Other·March 24, 2017

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 Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor Federal I.D. No. 36627 RN. HFEN Surveyor Federal I.D. No. 36500 RN. HFEN Surveyor Federal I.D. No. 36501 RN. HFEN Resident Census: 42 Resident Sample: 11 Highest S/S = G

F250 SS=D PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.15(g)(1)

F250 01/12/2017 The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility's social services failed to follow-up with the resident's complaint about missing dentures and dental recommendations for one out of 11 sample residents (Resident 1). This deficient practice had the potential for loss 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: 06WL11 Facility ID: CA970000085 If continuation sheet 1 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 weight due to inability to chew food without dentures and to impact on the resident's self image. Findings: According to admission records, Resident 1 was originally admitted to the facility on May 15, 2012 and readmitted on April 2, 2013, with diagnosis that included heart failure, pain, high blood pressure, and difficulty in walking. A review of a Minimum Data Set [MDS- a comprehensive assessment and screening tool], dated October 6, 2016, indicated that Resident 1 had moderately impaired cognition, had the ability to make self understood and was able to understand others. The MDS also indicated the resident needed extensive assistance with activities of daily living, supervision for eating, and used a wheelchair for mobility. On November 11, 2016 at 9 a.m., an interview, Resident 1 stated she had lost her lower dentures and she had informed unnamed facility staff member. However, the resident stated she had not heard a response yet. Resident 1 also stated that she had a visit from the dentist who looked at her upper dentures but did not do much. Resident 1 stated that it had been a while since she had lost her lower dentures, and that she had been asking the facility staff (unable to recall the names) regarding her missing lower dentures, but nothing had been done or said. She further stated that she wanted to have her lower dentures to be able to eat. On November 11, 2016 at 12:20 p.m., during lunch observation, Resident 1's tray was noted to include, rice, fish, zucchini, mixed vegetable salad (canned), vanilla pudding, one cup of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 2 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 milk, water, tea, and a small bowl of noodle soup. Upon closer observation, it was noted that Resident 1 was not able to chew the fish and zucchini served to her and she was removing it from out of her mouth. When asked why the resident did not swallow the food, she stated that it was difficult for her to chew the food. On November 11, 2016 at 1:15 p.m., during an interview, the Director of Social Services (DSS) stated that she was not aware of the time when Resident 1's lower dentures were lost, and that she had not contacted the responsible party in notifying them about the lost dentures or to ask wether the family wanted to pay privately for new lower dentures. During another interview on the same date at 3 p.m., the DSS stated that Resident 1's upper and lower dentures were replaced on October 23, 2015 and that there was a recall for 12 months. She further stated that she was not able to recall that the residents lower dentures were missing and that she must have missed the treatment recommendations provided by the dentist for follow-up with the residents lower dentures and the family on several occasions. On November 11, 2016 at 4:30 p.m., during a phone interview, Resident 1's alternate responsible party 1 (ARP 1) stated that the facility had contacted the family today and notified about the missing lower dentures and asked if the family would like to pay in cash for replacing the lower dentures. ARP 1 stated that the family was not able to pay the cost for the dentures at the time. She further stated that there had not been any previous contacts from the facility in regards to the dentures. On November 11, 2016, a review of the facility's theft and loss log in the presence of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 3 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 SSD, the only log that was found included a lost item which was discovered by SSD on September 21, 2015 for full upper dentures. Under the resulted date of October 23, 2015 indicated the dentures were in the process of being made. A review of the treatment notes dated March 31, 2016, indicated the resident had lost and was requesting full lower dentures. The treatment recommendation indicated that the eligibility for full lower denture to be checked and that the resident was not due for new denture until June 26, 2018. It further indicated to call the family and ask if they would want to pay privately for full lower dentures. A review of the treatment notes dated May 24 ,2016, indicated the resident was requesting private pay for full lower dentures. The treatment recommendation indicated to contact family member and notify that the resident wanted private full lower dentures. A review of a dental follow-up notification which was faxed to the Social Services from the dental office, dated June 20, 2016, indicated a treatment recommendation of private full lower denture and that as of date, they had not received any response from the responsible party (RP) after three attempts of calling on May 27, 2016, June 1, 2016, and June 15, 2016. Another review of a dental follow-up notification which as faxed to the Social Services from the dental office, dated November 11, 2016, indicated a treatment recommendation of new full upper and lower dentures, and that the resident was not eligible for new dentures until May 10, 2018, and a reline for full upper denture was done on August 5, 2016. However, there was no follow-up to implement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 4 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 the recommendation to have the resident dentures replaced. A review of the facility's policy and procedure with a revision date of December, 2010, titled "Social Services" indicated that the facility provided medically related social services to assure that each resident can attain or maintain his or her highest practicable physical, mental, or psychosocial well-being. The Director of Social Services is a qualified social worker and responsible for consultation to allied professional health personnel regarding provisions for the social and emotional needs of the resident and family, an adequate record system for obtaining, recording, and filing of social service data, and assistance in meeting the social and emotional needs of residents. This policy was not implemented timely in order to resolve the resident complaints related to missing dentures.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 01/12/2017 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to identity skin injury to the left arm, next to the arteriovascular shunt [AV shunt- a passageway, that allows blood to flow from an artery to a vein without going through a capillary network used to access FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 5 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 blood for dialysis treatment] caused by an adhesive tape (according to the resident) assess, and notify the physician to obtain treatment instructions. This deficient practice had the potential for a skin infection close to AV shunt used for a hemodialysis (a method for removing waste products such as potassium and urea as well as free water from the blood when the kidneys fail/renal failure) one of 11 sample residents (Resident 10). Findings: On November 1, 2016, at approximately 8:00 a.m., during the initial tour of the facility in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 10 was observed in the room, sitting in the wheelchair. LVN 1 stated Resident 10 goes out for hemodialysis three times a week. During an inspection, a skin injury was observed next to the AV shunt on the left upper arm that measured approximately 2.5 centimeter (cm) in length and 0.25 cm in width. When asked, Resident 10 stated the skin injury was caused by the removal of an adhesive tape applied over the AV shunt dressing. On the same date during an interview with LVN 1 present during the observation, she stated she was not aware of the resident's skin injury and would make a follow-up. A review of the admission record indicated Resident 10 was initially admitted to the facility on May 9, 2016 and readmitted on October 24, 2016, with diagnoses that included congestive heart failure, chronic pulmonary edema, and end stage renal disease (kidney failure). A review of the Minimum Data Set [MDS- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 6 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 comprehensive assessment and screening tool] dated August 16, 2016, indicated Resident 10's cognitive skills (the act or process of knowing, perceiving) were intact and required limited assistance with one person assist with activities of daily living (ADLs) such as transfers, walking in room and corridor, toilet use, personal hygiene, and extensive assistance with one person assist with bathing. A review of the physician's orders dated October 24, 2016, indicated Resident 10 has scheduled hemodialysis on Tuesdays, Wednesdays, and Saturdays. There was a care plan initiated on May 10, 2016, for potential for skin breakdown related to fragile skin, decrease endurance, ESRD (End stage renal disease) with hemodialysis, CHF (congestive heart failure), osteoporosis, history of breast cancer with mastectomy, diabetes mellitus 2 (is a disease characterized by increased blood sugar (glucose) in the body due to inadequate production of insulin- a hormone responsible to keep blood glucose at normal levels), and muscle weakness. The goal of the care plan indicated the resident will remain/minimize skin breakdown by next review for three months. One of the interventions was to check skin for redness, skin tears, swelling or pressure areas and report any signs of skin breakdown. A review of the dialysis communication log between the facility and the dialysis center from November 1, 2016, to November 10, 2016, did not indicate the resident had a skin injury at the AV shunt site related to removal of adhesive tape during dressing change. A review of the nurse's progress notes from October 1, 2016, to November 12, 2016, did not contain documentation of the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 7 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 skin injury on the left arm. On November 12, 2016 at approximately 8:59 a.m., during an interview, the Director of Nursing (DON) also stated she was not aware of the skin injury on the resident's left upper arm but added the resident has sensitive skin. The DON also stated the nursing staff at the facility should have called and asked the dialysis center regarding the skin breakdown on the resident's left upper arm. During a follow-up interview with the DON on the same day at 3:40 p.m., she stated there was no documentation in the dialysis communication log that indicated Resident 10 had a left upper arm skin injury as a result of dressing tape removal related to dressing change of AV shunt.

