Other·September 25, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one complaint and a COVID-19 Focused Infection Control Survey. Complaint number: CA00701161 Representing the Department: Health Facilities Evaluator Nurse 38108 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for complaint number CA00701161 and COVID-19 Focused Infection Control Survey.

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

F880 08/13/2020 §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 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: 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: DC4011 Facility ID: CA970000081 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 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 implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 12 of 12 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) by failing to: 1. Place a physical barrier to separate the COVID-19 area (Red Zone, area for residents who tested positive for COVID-19) from the suspected COVID-19 area (Yellow Zone, area for persons undetermined illness). 2. Dedicate Licensed Vocational Nurses 1 (LVN 1) to care for confirmed COVID-19 residents (Residents 1, 2, 3, 4, 5, and 6) and negative COVID-19 residents (Residents 7, 8, 9, 10, 11, and 12) at the same time. 3. Screen Surveyor 1 (S 1) and Physician Assistant 1 (PA 1) for signs and symptoms of COVID-19, history of travel and contact with positive COVID-19 persons upon entering the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 4. Place signages in front of the residents' rooms in the Yellow and Red Zone to remind staff to wash their hands, don (put on) and doff (take off) Personal Protective Equipment (PPE - gown, gloves, mask and face shield) before and after providing care to the residents. These deficient practices had the potential to result in the spread of COVID-19 from Residents 1, 2, 3, 4, 5, 6, 7 placing Residents 8, 9, 10, 11, 12, and staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: A review of Resident 1's Face Sheet indicated the facility admitted the resident on 7/16/20 with diagnoses that included acute respiratory disease (ARD, fluid collection in the lungs' air sacs, depriving organs of oxygen). A review of Resident 1's laboratory (lab/test) result, dated 7/9/20, indicated the resident tested positive for COVID-19. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 7/29/20 with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs, which may be filled with fluid). A review of Resident 2's lab result, dated 7/21/20, indicated the resident tested positive for COVID-19. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 7/29/20 with diagnoses that included chronic obstructive pulmonary disease (COPD, type of obstructive lung disease characterized by longterm poor airflow). A review of Resident 3's lab result, dated 7/19/20, indicated the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 tested positive for COVID-19 A review of Resident 4's Face Sheet indicated the facility admitted the resident on 7/31/20 with diagnoses that included congestive heart failure (CHF, a condition in which the heart's function as a pump is inadequate to deliver oxygen to the body). A review of Resident 4's lab results, dated 7/27/20, indicated the resident tested positive for COVID-19. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/7/20 with diagnoses that included pneumonia. A review of Resident 5's lab result, dated 7/30/20, indicated the resident tested positive for COVID-19. A review of Resident 6's Face Sheet indicated the facility admitted the resident on 7/31/20 with diagnoses that included ARD and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 6's lab result, dated 7/24/20, indicated the resident tested positive for COVID-19. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 8/12/2020 with diagnoses that included ARD. A review of Resident 7's lab result, dated 7/30/20, indicated the resident tested positive for COVID-19. A review of Resident 8's Face Sheet indicated the facility admitted the resident on 7/28/20 with diagnoses that included end stage renal disease [ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis which requires renal dialysis (procedure to remove metabolic waste products or toxic substances from the bloodstream)]. A review of Resident 8's lab FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 result, dated 8/3/20, indicated the resident tested negative for COVID-19. A review of Resident 9's Face Sheet indicated the facility admitted the resident on 7/28/20 with diagnoses that included ulcerative colitis (inflammatory bowel disease). A review of Resident 