) and concurrent interview, the following were observed: a. 20 loaves of brown bread which were not labeled with a delivering date, use by date, or an expiration date, were stored in the refrigerator. b. Three trays that contained twenty glasses of white fluid were stored in the refrigerator without a label to indicate the type of fluid contained in the glass. The Dietary Supervisor stated, the white fluids contained in glasses were milk and were usually not labeled immediately when prepared because the kitchen staff that works in the next shift were responsible to label the glasses of milk. The DS was asked, what type of milk were served at the facility? The DS stated, whole milk, mocha mix, non-fat milk, and 2% milk were served. The DS also stated, since there was no label on the type of milk were in the trays, there was a risk that the wrong milk could be served to residents who have kidney problems or allergies. On 12/26/18, at 2:40 p.m., during an interview and concurrent record review of the the facility policy and procedure titled, "Storage of Food 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Supplies," indicated the bread should not be stored in the refrigerator. The DS stated, the loaves of bread in the refrigerator were in the freezer but were moved to the refrigerator to be served at lunch. The DS took a loaf of bread from the refrigerator which was dated 11/11/18. The DS stated, she was not sure if the date on the loaf of bread package was the expiration date or the date that it should be used by. On 12/31/18, at 9:30 a.m., in an interview, the DS stated, she purchased a labeling device to ensure food items in the refrigerator were dated and labeled. A review of the facility policy and procedure, dated 2018, titled, "Storage of Food Supplies," indicated, bread will be delivered frequently and used in order that is delivered to assure freshness. Bread products not used can be frozen. Some bread do last 5-7 days, check manufacturer's recommendation. Do not store bread in the refrigerator.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 01/30/2019 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure, the goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible) visits outcomes were communicated to the facility staff for one of two sampled residents (Resident 6) with hospice care in a total resident sample of 24. For Resident 6 there was no documentation from the hospice agency staff to communicate with the facility staff about the hospice visits. This deficient practice had the potential for the delay in necessary care and services for the resident. Findings: 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of Resident 6's Resident Face Sheet indicated the resident was admitted to the facility on 3/9/18, with diagnoses of anemia (is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin [hemoglobin is a main part of red blood cells and binds oxygen]) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 6's physician's order dated 3/9/18, indicated Resident 6 was admitted to hospice care. During an interview and concurrent record review, on 12/28/18, at 7:15 a.m., the Director of Nursing (DON) verified there were no detailed hospice documentation of their visits in Resident 6's medical record. A review of the facility Hospice Contract dated 3/8/18, indicated the hospice provider who contract with the facility are held responsible for documentation of the services provided in the resident's medical record.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/30/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a covered trash can for one of two sampled residents in isolation (Resident 4) (separation and confinement of those known or suspected to be infected with a contagious disease agent to prevent further infections). This deficient practice had potential to spread infection and transmission of communicable diseases. Findings: A review Resident 4's Resident Face Sheet, indicated the resident was re-admitted on 11/16/16, with diagnoses that including anoxic brain damage (brain cells begin to die after approximately four minutes without oxygen), and cerebrovascular disease (diseases which damage the brain by altering its blood supply, depriving brain cells of the oxygen necessary to 055845 12/31/2018 LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE their survival). A review of the Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated 12/20/18, indicated Resident 4 had severely impaired cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on the staff for activities of daily living. A review of Resident 4's physician's orders dated 12/24/18, indicated contact isolation (used for infections, diseases, or germs that are spread by touching the resident or items in the room, wear a gown and gloves while in the resident's room) for sores until further notice. On 12/26/18, at 10:31 a.m., Resident 4 was observed to be on contact isolation. No covered trash can was observed in Resident 4's room. On 12/26/18, at 10:54 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated, there was no covered trash can in Resident 4's room. On 12/26/18, at 1:05 p.m., during an interview, the Director of Staff Development (DSD) stated, isolation rooms must have a covered trash can.