F315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(d)

F315 01/12/2017 Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure resident who is incontinent of bladder and had a history of urinary tract infection (UTI) would not have recurrent UTI that progressed to sepsis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 8 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 secondary to dehydration by failing to continuously assessed, monitored and evaluate for hydration status by mean of intake and output [I/O - quantified volume of fluid intake and output]. This deficient practice resulted in RSR 13's transfer to GACH, for treatment of UTI, acute kidney injury and with sepsis, dehydration (is condition in which the total body's fluids, inside and outside the vascular system are depleted due to several causes including insufficient fluid consumption) RSR 13 was hospitalized for five days UTI, acute kidney injury and with sepsis and dehydration. RSR 13 was discharged to the skilled nursing facility (SNF) on November 8, 2016. Findings: According to the admission record, RSR 13 was originally admitted to the facility on June 20, 2013 and was readmitted on November 8, 2016 with diagnoses that included hypertension (high blood pressure), congestive heart failure [CHF-a condition in which the heart can't pump enough blood to meet the body's needs], and gastro-esophageal reflux disease (stomach contents come back up into your esophagus causing heartburn). A review of the Registered Dietitian (RD) progress note dated September 29, 2016, indicated RSR 13 estimated fluid needs was 1740-2136 cc per day. The Minimum Data Set [MDS - an assessment and care screening tool], dated October 2, 2016, indicated RSR 13's cognition was severely impaired, required limited assistance and one person assist for eating, and had no impairment to upper and lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 9 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 care plan for recurrent UTI, at risk for recurrence, and was readmitted on October 8, 2016 with UTI. Contributing factors included difficulty swallowing and on thickened liquids, history of UTI, receiving diuretics, poor food intake. The goal was to minimized the risks for recurrent of UTI through next review of three months. The interventions included to encourage fluid intake unless contraindicated and monitor for signs and symptoms of UTI. A review of the Physician Orders for the month of October, 2016, indicated RSR 13 was on three diuretic (medications that increase urine output) as follows: 1. Aldactone 25 milligram (mg) daily. 2. Lasix 40 mg daily. 3. Zaroxolyn 2.5 mg daily. These medications (diuretics) have the potential to deplete the resident's fluid and there was no evidence that the resident's fluid intake and output were continuously evaluated to provide the volume of fluids as assessed by the RD. A review of the fluid intake with meals for the month of October, 2016, indicated RSR 13 had an average daily fluid intake of 831 cc's and this was a deficit of 810 cc (1740-831=810) per day for the entire month. A review of the laboratory test results dated October 5, 2016, indicated the following: 1. An elevated BUN [blood urea nitrogen- a test measures the amount of nitrogen waste in your blood] 44 mg/dl high (reference range 7-23 mg/dl) 2. Creatinine (an important indicator of renal/kidney health) 1.5 mg/dl high (reference FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 10 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 range 0.6-1.4 mg/dl) 3. An increased BUN/Cr ratio of 29 (reference range 5-20 mg/dL). A BUN/Cr ratio of 20:1 to 24:1 is an indicator for impending dehydration. A BUN/Cr ratio greater than or equal to 25:1 mg/dL is an indicator for actual dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, Page 47. A review of the urine specimen test result reported to the facility on October 9, 2016, indicated: Nitrite was positive (reference range is negative) which indicate that the cause of the UTI is a gram negative organism and bacteria was many (reference range is none). Licensed Nurse received and order for oral antibiotic on October 10, 2016 at 6:43 p.m. The first dose of antibiotic was administered on October 11, 2016 (two days after the result of the urine specimen). While the resident had insufficient fluid intake to maintain hydration from October 1, to October 5, 2016, as evidence by the above abnormal laboratory test results, there was no documented evidence that indicated the physician was notified in order to obtain timely treatment instruction(s). A review of the urine specimen test result reported to the facility on October 9, 2016, indicated Nitrite was positive and many bacteria which indicate RSR had a UTI. The resident was treated with oral antibiotic on October 10, 2016 at 6:43 p.m. The first dose of antibiotic was administered on October 11, 2016, two days after the result of the urine specimen. Following the order of the oral antibiotic to treat the UTI, the RD's instruction FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 11 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to provide 1740-2136 cc per day was not implemented. A review of the faxed document sent to the physician on October 18, 2016, indicated the resident was losing weight approximately seven pounds, not eating well, family providing meals but resident refusing it, resident was eating approximately 20 percent of all meals. According to the physician's response dated October 18, 2016, received via fax, orders for laboratory tests for complete blood count (CBC), chemistry, urine analysis, urine culture was obtained. A review of the Laboratory test result dated October 19, 2016 indicated the following: 1. An elevated blood Sodium of 137 mEq/L (reference range 135-145) 2. An elevated BUN 63 mg/dl high (reference range 7-23) 3. An elevated Creatinine mg/dl 2.0 (reference range 0.6-1.4) 4. An increased BUN/Cr ratio 32 (reference range 5-20 mg/dL). A BUN/CR ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47). 5. Urinalysis test result indicated positive nitrite (reference range negative), trace leukoestrase (reference range negative), WBC (white blood cells) of 2-5 (reference range negative), and many bacteria (reference range none), suggestive of UTI. The urine test results were faxed to the physician. However, there was no follow-up to obtain treatment instruction(s). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 12 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 another Laboratory urine test result dated October 21, 2016, indicate RSR 13's urine specimen resulted in positive nitrite, moderate leukoestrase, WBC greater 100 (reference range 0-2), and many bacteria (reference range none). The physician was notified and an order to administer Rocephin 1 gram I.M. (intramuscular antibiotic) daily for five days was obtained. A review of the fluid intake with meals for the month of November, 2016, indicated RSR 13 had an average daily fluid intake of 1492 cc, and therefore, resident had a fluid deficit of 248 cc per day for November 1 and 2, 2016. A review of the last laboratory test results dated November 3, 2016, indicated the following indicators for dehydration: 1. An elevated blood Sodium 151 mEq/L 2. An elevated blood BUN 105 mg/dl critical high 3. An elevated blood Creatinine 3.6 mg/dl BUN/Cr ratio 29 4. A urine osmolality of 345.5 mosm/kg (this is higher than previous of 301.8 mosm/kg) which indicated RSR 13's urine was more concentrated. Although the resident's laboratory test results indicate critical signs of dehydration, treatment for dehydration was not initiated. One of the complications associated with dehydration is urinary tract infections (AJN, American Journal of Nursing: June 2006 Volume 106 - Issue 6, pages 40-49. Delayed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 13 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 treatment of dehydration may lead to acute renal failure, which is a sudden decrease in renal function which, if uncorrected, can lead, to irreversible tubular necrosis [kidney failure (American Journal of Nursing, May 1999- Vol. 99-Issue 5 page 66-69]. A review of the Change of Condition record dated November 3, 2016, indicated RSR 13 was transfer to the GACH due to abnormal laboratory results. A further review of the History and Physical from the general acute care hospital (GACH) dated November 3, 2016, obtained from the GACH indicated RSR 13 was brought to the emergency department because of abnormal laboratory test results. A review of the History and Physical from the general acute care hospital dated November 3, 2016, indicated RSR 13 was noted to have UTI with sepsis (a systemic infection in which the body has a severe response to bacteria), dehydration, and acute kidney injury. The resident had an elevated BUN level of 106 mg/dl and Creatinine 3.7 mg/dl., elevated Sodium of 149 mEq/L RSR 13 was hospitalized for UTI with sepsis and dehydration for five days and discharged to the skilled nursing facility (SNF) on November 8, 2016. Cross refer to F327.

