Dreier's Nursing Care Center
DREIER'S NURSING CARE CENTER in GLENDALE, CA — inspection on June 11, 2024.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record review of Resident 53's Assessments with the DON on [DATE] at 6:12 PM, the DON stated she could not find documented evidence of a change of condition assessment from [DATE] to [DATE] for Resident 53.
A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 3/2015 indicated pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary.
The P&P indicated to conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.
The P&P indicated to assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.
The P&P indicated to monitor the resident by performing a basic assessment with enough detail and as needed, with standardized assessment tools and relevant criteria for measuring pain management.
The P&P indicated if pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.
The P&P indicated to report the following information to the physician or practitioner: significant changes in the level of the resident's pain.
A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017 indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.
The P&P indicated the nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; significant change in the resident's physical/emotional/mental condition; and need to alter the resident's medical treatment significantly.
The P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During the initial kitchen tour on 6/7/2024 at 9:44 AM, a piece of paper that included Resident 35 ' s name, room number and medical record number was observed inside a trash can near the dishwashing area with food and papers of other residents' information.
During a concurrent observation and interview with the Dietary Supervisor (DS) on 6/7/2024 at 9:46 AM, DS stated residents name card are always thrown in the trash because they are soiled with food after a meal. DS stated there was no other place to dispose of resident's name card.
During a concurrent observation and interview with the Director of Staff Development (DS) on 6/10/2024 at 2:08 PM, the DSD verified residen's information was exposed in the kitchen trash can.
The DSD stated resident's information should be disposed somewhere where it would be shredded because the resident name card exposes patient information.
The DSD stated he would buy a shredder for the kitchen.
A review of the facility's policy and procedure titled HIPPA Privacy- Basic Do's and Don'ts to Remember, dated 11/2017 indicated to shred any papers with any patient health information prior to discard or place in a locked bin (for proper destruction and disposal later per policy).
The policy indicated do not discard any papers with any patient health information in the trash in readable form.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During an interview on 6/09/2024 at 11:45 AM with Resident 32, Resident 32 stated someone from the facility had removed his personal extension cord from his room while he was out of the facility on 6/7/2024. Resident 32 stated upon his return he addressed his grievance to Social Service Director (SSD) who told him Maintenace supervisor had removed the extension cord but would follow up on location of extension cord. Resident 32 stated he informed SSD that if he was not allowed to have extension cord in facility and wanted it back as it was his personal property and would have his family take it home. Resident 32 stated that was 3 days ago and up to this date, the facility had not returned his extension cord or was there follow up notification to the location of his extension cord.
During an interview and concurrent record review of the facilities Grievance or Recommendation Form logs with SSD, on 6/9/2024 at 1:05 PM, the SSD stated she could not find documented evidence that a grievance was logged for Resident 32 ' s concern of missing personal belongings reported on 6/7/2024.
The SSD stated when the facility practice was that when a resident or family member complains about an issue in the facility a grievance should be initiated and follow through to completion of the problem.
The SSD stated she forgot to file a written grievance because she had verbally spoken to Resident 32 on 6/72024. SSD stated she had forgotten to follow up with maintenance and Resident 32.
The SSD stated the Social Service Department is responsible for filling out the grievance document.
A review of facility policy and procedure titled Grievances/Complaints-Staff Responsibility with a revision date of October 2027 indicated 1.
Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident ' s representative (sponsor), or another interested family member of a resident concerning the resident ' s medical care, treatment, food, clothing, or behavior of other residents etc, the staff member is encouraged to guide the resident , or person acting on the resident ' s behalf, as to how to file a written complaint with the facility.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During a concurrent interview and record review of Resident 26's MDS transmissions on 6/11/2024 at 2:53 PM, the DSD stated Resident 26 was discharged home on 2/14/2024.
The DSD stated he could not find documented evidence of a discharge MDS for Resident 26.
The DSD stated it was important to ensure the facility transmits the correct information to CMS and that nothing fraudulent was being relayed.
The DSD stated the purpose of transmitting a complete MDS was to ensure the facility was assessing the residents.
A review of facility's policy and procedures (P&P) titled Electronic Transmission of the MDS, with revision date of November 2019, indicated All MDS assessments (e.g., admission, annual, significant change , quarterly review , etc. ) and discharge and reentry records are completed and electronically encoded into our facility ' s MDS information system and transmitted to CMS ' QUIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.