9's lab result, dated 8/3/20, indicated the resident tested negative for COVID-19. A review of Resident 10's Face Sheet indicated the facility admitted the resident on 7/31/20 with diagnoses that included CHF. A review of Resident 10's lab result, dated 8/3/20, indicated the resident tested negative for COVID-19. A review of Resident 11's Face Sheet indicated the facility admitted the resident on 8/6/20 with diagnoses that included ESRD and dependence on renal dialysis. A review of Resident 11's lab result, dated 7/15/20, indicated the resident tested negative for COVID-19. A review of Resident 12's Face Sheet indicated the facility admitted the resident on 8/7/20 with diagnoses that included humerus fracture (a break of the bone in the upper arm). A review of Resident 12's lab result, dated 8/10/20, indicated the resident tested negative for COVID-19. 1. During the initial observation with ICN 1 on 8/13/20, at 11:10 a.m., Residents 1's, 2's, 3's, 4's, 5's, 6's, 7's, 8's, 9's, 10's, 11's, and 12's' Rooms were located in the same hallway of Unit 100, designated as Red and Yellow Zones. There was no physical barrier to separate the Red and Yellow Zones. A concurrent interview was conducted; ICN 1 stated there was no physical barrier to separate the Red and Yellow Zones. ICN 1 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 Residents 1's, 2's, 3's, 4's, 5's, 6's, and 7's rooms with opened doors are in Yellow Zone. ICN 1 stated Residents 8's, 9's, 10's, 11's and 12's rooms with closed doors and a red sticker are in the Red Zone. During an observation of the Yellow and Red Zones on 8/13/20, at 11:25 a.m., LVN 1 walked out of Resident 2's room (Red Zone) into Resident 11's room (Yellow Zone). LVN 1 spoke with Resident 11, then walked back to the Nursing Station 1, in front of Resident 2's room. A concurrent interview was conducted; LVN 1 stated there was no barrier or separation between the Yellow and the Red Zones. LVN 1 stated the facility used the residents' room doors as barriers. LVN 1 stated residents' rooms in the Yellow Zone had opened doors while residents' rooms in the Red Zone had closed doors. During a telephone interview on 8/13/20 at 2:10 p.m., Public Health Nurse 1 (PHN 1, local public health nurse who was assigned to work with the facility) stated she did not know facility's staff were using residents' room doors as a barrier between Yellow and Red Zone. PHN 1 stated closing of the residents' room doors is not enough as barriers. PHN 1 stated she recommended for the facility's Administrator to place clear barriers between the Yellow, Green, and Red Zones. During a review of the PHN's recommendation, dated 4/28/2020, indicated based on the Health Officer Order (HOO, measures taken to preserve the health of the public) residents who tested positive for COVID-19 or displayed symptoms associated with COVID-19 must be physically separated from those who do not have confirmed or suspected COVID-19. During an interview with the Administrator on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 8/13/20 at 2:40 p.m., she stated Residents 1's, 2's, 3's, 4's, 5's, 6's 7's rooms are designated for confirmed COVID 19 residents (Red Zone). The Administrator stated Residents 8's, 9's 10's, 11's 12's and other rooms' in the same hallway were designated for the Yellow Zone. The ADM stated he assumed closing residents' room doors was enough to use as a barrier between the Yellow and Red Zones. During an interview with the DON on 8/14/20 at 4:50 p.m., she stated a barrier should have been placed to separate the Yellow from the Red Zone. The DON stated separation is needed to avoid the spread of infection and for residents' safety. The DON stated a barrier or divider is needed to distinguish the different zones to prevent intermingling (mixing) of the positive COVID-19 residents (Red Zone) from the non-COVID-19 residents (Green Zone) and the suspected COVID-19 resident (Yellow Zone). A review of the facility's undated Mitigation Plan, under the section "Designation of Space for COVID-19 Positive and Suspected for COVID-19," indicated for the facility to have a designated space (COVID Unit) to care for residents with confirmed COVID- 19. The designated space ideally will be self-contained and easily definable by its barriers (e.g. Fire Doors). The MP indicated the barriers are used to limit movement in and out of COVID area to other non-COVID areas. 