F323 SS=E FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 01/12/2017 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 14 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible by failing to: 1. Ensure to a bed-alarm and a wheelchairalarm were applied and turned on, checked and monitored for proper functioning for Residents 4 and 6 who have histories of falls. 2. Ensure that the Resident 3 who had a diagnosis of epilepsy (seizure disorder) had both bedrails padded to prevent a potential injury. 3. Ensure that the medication cart is locked at all times and not accessible to unauthorized and non-licensed person(s) and visitors. These deficient practices had the potential for accident hazards. Findings: a. On November 11, 2016 at approximately 9:45 a.m., during an observation tour of the facility, Resident 4 was observed ambulating using a front wheel walker (FWW) with the Restorative Nursing Assistant 9 (RNA 1). RNA 1 was on the resident's left side holding onto the residents safety belt placed around the resident's waist and at the same time pushing the wheelchair (W/C) behind the resident. There was a W/C pad alarm that had a red light blinking attached to the back of the wheelchair. Resident 4 was observed taking a break from ambulating and sat on the W/C. When FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 15 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 4 stood up to resume walking with RNA 1, the w/c alarm did not sound off. During an interview with the RNA at the time of the observation, when asked why the alarm did not go off, she stated it should have alarmed, because its on. When RNA 1 was asked what the red blinking light indicate, RNA stated the w/c alarm is on. RNA 1 asked the resident to sit on the w/c and had her stand up to see if the alarm would go off. When Resident 4 stood up, the alarm still did not go off. RNA 1 then proceeded to rearrange the cushion and sheets on the W/C and only then did the alarm go off. RNA 1 stated she will let the charge nurse and central supply know that the resident's w/c pad alarm need to be changed because it was not functioning. A review of the admission record indicate Resident 4 was admitted to the facility on November 20, 2016, with diagnoses that included difficulty walking, heart failure, abnormal posture, and history of falling. The Minimum Data Set [MDS-a comprehensive assessment and screening tool] dated August 25, 2016, indicated Resident 4's cognitive skills (the act or process of knowing, perceiving) were moderately impaired and required extensive assistance with one person assist with activities of daily living (ADLs) such as bed mobility, dressing and toilet use, and limited assistance with one person assist with personal hygiene, locomotion on and off unit, and bathing. The MDS also indicated Resident 4 was frequently incontinent of urine and always continent of bowel. A review of the facility fall log from January 1, 2016 to November 11, 2016 indicated Resident 4 had falls on the following dates: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 16 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 1. On January 6, 2016 2. On September 15, 2016 3. On November 10, 2016 A review of the fall risk assessment dated November 11, 2016, indicated a score of 14. According to the assessment, a score of 14 represents Resident 4 was at moderate risk for fall. There was a physician order on January 8, 2016 for a pad alarm while on bed and on W/C for safety secondary to repeatedly getting up from bed/W/C without assistance and to alert staff if resident is getting up unassisted every shift. Resident 4 had a care plan revised on November 21, 2014, for potential for injury related to fall risk as evidenced by presence of fall risk factors which included: history of fall, poor safety judgment, impaired standing balance, psychotropic drug use. The goal of the care plan was for the resident to have no major injuries from fall. The interventions included to apply alarm on W/C and pad alarm on bed and to assist resident to the bathroom before breakfast, assist with perineal care, and ensure call light is within her reach. On November 11, 2016 at approximately 12:30 p.m., during an interview with Resident 4, in the presence of a family member, who provided translation, Resident 4 stated that on her recent fall on November 10, 2016, at approximately 6:30 a.m., she used the call light to ask assistance to go to the bathroom. Resident 4 stated she got out of the bed unassisted because no one came to answer the call light. On November 12, 2016, at approximately 3:45 p.m., during an interview with the Director of Nursing (DON), she stated the reason the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 17 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 alarm did not go off when Resident 4 stood up from the W/C was because the pad alarm was not placed properly in the W/C. The DON stated the pad alarm should not be under the pillow so that the sensor will be able to detect when Resident 4 is getting up from the W/C. b. A review of the admission record indicated Resident 3 was admitted to the facility on June 22, 2016, with diagnoses that included intracranial abscess (infection in the brain), encephalopathy and epilepsy (seizure disorder). On November 11, 2016, at approximately 8:00 a.m., during the initial tour of the facility Resident 3 was observed in bed watching television. Resident 3's right bedrail was padded and the left bedside rail was not spaded. A review of the Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 29, 2016, indicated Resident 3's cognitive skills (the act or process of knowing, perceiving) were intact and required extensive assistance with one person assist with activities of daily living (ADLs) such as transfers, bed mobility, locomotion on and off unit, toilet use, personal hygiene, dressing and bathing. There was a plan of care initiated on July 27, 2016, for risk for injury related to seizure activity. The goal of the care plan was the resident will have minimal injuries when seizure activity occurs daily for three months. The interventions included protect environment when having a seizure and pad siderails as needed. During an interview with the DON on November 12, 2016, at Resident 3's bedside, DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 18 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 showed surveyor the left siderails pad which was placed against the left side of the wall in the resident's room. DON stated Resident 3 should have both side rails padded. c. According to the admission record, Resident 6 was admitted on October 20, 2015 with diagnoses that included urinary tract infection, difficulty swallowing, high blood sugar and dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). The Minimum Data Set [MDS - an assessment and care screening tool], dated January 26, 2016, indicated Resident 6 was moderately impaired in cognition for daily decision making and required extensive care in activity of daily living. Resident had a history of fall with no injury. There was a physician order dated October 20, 2015, indicated for a tab alarm in bed and in wheelchair to alert staff of unassisted transfer/ambulation. Monitor placement and function every shift. A review of the care plan for potential for injury related to fall risk as evidence by presence of fall risk factors that included history of fall was initiate on October 21, 2015, indicated the goal was not to have major injuries from fall for three months. The interventions included to have 3/4 side rails up in bed as enabler for mobility and to keep resident in frequently monitored areas. However, plan of care did not include tab alarms for the bed and for the wheelchair. A review of the Fall Risk Assessment dated November 8, 2016, indicated Resident 6 was assessed as moderate risk for fall. On November 11, 2016 at 7:45 a.m., during the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 19 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 initial tour, Resident 6 was observed sleeping in her bed. When asked Licensed Vocational Nurse 3 (LVN 3) to check for the functioning of the alarm, LVN 3 stated the alarm was turned off. On November 11, 2016 at 9:00 a.m., Resident 6 was observed sitting in her wheelchair. When asked Restorative Nursing Assistant 2 (RNA 2) to check the tab alarm on the wheelchair, RNA 2 stated the alarm was turned off. On November 11, 2016 at 9:05 a.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated the alarms are checked every shift to make sure that it is working. LVN 3 stated that someone might have forgotten to turn it on. According to the facility's revised April 2013 policy and procedure titled, "Falls-Clinical Protocol," indicated the staff and physician will identify pertinent interventions to try to prevent subsequent falls. d. On November 12, 2016 at approximately 8:30 a.m., during a medication pass observation, the medication cart was observed un locked when unattended after Licensed Vocational Nurse 3 (LVN 3) finished preparing the medication for administration. On November 12, 2016 at approximately 9:00 a.m., during an interview, LVN 3 stated she should have locked the medication cart before going into the resident's room to administer the medications.