A review of CMS's RAI Version 3.0 Manual dated October 2023, indicated 5.2 Timeliness Criteria- For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During a concurrent interview and record review of Resident 44's care plans on 6/11/2023 at 2:22 PM, the Director of Staff Development (DSD) stated he could not find documented evidence of a care plan that indicated how Resident 44 was monitored for the use of Eliquis that included monitoring for adverse reactions. At 2:24 PM, the DSD stated he could not find documented evidence of a care plan that indicated how Resident 44 was monitored for the use of Risperdal that indicated the specific behaviors manifested by the resident.
The DSD stated there should be a care plan that was specific and included side effects and what to monitor for the resident.
A review of the facility's policy titled, Care Plans, Comprehensive Person Centered with a revision date of December 2016, indicated A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
According to the National Library of Medicine, dated [DATE], a transient ischemic attack (TIA) is a stroke that lasts only a few minutes. It happens when the blood supply to part of the brain is briefly blocked.
Symptoms of a TIA are like other stroke symptoms, but do not last as long.
They happen suddenly, and include: Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Difficulty walking Dizziness Loss of balance or coordination Most symptoms of a TIA disappear within an hour, although they may last for up to 24 hours.
Because you cannot tell if these symptoms are from a TIA or a stroke, you should go to the hospital right away. https://medlineplus.gov/transientischemicattack.html A review of the Centers for Disease Control and Prevention (CDC) website titled Signs and Symptoms of Stroke, dated [DATE] indicated the signs of stroke in men and women include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking, dizziness, or problems with balance; and severe headache with no known cause.
The website indicated if any of the following signs appear suddenly, to call 9-1-1 right away. [https://www.cdc.gov/stroke/signs-symptoms/index.htm
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During an observation in Resident 44 ' s room on 6/7/2024 at 10:23 AM, Resident 44 was observed receiving oxygen therapy via nasal cannula. Resident 44 ' s oxygen tubing was touching the floor.
During a concurrent observation and interview with licensed vocational nurse (LVN) 3 on 6/7/2024 at 10:35 AM, LVN 3 confirmed Resident 44 ' s oxygen tubing was touching the floor. LVN 3 stated Resident 44 ' s oxygen tubing should not be touching the floor, and she would go change it because the floor is dirty and infection control.
During an interview with the Director of Staff Development on 6/11/2024 at 2:38 PM, the DSD stated oxygen tubing should not touch the floor for infection control purposes.
A review of the facility ' s policy and procedure titled Oxygen Administration dated 10/2010 indicated the facility will promote resident safety in administering oxygen.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During a concurrent interview and record review of the LVN Competency Checklist on 6/8/24 at 6PM, the Director of Nursing (DON) stated that under skills of the Competency Checklist, LVN was responsible for reporting observed changes of condition (COC) including vital signs: temperature and blood pressure. DON stated the competency checklist did not indicate to perform respiratory assessment such as lung auscultation and abnormal breathing patterns DON stated while reviewing Resident 53 ' s Medication Administration Record dated May 2024 LVN 1 assessed and documented the Resident 53 pain level 7 out of 10 then gave Tylenol for pain on 5/2/2024 at 9:03PM, the blood pressure was 90/46, LVN 1 did not notify Physician 1 regarding the high pain level, increased HR and the low the BP. DON stated that LVN 1 should have contacted Physician 1 immediately for the high pain level, increased HR and low BP.
The DON stated, LVN 2 ' s Progress Note dated 5/2/2024 at 3:51AM, indicated Resident 53 ' s behavior did not indicate the resident was aggressive towards staff, but Resident 53 was guarding the GT site and abdomen, Ativan (medication used to treat anxiety [the feeling of fear of the unknown])should have not been given, rather Physician 1 should have been notified.
The DON stated that LVN 2 progress note did not indicate the Physican 1 was notified.
The DON stated that LVN 1 and LVN 2 did not have the competency skills to care for Resident 53 ' s with a COC, including not notifying the MD.
During a review of the facility ' s policy and procedure titled, Staffing, Sufficient and Competency Nursing, revised 8/2022, indicated the facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment.
The policy indicated licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During an observation on 6/8/2024 at 10:39AM, the staffing information posted by Nursing Station 1, indicated the date of 6/7/2024.