2. During an observation of the Yellow and Red Zones on 8/13/20, at 11:25 a.m., LVN 1 walked out of Resident 2's room (Red Zone) into Resident 11's room (Yellow Zone). LVN 1 spoke with Resident 11, then walked back to the nursing station in front of Resident 2's room. A concurrent interview was conducted; ICN 1 stated LVN 1 was assigned to care for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 residents in both Yellow and Red Zones. During an interview on 8/13/20 at 11:35 a.m., LVN 1 stated she was assigned by the DON to care for all residents in Unit 100 where both Yellow and Red Zones are located. LVN 1 stated Unit 100 housed Residents 1, 2, 3, 4, 5, 6, 7 who tested posited for COVID-19 and Residents 8, 9, 10, 11, and 12, who tested negative for COVID-19. During a telephone interview on 8/13/20 at 2:10 p.m., PHN 1 stated she recommended to the facility's Administrator that there should be no sharing of staff between COVID and NonCOVID residents. A review of the facility's Shift Assignment, dated 8/14/20, indicated one LVN was assigned to Unit 100 to take care of residents from both Yellow and Red Zones per each shift. During a review of the facility's "Shift Assignment," dated 8/14/20 and a concurrent interview with the Administrator on 8/14/20 at 4:50 p.m., she stated LVN1 was assigned to care for both suspected COVID and confirmed COVID residents. The ADM stated mixing staff can be a source of spreading infection to the residents who had not yet confirmed with COVID-19. A review of the facility's undated Mitigation Plan, under section "Designation of Space for COVID-19 Positive and Suspected for COVID-19," indicated the facility will have a designated Health Care Provider to work in COVID Unit. The MP indicated staffing with at least a nursing assistant and a Licensed Nurse will be assigned to care for the residents. A review of the facility's policy, titled "Facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus (COVID-19) in Skilled Nursing Facility," dated 4/13/2020, indicated for facility to have assigned staff specially to care for only suspected or confirmed COVID-19 residents. 3. During an observation at the facility's entrance area on 8/13/20 at 11:00 a.m., Greeter 1 (GRT1) requested Surveyor 1's name and type of visit. GRT 1 checked Surveyor 1's temperature and did not screen for signs and symptoms of COVID 19. GRT 1 then proceeded to take PA 1's temperature who was next person in line. A review of the facility's Visitor Log, dated 8/13/20 for the 7 a.m. - 3 p.m. shift, indicated screening questions for signs and symptoms of COVID-19 including respiratory illness, fever, chills, contact with positive COVID-19 residents, international travel, were left blank for Surveyor 1 and the PA 1. During an interview on 8/14/20 at 3:30 p.m., GRT 1 stated she filled out the blank sections on the Visitor Log dated 8/13/20 from the 7 a.m. -3 p.m. shift later although she did not ask the screening questions because she did not want to get in trouble. GRT1 stated she was aware that she should carefully screen staff and visitors prior to entering the facility. During an interview with ICN 1 on 8/14/20 at 4:30 p.m., she stated GRT 1 need to ask all visitors and surveyors the screening questions prior to entering the facility. ICN 1 stated careful screening is a source of control of who comes in and out of the facility to prevent COVID 19 and or other diseases from spreading in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055845 (X3) DATE SURVEY COMPLETED 08/14/2020 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 the facility's undated job description for Health Screener/Greeter indicated the health screeners need to check temperature and ask basic health screening questions to all employees and visitors before they enter the facility daily. 4. During initial tour of the Yellow and Red Zones on 8/13/20 at 11:10 a.m., there were no signages posted to remind facility's staff to perform hand washing, don and doff PPEs for infection control precautions. A concurrent interview was conducted; ICN 1 stated there were no signages in front of the resident's room in the Yellow and Red Zones. During an interview on 8/13/20 at 2:35 p.m., ICN 1 stated residents in the Yellow or Red Zones are on contact and droplet isolation (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing). ICN 1 stated signages or reminders are important for staff to help control the spread of infection. A review of the facility's undated Mitigation Plan, titled "Designation of Space for COVID-19 Positive and Suspected for COVID-19," indicated for COVID Unit to have clear signages at the entrance and exit to instruct HCP to don and doff proper PPE and perform hand washing or apply Alcohol-Based Hand Sanitizer Procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DC4011 Facility ID: CA970000081 If continuation sheet 11 of 11