F325 SS=E MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE CFR(s): 483.25(i)

F325 01/12/2017 Based on a resident's comprehensive assessment, the facility must ensure that a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 20 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent unplanned progressive weight loss for one Random Sample Resident (RSR 13) and for three of 11 sample residents (Residents 1, 8, 6) and by failing to: 1. Ensure resident was offered meal substitute and assist with meals/feeding as indicated on the plan of care when the meal intake was less than 50 percent and/or meal refusal and supervised resident's meal consumption and accurately document the daily intake as indicated in the care plan (RSR 13, Residents 6,8,1). 2. Ensure the Registered Dietitian (RD) was notified when facility did not have the nourishment (Magic Cup) that was recommended so that an alternative may be recommended (RSR 13). 3. Ensure that Resident 1's chewing problem related to missing dentures was resolved timely in order to prevent the potential for continued weight loss. These deficient practices had potential to continued progressive unplanned weight loss FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 21 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 and had the potential for complications associated with altered nutrition. Findings: a. According to the admission record, RSR 13 was originally admitted to the facility on June 20, 2013 and was readmitted on November 8, 2016 with diagnoses that included hypertension (high blood pressure), congestive heart failure [CHF-a condition in which the heart can't pump enough blood to meet the body's needs], and gastro-esophageal reflux disease (stomach contents come back up into your esophagus causing heartburn), sepsis, acute kidney failure. According to the Registered Dietitian's (RD) Nutritional Assessment form dated July 15, 2015, indicated RSR 13's weight was 196 pound (lbs.). The RD recommended continuing oral intake to meet at least 75 percent of the estimated nutritional needs during facility stay. The Minimum Data Set [MDS- an assessment and care screening tool] dated October 2, 2016, indicated Resident's height was 64 inches and weight was 172 pounds. RSR 13's cognition was severely impaired, required limited assistance and one person assist for eating, and had no impairment to upper and lower extremities. There was a progressive weight loss of 24 pounds between July 15, 2015 and October 2, 2016 (196 - 172 = 24) in approximately fifteen months). A review of the care plan for potential for further nutritional deficit related to poor appetite, refusing to eat, choosy eater initiated on January 6, 2015 and was not updated until November 15, 2016, indicated the goals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 22 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 included resident will consume 50-100 percent of meals. The interventions included to assist with meals/oral intake if indicated and offer meal replacement/substitutes if meal consumption is less that 50 percent. A review of the RD's progress notes from May 3, 2016 to May 25, 2016, indicated recommendation for Vitamin C daily for wound healing and Zinc Sulfate 220 milligram for two weeks for wound healing, snack twice a day at 10:00 a.m. and 8:00 p.m. (resident's preference), sugar free HPN four ounces twice a day with breakfast and lunch (for poor oral intake, weight loss, and elevated blood glucose), and discontinue no added salt to diet. Resident will be provided yogurt with all meals (resident likes yogurt and has good intake). A review of the RD's progress notes dated September 29, 2016, recommendation included to discontinue pureed consistent carbohydrate (CCHO) diet with nectar thick liquids to pureed diet with nectar thick liquids (liberalization due to poor intake) and Magic Cup (four ounces daily at 2:00 p.m. A review of the Physician Order for the month of October, 2016, indicated RSR 13 was ordered for puree consistent carbohydrate diet with nectar thick liquids including soups with meals for dysphagia (difficulty swallowing). Resident requires supervision during intake, slow rate during oral intake, and alternate liquids and solids. On November 11, 2016 at 7:40 a.m., RSR 13 was observed sleeping in bed. There was a full thickened water pitcher and a glass of thickened water on the bedside table. On November 11, 2016 at 12:10 p.m., during a lunch observation, RSR 13 was feeding herself FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 23 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 in the dining room, resident consumed 100 percent of the four ounces of milk, 10 percent of the four ounces of juice, 75 percent of the eight ounces of water, but resident did not eat anything from her entree. RSR 13 wheeled herself out of the dining room. There were three staff members in the dining room [two Certified Nursing Assistants (CNAs) and one Restoration Nursing Assistant (RNA)], non of them assisted the resident, encouraged her to eat and/or offered RSR 13 a food substitute since RSR 13's cognition was severely impaired. A review of the meal intake for the month of October, 2016, indicated RSR 13 had 65 meals that were documented as less than 50 percent and five meals refusal. On November 11, 2016 at 12:45 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated RSR 13 was not a feeder. A review of RSR 13's meal card, indicated resident was on a puree nectar thick liquid diet, cranberry juice, high protein nourishment (HPN), and yogurt. During the same observation, RSR 13's HPN was not on her lunch tray. On November 11, 2016 at 12:30 p.m., during an interview, Dietary Supervisor (DS) stated RSR 13's HPN was missed on her lunch tray. On November 11, 2016 at 1:35 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated RSR 13 consumed 20 percent of her lunch. When asked what you do when the RSR 13 only consumed 20 percent of the meal, CNA 2 stated we should offered resident something else to eat or give resident the house shake. CNA 2 stated he did not offer resident a substitution. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 24 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On November 13, 2016 at 10:00 a.m., during an interview, Director of Nursing (DON) stated RNA was supposed to encourage resident to eat and offered substitution when resident did not eat enough. Also, a Licensed Nurse has to be present during the meal time in the dining room at all times in case of emergency. However, during a lunch observation on November 11, 2016, the RNA was feeding a resident; the Licensed Nurse came in once and left the dining room. On November 13, 2016 at 4:30 p.m., during an interview, resident's daughter stated RSR 13 was very thirsty today. RSR 13 wanted to drink more water. Resident's daughter further stated that resident cannot ask for water when resident is thirsty. However, when the resident's food consumption declined, cannot ask for food or fluids due to impaired cognition, the facility did not consider to place the resident on a special feeding program in order to prevent further weight loss. A review of the Medication Administration Record for the month of October, 2016, indicated Magic Cup daily at 2:00 p.m. was ordered on October 2, 2016 at 5:58 p.m. However, it was crossed out to indicate the order was clarified on October 3, 2016. On November 13, 2016 at 5:00 p.m., during an interview, DON stated they (the facility) did not have supply of Magic Cup. When asked if the RD was notified, DON stated no. According to the facility's revised December, 2011 policy and procedure titled, "Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol," indicated staff evaluate the care plan to determine if the interventions are being implemented and whether they are effective in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 25 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 attaining the established nutritional and weight goals and observing for and reporting significant weight gain or loss b. According to the admission record, Resident 6 was admitted to the facility on October 20, 2015 with diagnoses that included urinary tract infection, difficulty swallowing, high blood sugar and dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). The Minimum Data Set [MDS - an assessment and care screening tool], dated January 26, 2016, indicated Resident 6 was moderately impaired in cognition for daily decision making and required extensive care in activity of daily living. Resident height and weight was 58 inches and 106 pounds respectively. A review of the care plan potential for nutritional risk related to poor appetite and medications that may alter appetite initiated on October 21, 2015 and was revised November 8, 2016, indicated the goals included for resident to consume 75-100 percent of meals, remain adequately hydrated without signs and symptoms of dehydration for three months, and moderate weight loss/gain of 2-4 pounds per month. The interventions included to assist with meals/oral intake if indicated and offer meal substitutes if meal consumption is less than 75 percent. A review of the Registered Dietitian Progress Notes dated April 13, 2016, indicated Resident 6 was on a Fortified mechanical soft no added salt high protein diet. Resident's estimated nutritional needs included 1340-1608 kilocalories, 43-54 grams of protein, and 13401608 milliliters of fluids per day. No new recommendation given at this time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 26 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 Physician Orders indicated the following: 1. On October 26, 2015 - high protein nourishment three times a day between meals. 