During an interview on 6/8/2024 at 10:50AM with Director of Staff Development (DSD) stated the nurse staffing data needs to be posted on a daily basis before the beginning of each shift.
The DSD stated the nurse staffing posted for 6/8/2024 was incorrect that he forgot to post the correct one, it had yesterday ' s date of 6/7/2024.
During a review of the facility ' s policy and procedure titled, Posted Direct Care Daily Staffing Numbers, revised 8/2006, indicated the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to resident.
The policy indicated within two hours of the beginning of each shift the number of Licensed Nurses (RNs, LPNs and LVNs) and the number of Certified Nursing Assistants (CNA) directly responsible for resident care will be posted in a prominent location and in a clear and readable format.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
mouth for Resident 53 was incorrect and Physician 1 should have been notified.
The DSD stated the
DSD on 6/9/2024 at 9:50 AM, LVN 2 stated she gave Resident 53, Ativan 0.5 mg via G-tube on 5/2/2024 at 4 AM. LVN 2 stated she did not notice that the medication order transcribed for Ativan 0.5 mg was by mouth. LVN 2 stated if she noticed that the order for Ativan 0.5 mg had the incorrect route, she would have contacted Physician 1 to revise the order to the correct route.
A review of the facility ' s policy and procedure (P&P) titled Administering medications through an Enteral Tube dated 3/2015 indicated to provide guidelines for the safe administration of medications through an enteral tube.
The P&P indicated to verify that there is a physician ' s medication order for the procedure.
A review of the facility ' s P&P titled Administering Medications, dated 4/2019 indicated medications are administered in a safe and timely manner, and as prescribed.
The P&P indicated the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
concerns and how Resident 44 was being monitored for auditory hallucinations as indicated for the
effects and what to monitor for the resident.
A review of the facility ' s policy and procedure (P&P) titled Psychotropic Medication Use, dated 7/2022 indicated consideration of the use of any psychotropic medication is based on comprehensive review of the resident, this includes evaluation of the resident ' s signs and symptoms in order to identify underlying causes.
The P&P indicated psychotropic medication management includes adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During an interview and concurrent record review on 6/10/2024 at 5:39 PM with Director of Staff Development (DSD) and Administrator (ADM) of facility ' s Policies and procedure titled Change in a Resident ' s Condition or Status, dated 5/2017 and Pain Assessment and Management, dated 3/2015.
The DSD stated these were the facility ' s current policies as the facility had purchased them from a third party vendor online in the past. DSD stated the facility did not have a sign in sheet to provide indicating the last annual review of facilities policies by Quality Assurance Committee or facilities Medical Director.
Administrator stated his plan was to reach out to an outside hired facility consultant to work on updating facility policies to reflect updated current regulations and standards of practice.
During an interview and record review on 6/11/2024 at 3:38 PM with DSD and ADM stated the facility had not had a Medical Director since June of 2023 when the previous Medical Directors contract had been terminated, Administrator stated he was currently in the process of hiring a Medical Director but had not finalized a decision or contract with any candidate as of this time.
A review of the facility ' s policy and procedure titled Medical Director Roles and Functions dated with a revision date of April 2023 indicated 1.
The facility shall retain a qualified physician to serve as the medical director, 2.
The Medical Director shall coordinate care in the facility, 3.
The Medical Director shall help identify, create, implement and review/ patient care policies.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During a concurrent interview and record review on [DATE] at 3:36 PM of the facilities QUAPI/QAA (/Quality Assurance and Performance Improvement- data driven and proactive approach to quality improvement/Quality Assessment and Assurance - A Committee is responsible for identifying and responding to quality deficiencies that are identified in the facility) plan with Administrator (ADM) and Director of Staff Development (DSD).
The DSD stated the facility had not identified or implemented any adverse event into facility ' s QAPI Program.
The DSD stated the cause of death of Resident 53 was not investigated to determine if there were quality deficiencies and measures to address in the QAPI.
The DSD confirmed current facility ' s QAPI was only for Fall reduction.
The DSD stated the facility only relied on the [NAME] 3 (Minimum Data Set 3.0 Quality Measure Reports) report to identify issues to implement into their QUAPI/QAA plan and the only issue they had identified was related to falls.
The ADM stated he had not been involved the facilities QAPI/QAA program oversight since last year.
