Other·April 3, 2019

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 the investigation of a complaint. Complaint number: CA00618528. Representing the Department: HFEN # 33670. Three deficiencies were issued for complaint number CA00618528.

F684 SS=G Quality of Care CFR(s): 483.25

F684 03/15/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to accurately assess and provide the necessary care and services (wound treatments) by the physician, the physician designee (NP, Nurse Practitioner), the Director of Nursing (DON), the registered nurses, and the licensed vocational nurses (treatment nurses); after a resident sustained a deep skin tear on the right lateral (side) leg for one of three sampled residents (Resident 1). Cross Reference F 689. 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: 62LM11 Facility ID: CA970000081 If continuation sheet 1 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 This deficient practice resulted to a wound infection of a MRSA (Methicillin Resistant Staphylococcus Aureus, an organism difficult to treat due to resistance to commonly used antibiotics) to resident's injury. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 10/22/18, with diagnoses that included Parkinson's Disease (a progressive brain disorder that results in poor balance, trembling and stiffness of hands, arms, legs, jaw and face and slow movement), peripheral vascular disease (narrowing or blockage of blood vessels in the legs and arms that results in poor blood flow), and lymphedema (swelling of the arms or legs due to lymph fluid builds when the lymph system is damaged or blocked). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/3/18, indicated resident was able to understand others and express her needs and wants, and required extensive assistance (resident involved in activity, staff provide weight bearing support) with two person physical assistance with bed mobility and transfers. A review of Resident 1's SBAR (Situational Background Assessment Report) Communication Forms, dated 12/13/18 timed at 10 a.m. by Licensed Vocational Nurse 3 (LVN 3), indicated, a Certified Nursing Assistant 1 (CNA 1) reported to the charge nurse that Resident 1 sustained right lower leg skin tear with skin flap and bleeding when the resident bumped leg on the footrest of Resident 1's wheelchair while transferring from the wheelchair to the bed and sustained a skin tear FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 2 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 wound cause by shear, friction, and/or blunt force resulting in separation of skin layers) measuring 4.5 centimeter (cm) in length x (by) 1 cm. A review of Resident 1's Physician Order, dated 12/13/18, indicated to clean the right shin skin tear with Normal Saline (water with salt used to retard the growth of bacteria), pat dry, apply sterile strips (dressing strips that keep the tissues intact) and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/19/18 at 2:20 p.m. by LVN 2, indicated, Resident 1 wound size increased to length 3.8 cm x width 5.8 cm. x depth 0.3 cm. A review of Resident 1's Physician Order, on 12/19/18, indicated to clean the right shin skin tear with Normal Saline pat dry, apply triple antibiotic (medication used to treat infection) ointment and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's medical records indicated no documented evidence that the NP assessed the wound prior to changing the wound treatment, dated 12/19/18, when the LVN 2 reported to the NP that the wound was not improving. A review of the Resident 1's Progress Notes, dated 12/19/18 timed at 12:33 p.m., LVN 2 documented received change in order. The note did not describe what order received, or why the order was changed. On 12/31/18 at 10:15 a.m., during a wound treatment observation in Resident 1's room with LVN 1, Resident 1 was observed grimacing. The wound observed on the right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 3 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 leg had pink tissue with bright red blood oozing from an open deep wound. On 12/31/18 at 10:18 a.m., during an interview, LVN 1 explained, she initially assessed Resident 1's wound, as a "Skin tear," because the wound had a skin flap, however, the wound had increase in size and was now deeper. LVN 1 stated Resident 1 sustained the wound from a sharp edge metal on the side of resident's wheelchair during a transfer from a wheelchair to bed two weeks ago. On 12/31/18 at 11:19 a.m., during an observation in Resident 1's room and concurrent interview with the DON, the DON stated she had never seen or assessed the wound on 12/13/18. The DON stated the wound did not look like a skin tear. The DON stated the wound was a laceration (a cut or jagged wound). The DON stated a registered nurse and a physician should have assessed the wound to ensure accurate assessment for immediate interventions to prevent complication such as infection. On 12/31/18 at 11:47 a.m., during an interview, LVN 2 stated the wound treatment using the steri-strip was not working and the wound was not getting better. LVN 2 stated LVN 2 called the Nurse Practitioner (NP), on 12/ 19/18, for new treatment order. LVN 2 stated the NP changed the order to apply triple antibiotics to the wound. LVN 2 stated the NP did not physically assess Resident 1's wound on 12/19/18. On 12/31/18 at 1:10 p.m., during an interview, the NP stated she had not assessed Resident 1's skin tear on the right leg. The NP stated the staff reported Resident 1's skin tear was not improving, and the treatment was changed to triple antibiotic. The NP stated she did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 4 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 order any laboratory test to check for infection of the wound or assessed the skin tear prior to changing the treatment. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/31/18 timed at 1:31 p.m. by LVN 2, indicated Resident 1 had a skin tear on the right anterior (front) lateral leg measuring 3 cm in length x 5.5 cm in width x 0.6 cm in depth. On 12/31/18 at 2:05 p.m., during an interview with the DON and concurrent review of Resident 1's medical records, there were no documented evidence that the Interdisciplinary Team (IDT, team of facility staff responsible to assess and plan the care of the residents) discussed with the responsible party and a care plan for resident's skin tear. The DON stated the IDT should have assessed the resident and developed a care plan. A review of the Physician's Progress Record, dated 1/2/19, indicated Resident 1 had painful right leg ulceration/laceration from a skin rupture (separate) with a wheelchair. The progress notes indicated the wound was infected and with erythema (redness), measured 2 cm x 3.5 x 1 cm that was cleaned with Dakins Solution (diluted bleach used as strong antiseptic that kills most forms of bacteria and viruses) and applied wet to dry dressing. A review of Resident 1's Surgical Consult, dated 1/7/19, indicated a right anterior lower leg debridement (the removal of damaged tissue) performed by surgical excision due to 75 % wound slough (dead tissue, usually cream or yellow in color). The wound measured on length 3.0 cm x width 4.0 cm x depth described as unstageable tissue damage (UTD). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 5 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Laboratory Report, result date 1/8/19, indicated Resident 1's right leg skin tear was infected with MRSA. A review of Resident 1's Physician Order, dated 1/9/19 at 6:56 a.m., indicated to place Resident 1 on Contact Isolation for MRSA of the right lower leg wound, and to administer Vibramycin (medication used to treat infection) for ten days for the MRSA infection. A review of Resident 1's Laboratory Report, result date 1/15/19, indicated Resident 1's right leg skin tear continued to be infected with MRSA. A review of Resident 1's Surgical Consults, dated 1/21/19 and 2/11/19, indicated resident had repeat wound debridement. On 3/1/19 at 10:36 a.m., during a telephone interview, the facility's Medical Director (MD 1) stated for reported skin tear, he wound find out what happened, assess the wound, administer antibiotics, consult with the wound consult, and refer to the surgeon if needed. MD 1 stated MD 1 observed the treatment nurses (no specified date given), and stated, "The treatment nurses did not know what they were doing." A review of the undated facility's job description, titled, "Treatment Nurse," indicated the primary job position of a treatment nurse was to provide primary skin care to residents under the medical direction and supervision of the DON, attending physician, and the Medical Director. A review of the undated facility's job description, titled, "Director of Nursing," indicated the DON will provided close supervision and direction to the nurses to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 6 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 continually improve the nursing care of the residents and will assume ultimate responsibility for coordinating plans for the total care of each residents, which comply with physician's order, government regulation and facility policies. A review of the facility's policy and procedure, dated 8/06, titled, "Physician's Services," indicated the resident's attending physician participated in resident assessment, care planning, monitoring changes, in resident's medical status, and providing consultation and treatment when called by the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/15/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 7 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prevent an accident and provide a safe, hazard free wheelchair when the wheelchair had a sharp edge, transfer by two-person assistance, and there was no investigation on the cause of the resident's injury from the wheelchair for one of three sampled residents (Resident 1). Resident 1 sustained a laceration (a deep cut or jagged wound) on the right lateral leg, on 12/13/18, from a sharp edge on the side of resident's wheelchair when a staff rushed to assist resident to avoid a fall. This deficient practice resulted to resident's wheelchair remained a hazard and the Director of Nursing (DON) did not assess Resident 1's injury sustained from the wheelchair until 12/31/18 (18 days after the injury). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 10/22/18, with diagnoses that included Parkinson's Disease (a progressive brain disorder that results in poor balance, trembling and stiffness of hands, arms, legs, jaw and face and slow movement), peripheral vascular disease (narrowing or blockage of blood vessels in the legs and arms that results in poor blood flow), and lymphedema (swelling of the arms or legs due to lymph fluid builds when the lymph system is damaged or blocked). A review of Resident 1's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 8 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 (MDS, a standardized resident assessment and care screening tool), dated 11/3/18, indicated Resident 1 was able to understand others and express her needs and wants, and required extensive assistance (resident involved in activity, staff provide weight bearing support) with two person physical assistance with bed mobility and transfers. A review of Resident 1's SBAR (Situational Background Assessment Report) Communication Forms, dated 12/13/18 timed at 10 a.m. by Licensed Vocational Nurse 3 (LVN 3), indicated, a Certified Nursing Assistant (CNA 1) reported to the charge nurse that Resident 1 sustained right lower leg skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers) with skin flap and bleeding when the Resident 1 bumped leg on the footrest of while transferring from the wheelchair to the bed and sustained a skin tear measuring 4.5 centimeter (cm) in length x 1 cm. A review of Resident 1's Physician Order, dated 12/13/18, indicated to clean the right shin skin tear with Normal Saline (water with salt used to retard the growth of bacteria), pat dry, apply sterile strips ( strips that keep the tissues intact) and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/19/18 at 2:20 p.m. by LVN 2, indicated, Resident 1 wound size increased to length 3.8 cm x width 5.8 cm. x depth 0.3 cm. A review of Resident 1's Physician Order, on 12/19/18, indicated to clean the right shin skin tear with Normal Saline pat dry, apply triple antibiotic (medication used to treat infection) ointment and cover with dry dressing for 21 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 9 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 days then reevaluate. On 12/31/18 at 10:15 a.m., during a wound treatment observation with LVN 1, Resident 1 observed grimacing when interviewed Resident 1 stated she had pain on the wound site but refused to take pain medication. The wound observed on the right leg had pink tissue with bright red blood oozing from an open deep wound. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/31/18 timed at 1:31 p.m. by LVN 2, indicated Resident 1 had a skin tear on the right anterior lateral leg measuring 3 cm in length x 5.5 cm in width x 0.6 cm in depth. On 12/31/18 at 2:00 p.m., during an interview and concurrent record review with the DON of Resident 1's medical records, the DON stated there was no documented evidence Resident 1 skin injury was investigated. The DON stated she should have investigated the incident of the exact cause of the skin injury such as checking the sharp edge on the wheelchair to determine the appropriate care. On 12/31/18 at 2:05 p.m., during an interview and concurrent record review with the DON of Resident 1's medical records, the DON stated resident's laceration was reported during the stand-up meeting that resident had a skin tear. The DON stated she did not observe or investigate the exact cause of the skin tear. The DON stated she was responsible to investigate any type of resident injury. On 12/31/18 at 2:22 p.m. during an observation and concurrent interview with LVN 3 and CNA 1, Resident 1 observed sitting on the wheelchair. CNA 1 stated Resident 1 sustained a "Skin tear," and pointed at the side FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 10 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 of resident's wheelchair that had a sharp edge without a rubber cap. CNA 1 stated the resident's wheelchair was the same wheelchair that caused the injury to resident's leg on 12/13/18. CNA 1 stated she transferred Resident 1 alone, and she should have had another staff to assist her. CNA 1 stated resident was heavy. CNA 1 stated the resident stood up, started losing balance, and had to move the resident into the bed right away to prevent the resident from falling. On 12/31/18 at 2:58 p.m. during an observation of Resident 1's wheelchair and interview, the DON stated the side of the wheelchair should have had a rubber cap to cover the sharp edge. The DON stated no one inspected the wheelchair after resident was injured to ensure the sharp edge was covered. A review of the facility's policy and procedure, dated 12/07, titled "Safety and Supervision of Residents," indicated the facility will provide safety and supervision to residents to prevent accidents. The policy and procedure indicated safety risk and environmental hazards were identified on an ongoing basis, and when an accident hazards were identified, and the Quality Assurance and Safety Committee (group of facility staff from different healthcare disciplines) shall evaluate and analyze the cause of the hazards and develop strategies to remove the hazards. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 11 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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