2. On November 27, 2015 - ice cream with lunch and dinner two times a day. 3. On May 31, 2016 - fortified mechanical soft high protein diet. On November 11, 2016 at 12:10 p.m., during a lunch observation in the dining room, Resident 6 was missing the fortified milk on the tray. During an interview, Dietary Supervisor (DS) stated resident did not have the fortified milk on the tray and DS will bring one for the resident. According to the facility's revised December 2011 policy and procedure titled, "Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol," indicated supplementation strategy was to increase a resident's intake of nutrients and calories that may include fortification of foods. c. On November 11, 2016 at 5:00 p.m., during an observation, Resident 8's dinner tray was placed on the bedside table that was not accessible for the resident. A follow up observation at 5:23 p.m., the resident's tray was still on the bedside table. On November 11, 2016 at 5:25 p.m., during an interview, Certified Nursing Assistant 5 (CNA 5) stated she passed out other trays and then come back. CNA 5 also stated resident cannot eat by himself. According to the admission record, Resident 8 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 27 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 was admitted to the facility on February 26, 2014 and was readmitted on July 18, 2016 with diagnoses that included stroke with left side paralysis, left hand contracture, and high blood glucose. The Minimum Data Set [MDS - an assessment and care screening tool],dated January 26, 2016, indicated Resident 8 was severely impaired in cognition for daily decision making, required extensive care in activity of daily living, and had impairment on one side of the upper extremity. Resident height and weight was 62 inches and 148 pounds respectively. There was a physician order dated September 2, 2016 for consistent carbohydrate, no added salt, mechanical soft diet. A review of the care plan for therapeutic diet was initiated on March 4, 2016, indicated the goals included for resident to be compliance with therapeutic diet. The interventions included record food intake at each meal, offer appropriate substitutes for uneaten food, and to use built up utensils with every meal daily. A review of the care plan for alteration in physical functioning due to decrease endurance, effects of stroke, requires limited to extensive assist with eating was initiated on September 17, 2014 and was revised on July 26, 2016, indicated the goals that included for resident to participate/assist with activity to the highest degrees possible within physical and medical current level of function by next review. The interventions included to set up meals and assist/supervise as needed. According to the facility's revised December 2011 policy and procedure titled, "Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol," indicated functional impairment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 28 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 would most likely needs some form of assistance with eating. Assistance may include ensuring that needed implements (eyeglasses, dentures) are used, providing assistive utensils and devices as identified in the care plan and providing feeding assistance as needed. d. According to admission records, Resident 1 was originally admitted to the facility on May 15, 2012 with a readmission date of April 2, 2013 with diagnosis that included heart failure, pain, high blood pressure, and difficulty in walking. A review of Annual Minimum Data Set [MDS- a comprehensive assessment and screening tool], dated April 11, 2016, indicated that Resident 1 had moderately impaired cognition, had the ability to make self understood and was able to understand others. It further indicated that the resident needed extensive assistance with activities of daily living, limited assistance for personal hygiene, supervision for eating, and used a wheelchair for mobility. The resident's weight was 191 pounds and height was 59 inches. There was a plan of care initiated on January 14, 2015, indicated that the resident had potential for nutritional risk and the goal was for the resident to consume 75-100 percent of meals. The interventions included to assist the resident with meals and oral intake if indicated, offer meal replacement substitutes if meal consumption less than 75 percent. A review of the Quarterly Minimum Data Set [MDS- a comprehensive assessment and screening tool], dated October 11, 2016, indicated that Resident 1 had moderately impaired cognition, had the ability to make self understood and was able to understand others. It further indicated that the resident needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 29 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 extensive assistance with activities of daily living, limited assistance for personal hygiene, supervision for eating, and used a wheelchair for mobility. The resident's weight was 186 pounds and height was 59 inches. There was a progressive weight loss of 5 pounds (191-186=5) between April 11, 2016 and October 11, 2016, in approximately six months. A review of Resident 1's care plan with an initiated date of April 14, 2015 indicated that the resident had decline to receive dentures at times. The interventions indicated to arrange services as desired and requested, to encourage the resident and family to allow the provision of ancillary Services and use of ancillary devices, to involve the family as appropriate in encouraging acceptance of Ancillary services. There was a plan of care initiated on January 12, 2016 indicated that the resident receives therapeutic diet, and mechanically altered diet. The interventions section of the care plan indicated to insert dentures prior to meal if resident uses it, and to record food intake at each meal, offer appropriate substitutes for uneaten food. A review of Resident 1's monthly weight record, indicated that there was a progressive weight loss of 7 pounds (194-181=7) between May and November 2016 in approximately seven months. A review of Resident 1's care plan with an initiated date of October 12, 2015 indicated that all natural teeth lost, prefers not to wear dentures at times, and at risk for poor oral intake. The goals section of the care plan indicated that the resident will consume at least FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 30 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 75 percent of meals without difficulty. The interventions section of the care plan indicated to encourage resident to wear dentures, to monitor for signs and symptoms of dental problems, difficulty with diet texture, decreased or poor intake. It further indicated to provide diet as ordered and monitor intake tolerance to consistency. On November 11, 2016 at 9 a.m., during resident interview, Resident 1 stated that she had lost her lower dentures, had notified staff, and had not heard of it yet. She also stated that she had a visit from the dentist who looked at her upper dentures but did not do much. Resident 1 stated that it had been a while since she had lost her lower dentures, and that she had been asking the facility staff (unable to recall the names) regarding her missing lower dentures, but nothing had been done or said. She further stated that she wanted to have her lower dentures to be able to eat. When asked about food, Resident 1 stated when she does not like the food offered, she does not eat it, and the staff remove her tray without offering any alternatives or substitutes. Resident further stated that she drinks water which helps her when she gets hungry. On November 11, 2016 at 12:20 p.m., during lunch observation, Resident 1's tray was noted to include, rice, fish, zucchini, mixed vegetable salad (canned), vanilla pudding, one cup of milk, water, tea, and a small bowl of noodle soup. Upon closer observation, it was noted that Resident 1 was not swallowing the fish and zucchini consumed rather was chewing it and removing it from out of her mouth. When asked why the resident did not swallow the food, she stated that it was difficult for her to chew. Resident 1 only had a few bites of the fish and zucchini, drank the water and milk, and left the other items on her tray untouched. None of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 31 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 staff present in the dining room were noted to be observing the resident. When finished, Resident 1 continued to ask the staff in her native language to be assisted out of the dining room, but no one answered or assisted the resident. There were no substitutes food offered to the resident by the staff. On November 11, 2016, after lunch observation at approximately 1 p.m., during an interview, restorative nurses aid (RNA 2) stated that Resident 1 had ate only 20 percent of her lunch. RNA 2 further stated that the residents meal consumption varied, and at times when the resident liked the food she would eat it. She further stated that on average, the resident would eat about 50 percent of her meals. RNA 2 also stated that usually the resident needed encouragement, and with encouragement, the resident would be able to eat more. RNA 2 stated that when resident's don't eat enough, the staff offer them nourishments or substitutes. A review of the facility's policy and procedure revised on December 2011 titled, "Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol," indicated supplementation strategies was to increase a resident's intake of nutrients and calories that may include fortification of foods, providing between-meal snacks or nutritional supplementation. For residents with chewing and swallowing abnormalities, modifications in diet will be ordered, and a review of the underlying problems related to the chewing and swallowing difficulties. Monitoring is also required for resident whose current nutritional status is stable such as recognizing deviations from the residents usual habits and preferences including mealtime habits, snacking and food preferences, observing for and documenting any sustained decline in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 32 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 appetite and or food intake.