The ADM stated it had been the facilities Director of Nursing who had been in charge of the oversight, and he was unaware the facility failed to have a system other than relying on [NAME] 3 to identify and address and analyze adverse events.
The ADM stated the DON resigned on [DATE] and he is currently hiring a replacement.
A review of the facility ' s policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Plan with a revision date of [DATE] indicated The QAPI program overseen by the QAPI committee is designated to identify and address quality deficiencies though analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level.
555839 06/11/2024
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
During a concurrent interview and record review on [DATE] at 3:36 PM of the facilities QUAPI/QAA (/Quality Assurance and Performance Improvement- data driven and proactive approach to quality improvement/Quality Assessment and Assurance - A Committee is responsible for identifying and responding to quality deficiencies that are identified in the facility) plan with Administrator (ADM) and Director of Staff Development (DSD).
The DSD stated the facility had not identified or implemented any adverse event into facility ' s QAPI Program.
The DSD stated the cause of death of Resident 53 was not investigated to determine if there were quality deficiencies and measures to address in the QAPI.
The DSD confirmed current facility ' s QAPI was only for Fall reduction.
The DSD stated the facility only relied on the [NAME] 3 (Minimum Data Set 3.0 Quality Measure Reports) report to identify issues to implement into their QUAPI/QAA plan and the only issue they had identified was related to falls.
The ADM stated he had not been involved the facilities QAPI/QAA program oversight since last year.
The ADM stated it had been the facilities Director of Nursing who had been in charge of the oversight, and he was unaware the facility failed to have a system other than relying on [NAME] 3 to identify and address and analyze adverse events.
The ADM stated the DON resigned on [DATE] and he is currently hiring a replacement.
A review of the facility ' s policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Plan with a revision date of [DATE] indicated The QAPI program overseen by the QAPI committee is designated to identify and address quality deficiencies though analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level.
555839
During an interview on [DATE] at 3:32 PM, LVN 1 stated during the 3 PM to 11 PM shift on the night of [DATE], Resident 53's family member (Family) 1 requested for LVN 1 to administer pain medication to Resident 53 because, Resident 53 was crying a lot, moaning, and fidgeting with her hands. LVN 1 stated she asked Resident 53 about her pain level, but the resident moaned and moved her arms around. LVN 1 stated she took Resident 53's vital signs (VS), but she did not document the VS and she could not recall what they were. LVN 1 stated she did not notify Physician 1 when she observed Resident 53 moaning. LVN 1 stated she gave Resident 53 a pain medication Tylenol and the resident stopped moaning. LVN 1 stated she did not document Resident 53's behavior of moaning, but she should have.
During a concurrent interview and record review of the VS records on [DATE] at 4:37 PM with LVN 1, LVN 1 stated Resident 53's last blood pressure was at ,d+[DATE] on [DATE] at 5:47 PM. LVN 1 stated she did not notify Physician 1 or monitored and rechecked the BP when Resident 53's BP was trending down and lower from baseline BP, which could have been the cause of the significant change in the resident's condition. LVN 1 stated on [DATE] at around 9 PM, she assessed Resident 53 and Resident 53 was having pain at a evel of 7 out of 10. LVN 1 stated she administered Tylenol to Resident 53, which was ordered by the physician for the resident's pain level of ,d+[DATE]. LVN 1 stated she did not notify Physician 1 about Resident 53 having the pain level of 7 out of 10 even when Resident 53 did not have any physician order for pain medication stronger than Tylenol at the time. LVN 1 also stated Family 1 was content with the Tylenol and the results of the Tylenol. LVN 1 stated she could not recall why she did not notify Physician 1.
During a telephone interview with Physician 1 on [DATE] at 9:20 AM, Physician 1 stated if a resident's blood pressure continues to decrease, he would expect to be notified by the facility's staff.
Physician 1 stated the staff should have monitored Resident 53's blood pressure.
Physician 1 stated he could not recall if he was informed that Resident 53's pain level went above a 3 on the pain scale.
The Physician 1 stated if Resident 53's pain was not controlled, he would expect to be notified by the facility staffs.
Physician 1 stated if there were other things happening while Resident 53 was observed with pain like if resident's heart was going up from 60 bpm to 100 bpm, Physician 1 stated he would expect to be notified.
555839
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555839 B.
Wing 06/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.