F710 Resident's Care Supervised by a Physician CFR(s): 483.30(a)(1)(2)

F710 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/15/2019 §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. §483.30(a) Physician Supervision. The facility must ensure that§483.30(a)(1) The medical care of each resident is supervised by a physician; §483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the physician and the physician's designee (Nurse Practitioner) failed to assess and provide medical supervision for the care of an injury for one of three sampled residents ( Resident 1 ). Resident 1 sustained a laceration (a deep cut or jagged wound) on the right lateral leg, on 12/13/18, from a sharp edge on the side of resident's wheelchair when a staff rushed to assist resident to avoid a fall. Cross Reference F 684 and F 689. The deficient practice resulted in delayed of necessary care and resident's wound injury became infected with a MRSA (Methicillin Resistant Staphylococcus Aureus, an organism FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 12 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 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 difficult to treat due to resistance to commonly used antibiotics) on 1/8/19. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 10/22/18, with diagnoses that included Parkinson's Disease (a progressive brain disorder that results in poor balance, trembling and stiffness of hands, arms, legs, jaw and face and slow movement), peripheral vascular disease (narrowing or blockage of blood vessels in the legs and arms that results in poor blood flow), and lymphedema (swelling of the arms or legs due to lymph fluid builds when the lymph system is damaged or blocked). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/3/18, indicated resident was able to understand others and express her needs and wants, and required extensive assistance (resident involved in activity, staff provide weight bearing support) with two person physical assistance with bed mobility and transfers. A review of Resident 1's SBAR (Situational Background Assessment Report) Communication Forms, dated 12/13/18 timed at 10 a.m. by Licensed Vocational Nurse 3 (LVN 3), indicated, a Certified Nursing Assistant (CNA 1) reported to the charge nurse that Resident 1 sustained right lower leg skin tear (a wound caused by shear, friction, and/or blunt force resulting in separation of skin layes) with skin flap and bleeding when the resident bumped leg on the footrest of while transferring from the wheelchair to the bed and sustained a skin tear measuring 4.5 cm in length x 1 cm.. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 13 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Physician Order, dated 12/13/18, indicated to clean the right shin skin tear with Normal Saline (water with salt used to retard the growth of bacteria), pat dry, apply sterile strips ( strips that keep the tissues intact) and cover with dry dressing for 21 days then reevaluate. On 12/31/18 at 11:47 a.m., during an interview, LVN 2 stated the wound treatment using the steri-strip was not working and the wound was not getting better. LVN 2 stated LVN 2 called the Nurse Practitioner (NP), on 12/ 19/18, for new treatment order. LVN 2 stated the NP changed the order to apply triple antibiotics to the wound. LVN 2 stated the NP did not physically assess Resident 1. On 12/31/18 at 1:10 p.m., during an interview, the NP stated she had not assessed Resident 1's skin tear on the right leg. The NP stated the staff reported Resident 1's skin tear was not improving, and the treatment was changed to triple antibiotic. The NP stated she did not order any laboratory test to check for infection of the wound or assessed the skin tear prior to changing the treatment. On 12/31/18 at 2:05 p.m., during an interview and record review Resident 1's medical records, the Director of Nursing (DON) stated there was no documented evidence the physician or the NP physically assessed and evaluated if the treatment for Resident 1's laceration was appropriate. A review of the Physician's Progress Record, dated 1/2/19, indicated Resident 1 had painful right leg ulceration/laceration from a skin rupture with a wheelchair. The progress notes indicated the wound was infected and with erythema (redness), measured 2 cm x 3.5 x 1 cm.. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 14 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 03/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LEISURE GLEN POST ACUTE CARE CENTER 330 Mission Rd Glendale, CA 91205 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Laboratory Report, result date 1/8/19, indicated Resident 1's right leg skin tear was infected with MRSA. According to the facility's policy and procedure, titled "Physician's Services" the resident's attending physician participated in resident assessment, care planning, monitoring changes, in resident's medical status, and providing consultation and treatment when called by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 62LM11 Facility ID: CA970000081 If continuation sheet 15 of 15