F327 SS=G SUFFICIENT FLUID TO MAINTAIN HYDRATION CFR(s): 483.25(j)

F327 01/12/2017 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide sufficient fluid to maintain proper hydration and health for one Random Sample Resident 13 (RSR 13) by failing to: 1. Ensure that RSR 13 who was assessed at risk for dehydration, had poor oral intake, unable to request fluids due to cognitive impairment and who received diuretics (medications that increase urine output), was provided the volume of fluid (1580-1896 cc) daily at set intervals. 2. Monitor RSR 13's health conditions and dehydration-associated indicators, such as abnormal laboratory test results, weight loss, skin conditions, urinary tract infection (UTI), and notify the physician to obtain treatment instruction(s) and to provide timely interventions to correct the reduction or depletion of fluid volume accordingly. This deficient practice resulted in RSR 13's transfer to GACH, for treatment of dehydration (is condition in which the total body's fluids, inside and outside the vascular system are depleted due to several causes including insufficient fluid consumption) and associated health conditions that included UTI, acute kidney injury and with sepsis. RSR 13 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 33 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 hospitalized for among others dehydration for five days and discharged to the skilled nursing facility (SNF) on November 8, 2016. Findings: According to the admission record, RSR 13 was originally admitted to the facility on June 20, 2013 and was readmitted on November 8, 2016 with diagnoses that included dementia (a loss of intellectual and social abilities severe enough to interfere with daily functioning caused due to the degeneration of a healthy brain tissue), hypertension (high blood pressure), congestive heart failure [CHF-a condition in which the heart can't pump enough blood to meet the body's needs], and gastroesophageal reflux disease (stomach contents come back up into your esophagus causing heartburn), sepsis, acute kidney failure. A review of the Minimum Data Set [MDS - an assessment and care screening tool] dated October 2, 2015, RSR 13, had intact cognitive skills, incontinent of bowel and bladder, and had a height and weight of 63 inches and 196 pound respectively. A review of the care plan for risk of dehydration (fluid volume deficit) related to diuretic (medication that increase urine output) initiated on September 12, 2014, not revised/updated until November 14, 2016, indicated the goal was to minimize further risks of dehydration as evidence by good to fair skin turgor and moist mucous membranes daily through next review for three months. The interventions included to keep fluids nectar thick within easy reach, assist to consume as needed, observe for contributing factors of fluid volume depletion such as poor appetite and intake, offer food substitute if intake is below 50 percent, report when meals were refused, and to refer to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 34 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 dietitian for evaluation and recommendations. However, the plan of care was incomplete in that it did not indicate the resident ' s daily fluid requirement, the volume of fluid to be provided to the resident at a set interval and to maintain a fluid intake and output record. A review of the Registered Dietitian's (RD) Nutritional Assessment record dated July 15, 2015, indicated RSR 13's daily fluid requirement was 1580-1896 cc ' s. A review of the RD's reassessment record dated September 29, 2016, indicated RSR 13 ' s daily fluid intake was increased to 1740-2136 cc per day for an specified reason written on the clinical record. Despite the increased fluid needs, the licensed nursing staff did not update the plan of care to indicate the increase in fluid intake, to monitor the resident ' s hydration status by means of an intake and output record. In addition, there was no documented evidence that indicated RSR 13 was provided 1740-2136 cc per day from October 1, to November 2, 2016. On November 13, 2016 at 5:30 p.m., during an interview, the DON stated RSR 13 was not drinking enough fluid, not eating enough, and resident was very weak. When asked if there was documentation of resident's intake and output record when resident was not drinking or eating enough, DON stated " No. " The Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated October 2, 2016, indicated RSR 13's cognition status has changed to severely impaired, required limited assistance and one person assist for eating, and had no impairment to upper and lower extremities. Although the MDS dated October 2, 2016, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 35 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 indicated RSR 13 had impaired cognitive skills, and a diagnosis of dementia, the plan of care was not updated to include interventions to place the resident on special feeding and hydration program to assure the resident would be adequately hydrated since the resident will have challenges to access and/or ask for fluid due to dementia related impaired cognition. A review of the literature indicates, Patients with dementia are at high risk for eating and feeding difficulties and inadequate food and fluid intake. Depending on the severity of their cognitive impairment, they may forget to eat, forget they have eaten, fail to recognize food, or eat things that are not food. They may have difficulty with specific tasks (e.g., removing plate covers and wrappings, knowing what the utensils are for and using them, moving food or fluid to their mouth, chewing, and swallowing). They may have difficulty initiating the eating/drinking process, or they may start eating, get distracted, and fail to finish meals (AJN, August 2008, Vol. 108 No 8 pages 5152). There was no documented evidence that indicated the facility had developed a plan of care based on assessed needs of the resident to meet the resident's challenges to access food and fluids independently, in order to ensure adequate hydration. A review of the physician orders for the month of October, 2016, also indicated RSR 13 was on three diuretic medications (Aldactone 25 milligram (mg), Lasix 40 mg and Zaroxolyn 2.5 mg). These medications have the potential to deplete the resident ' s fluid. However, while RSR 13 was on three diuretics, the licensed nursing staff did not update the plan of care to include interventions to closely evaluate the resident ' s hydration status. The plan of care did not include useful interventions to monitor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 36 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 the resident and to ensure the daily fluid intake as assessed by the RD was met. On November 13, 2016 at 5:30 p.m., during an interview, the DON stated RSR 13 while taking three diuretics that could cause her to be dehydrated, was not drinking or eating enough. Further review of the physician orders dated September 23, 2016, indicated RSR 13 was ordered for puree consistent carbohydrate diet with nectar thick liquids including soups with meals for dysphagia (difficulty swallowing). Resident requires supervision during intake, slow rate during oral intake, and alternate liquids and solids. However, during a lunch observation, on November 11, 2016 at 12:10 p.m. RSR 13 was not assisted or supervised to ensure she consumed adequate fluid intake. According to the Certified Nursing Assistant documentation, resident consumed only 20 percent of meal. On November 11, 2016 at 12:10 p.m., during a lunch observation, RSR 13 was feeding herself in the dining room. The resident consumed the four ounces of milk, 10 percent of the four ounces of juice, and 75 percent of the eight ounces of water. The resident did not eat her entree. RSR 13 wheeled herself out of the dining room. There were three staff members in the dining room [two Certified Nursing Assistants (CNAs) and one Restoration Nursing Assistant (RNA), but none of them was assign to the resident to assist the resident consume her fluids. A review of the fluid intake with meals for the month of October, 2016, indicated RSR 13 had an average daily fluid intake of 831 cc. This was an average of daily fluid intake deficit of 810 cc (1740-831= 810). However, the plan of care was not updated with interventions to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 37 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 increase the resident's fluid intake. A review of the Laboratory test results dated October 5, 2016, had the following indicators for dehydration: 1. An elevated BUN [blood urea nitrogen- a test measures the amount of nitrogen waste in your blood] 44 mg/dl high (reference range 7-23 mg/dl) 2. Creatinine (an important indicator of renal/kidney health) 1.5 mg/dl high (reference range 0.6-1.4 mg/dl) 3. An increased BUN/Cr ratio of 29 (reference range 5-20 mg/dL). A BUN/Cr ratio greater than or equal to 25:1 mg/dL is an indicator for actual dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, Page 47. While the resident had insufficient fluid intake to maintain hydration from October 1, to October 5, 2016, as evidence by the above abnormal laboratory test results, there was no documented evidence that indicated the physician was notified in order to obtain treatment instruction(s). A review of the urine specimen test result reported to the facility on October 9, 2016, indicated Nitrite was positive and many bacteria which indicate RSR had a UTI. The resident was treated with oral antibiotic on October 10, 2016 at 6:43 p.m. The first dose of antibiotic was administered on October 11, 2016, two days after the result of the urine specimen. Following the order of the oral antibiotic to treat the UTI, the RD's instruction to provide 1740-2136 cc per day was not implemented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 38 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 faxed document sent to the physician on October 18, 2016, indicated the resident was losing weight approximately seven pounds, not eating well, family providing meals but resident refusing it, resident was eating approximately 20 percent of all meals. According to the physician's response dated October 18, 2016, received via fax, orders for laboratory tests for complete blood count (CBC), chemistry, urine analysis, urine culture was obtained. A review of the Laboratory test result dated October 19, 2016 indicated the following: 1. An elevated blood Sodium of 137 mEq/L (reference range 135-145) 2. An elevated BUN 63 mg/dl high (reference range 7-23) 3. An elevated Creatinine mg/dl 2.0 (reference range 0.6-1.4) 4. An increased BUN/Cr ratio 32 (reference range 5-20 mg/dL). A BUN/CR ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47). 5. Urinalysis test result indicated positive nitrite (reference range negative), trace leukoestrase (reference range negative), WBC (white blood cells) of 2-5 (reference range negative), and many bacteria (reference range none), suggestive of UTI. The urine test results were faxed to the physician. However, there was no follow-up to obtain treatment instruction(s). 6. A urine osmolality of 301.8 mosm/kg (reference range 275-295 mosm/kg). Urine osmolality is used to measure the number of dissolved particles per unit of water in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 39 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 urine. Urine osmolality is useful in assessing hydration status (Nursing Care Ready Reference Resident Assessment Protocol Pages 53- 55). A review of another Laboratory urine test result dated October 21, 2016, indicate RSR 13's urine specimen resulted in positive nitrite, moderate leukoestrase, WBC greater 100 (reference range 0-2), and many bacteria (reference range none). The physician was notified and an order to administer Rocephin 1 gram I.M. (intramuscular antibiotic) daily for five days was obtained. One of the complications associated with dehydration is urinary tract infections (AJN, American Journal of Nursing: June 2006 Volume 106 - Issue 6, pages 40-49. A review of the fluid intake with meals for the month of November, 2016, indicated RSR 13 had an average daily fluid intake of 1492 cc, and therefore, resident had a fluid deficit of 248 cc per day for November 1 and 2, 2016. A review of the last laboratory test results dated November 3, 2016, indicated the following: 1. An elevated blood Sodium 151 mEq/L 2. An elevated blood BUN 105 mg/dl critical high 3. An elevated blood Creatinine 3.6 mg/dl BUN/Cr ratio 29 4. A urine osmolality of 345.5 mosm/kg (this is higher than previous of 301.8 mosm/kg) which indicated RSR 13's urine was more concentrated. Although the resident's laboratory test results FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 40 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 indicate critical signs of dehydration, treatment for dehydration was not initiated. Delayed treatment of dehydration may lead to acute renal failure, which is a sudden decrease in renal function which, if uncorrected, can lead, to irreversible tubular necrosis [kidney failure (American Journal of Nursing, May 1999- Vol. 99-Issue 5 page 66-69]. A review of the Change of Condition record dated November 3, 2016, indicated RSR 13 was transfer to the general acute care hospital (GACH) dated GACH due to abnormal laboratory results. A further review of the History and Physical from the GACH dated November 3, 2016, obtained from the GACH indicated RSR 13 was brought to the emergency department because of abnormal laboratory test results. A review of the History and Physical (H&P) from the GACH dated November 3, 2016, indicated RSR 13 was noted to have UTI with sepsis (a systemic infection in which the body has a severe response to bacteria), dehydration, and acute kidney injury. According to the H&P, the resident had an elevated BUN level of 106 mg/dl and Creatinine 3.7 mg/dl., elevated Sodium of 149 mEq/L RSR 13 was hospitalized for UTI with sepsis and dehydration for five days and discharged to the skilled nursing facility (SNF) on November 8, 2016. Cross refer to F315

F334 SS=E INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS CFR(s): 483.25(n)

F334 01/12/2017 The facility must develop policies and procedures that ensure that -FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 41 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 (i) Before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. The facility must develop policies and procedures that ensure that -(i) Before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 42 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. (v) As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to maintain an accurate and factual documentations of residents' (Resident 4, 5) refusal of or medical contraindications to the influenza vaccine for two out of 11 sample residents. Findings: a. A review of the admission record indicate Resident 4 was admitted to the facility on November 20, 2016, with diagnoses that included difficulty walking, heart failure, abnormal posture, and history of falling. The Minimum Data Set [MDS-a comprehensive assessment and screening tool] dated August 16, 2016, indicated Resident 4's cognitive skills (the act or process of knowing, perceiving) were intact. A review of Resident 4's influenza FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 43 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 immunization Informed Consent Form dated October 13, 2016, indicated Resident 4 declined the influenza vaccine due to Resident 4 had an allergic reaction or anaphylactic reaction from the influenza vaccination in the past. A review of Resident 4's admission record indicated the resident did not have any allergies. On November 11, 2016 at approximately 4:10 p.m., during an interview with the Director of the Nursing (DON), she stated the form that was used to obtain consent for influenza vaccination from Resident 4 was not applicable because the resident did not have an allergy to the vaccine. On November 11, 2016 at approximately 5:00 p.m., during an interview with Licensed Vocational 2 (LVN 2) who obtained the consent from Resident 4, he stated Resident 4 did not give a reason for refusing the influenza vaccine. LVN 2 stated he did not recall the resident stating she had an allergic reaction to the influenza vaccine in the past. A review of the facility's policy titled "Influenza Vaccine" with a revised date of December 2012, indicated "a resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record." b. A review of the admission record indicated Resident 5 was admitted to the facility on August 4, 2016, with diagnoses that included cellulitis of the left lower limb, non-pressure chronic ulcer of lower leg and hypertension. The Minimum Data Set [MDS-a comprehensive assessment and screening tool] dated August FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 44 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 16, 2016, indicated Resident 5's cognitive skills (the act or process of knowing, perceiving) were intact. A review of the Influenza Immunization Informed Consent form dated October 6, 2016, indicated Resident 5 declined the influenza vaccine due to Resident 5 had an allergic reaction or anaphylactic reaction from the influenza vaccination in the past. A review of Resident 5's admission record indicated the resident did not have any allergies. On November 11, 2016 at approximately 3:20 p.m., during an interview with Resident 5, she stated she is not allergic to the influenza vaccine. Resident 5 stated she declined the vaccination because she got vaccinated in the doctor's office. On November 11, 2016 at approximately 4:10 p.m., during an interview with the Director of the Nursing (DON), she stated she will further investigate and talk to the resident. During a follow-up interview with the DON on the same day at approximately 5:00 p.m., DON stated the facility is using a new influenza vaccination consent form that included reasons for declination of the vaccine such as resident has already received the vaccine outside of the facility, the vaccine is medically inadvisable and personal reasons. A review of the facility's policy titled "Influenza Vaccine," with a revised date of December 2012, indicated "a resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 45 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F356 POSTED NURSE STAFFING INFORMATION CFR(s): 483.30(e)

F356 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/12/2017 The facility must post the following information on a daily basis: o Facility name. o The current date. o 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: - Registered nurses. - Licensed practical nurses or licensed vocational nurses (as defined under State law). - Certified nurse aides. o Resident census. The facility must post the nurse staffing data specified above on a daily basis at the beginning of each shift. Data must be posted as follows: o Clear and readable format. o In a prominent place readily accessible to residents and visitors. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. The facility must maintain the posted daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 46 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 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 nursing staff data that included the total number and actual hours worked by licensed nursing staff and unlicensed direct care givers in a prominent place accessible to resident and visitors to assure that facility has met a minimum nursing hours as required in the state law. This deficient practice had the potential for undetected insufficient licensed nursing staff. Findings: On November 13, 2016 at 10:45 a.m., the Daily Direct Care Staffing dated November 12, 2016 posting was displayed on the counter of the main lobby. During a concurrent interview, the Administrator stated he will update the posting for today (November 13, 2016).

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.35(i) 01/12/2017 The facility must (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 47 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the sanitizing cleaning solution used by the kitchen staff has the proper disinfectant level. This had the potential to result in improper sanitation practices that can lead to the outbreak of foodborne illness. Findings: During the initial kitchen tour in the presence of the Dietary Supervisor (DS), the DS was observed testing the sanitizer cleaning solution for proper disinfectant levels using a quaternary test strip (strip dipped in the cleaning solution to see the composition of the disinfectant in the cleaning solution). The strip gave the reading of 100 ppm (parts per million - a unit of measure). During this observation the Dietary Supervisor stated that the solution should be at least 200 ppm. A review of the facility's policy titled "Quaternary Ammonium Log," with a revised date of February 2010, indicated "the dietary worker will record the ammonium level on the log prior to sanitizing the counters or washing pots and pans daily to assure the level is at least 150 ppm. Read instructions on quat container for proper level. This may differ from policy." During a follow-up interview with the DS on November 12, 2016 at 4:00 p.m., she stated the container instructions for preparing the sanitizing solution indicated the level should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 48 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 at 200-400 ppm.

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.60(b), (d), (e)

F431 01/12/2017 The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. 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. 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. 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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 49 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review the facility failed to ensure controlled drugs (medications) were in a securely stored using double lock as directed on the facility's Policy and Procedures. This deficient practice had the potential for loss, diversion, or theft of discontinued controlled drugs stored in the Director of Nursing (DON) office. Findings: On November 13, 2016 at approximately 11:00 a.m., during medication storage inspection, and audit in the presence of the DON, the discontinued controlled medications were observed stored in a single locked cabinet in the DON's office. The DON stated the locked door of the office is considered as the other lock. When the DON was asked on how she ensures the room is secured at all times, she stated she keeps the door to the room locked at all times. After the inspection and audit of the discontinued drugs, DON was observed storing the key to the locked cabinet where the discontinued controlled substances were retained, in an unlocked drawer in the room. The DON was also observed leaving the room with the door open. During a follow-up interview with the DON on the same day at approximately 11:30, she stated, she should have locked the door. The DON also stated she will make sure the facility will use double lock procedures to ensure restricted access to controlled substances. A review of the facility's policy and procedure titled "Disposal of Medications and MedicationRelated Supplies: Medication Destruction," with a revised date of April 2014, indicated...."controlled substances are retained FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 50 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 in a securely locked area using "double-lock" procedures, with restricted access until destroyed by the facility DON and a consultant pharmacist..."

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 01/12/2017 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 51 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their infection control policy and procedures by not having documented evidence of staff receiving an influenza vaccine to wear a mask while providing direct care to residents during the flu season. This deficient practice had a potential to spread infection in the facility. Findings: On November 11, 2016 at approximately from 7:30 a.m. to 9:30 a.m., there was no staff observed wearing a mask in the facility. On November 12, 2016 at approximately from 2:30 p.m. to 4:30 p.m., there was no staff observed wearing a mask in the facility. On November 13, 2016 at 8:10 a.m., during an interview, when asked if staffs received their influenza vaccination, Director of Staff Development (DSD) stated only some staff have received the influenza vaccine. DSD further stated that the ones that did not received the influenza vaccine or did not show proof that they had received it somewhere else, should be wearing a mask during the flu season. According to the facility's revised December 2012 policy and procedure titled, "Influenza Vaccine," indicated staff may obtain influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 52 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F517 WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/12/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure that all emergency carts were stocked with supplies and be ready for use during an emergency as listed in the facility's list. This deficient practice had the potential to affect all residents, staff and visitors that the facility would be responsible for. Findings: On November 13, 2016 at 9:50 a.m., during an observation of the emergency crash cart with Registered Nurse 1 (RN 1), the following were not found as indicated on the facility's Emergency Cart Checklist: 1. On top of the cart, there was no normal saline solution. 2. In the first drawer, there were no airways of various sizes and no extra suction cannulas, 3. In the bottom drawer, there was no extension wire. A review of the Emergency Cart Checklist dated November 11, 2016, indicated the cart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 53 of 54 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: _______________ 555609 (X3) DATE SURVEY COMPLETED 11/13/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENDALE HEALTHCARE CENTER 1208 S Central Ave Glendale, CA 91204 (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 was all checked to indicate supplies are available and ready to use during an emergency. On November 13, 2016 at 10:15 a.m., during an interview, Central Supply (CS) staff stated the facility had used the emergency cart on November 10, 2016 and the airways were supposed to be reordered to replace what was used during the emergency. CS staff further stated the charge nurse is responsible for checking and restocking the emergency cart for what was missing. A further review of the Emergency Cart Checklist, November 12 and 13, 2016 was blank. On November 13, 2016 at 9:55 a.m., during an interview, RN 1 stated November 12 and 13, 2016 should have been checked daily on the night shift (11-7). According to the facility's undated policy and procedure titled, "Emergency Cart," indicated the emergency cart will be checked daily and after each use by the charge nurse or RN supervisor. The Emergency Cart will be restocked after each use and/or as needed. Restocking of all crash carts will be done by the central supply staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 06WL11 Facility ID: CA970000085 If continuation sheet 54 of 54