Dreier's Nursing Care Center

F-F580

Findings:

A review of facilities Performance improvement Project with a start date of [DATE REDACTED] indicated the facility did not have a written system in place to identify adverse events that included monitoring investigating, analyzing root cause, implement and evaluate its Quality Assurance and Performance Improvement Program, such in

the case of Resident 53 ' s death.

A review if the facility's QAPI program indicated the facility did not perform an investigation to what lead to Resident 53 ' s death on [DATE REDACTED]. Resident 53 had a significant change of condition to prevent recurrence of

the deficient practice that impact quality of care, quality of life, and resident safety.

A review of Resident 53 's Admission Record indicated resident was readmitted to the facility on [DATE REDACTED], with diagnoses that included aftercare following surgery on the digestive system, insertion of gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), and dysphagia (difficulty swallowing) following cerebral infarction.

A review of the Minimum Data Set (MDS) dated [DATE REDACTED], Resident 53 had severe cognitive (ability to process information) impairment and required set up and clean up help with eating and maximum assistance with personal hygiene.

For Resident 53 the facility failed to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Ensure Licensed Vocational Nurse (LVN) 1 notified Registered Nurse (RN) 1 and Physician 1 for a significant change from baseline of Resident 53 ' s blood pressure of ,d+[DATE REDACTED] (reference range ,d+[DATE REDACTED]) and heart Level of Harm - Minimal harm or rate of 106 beats per minute ([bpm] reference range ,d+[DATE REDACTED] bpm) from baseline on [DATE REDACTED] at 5:47 PM. potential for actual harm Ensure LVN 1 notified Physician 1 and Registered Nurse 1 about Resident 53 ' s was observed fidgeting, Residents Affected - Some agitated and with pain assessed at level of 7 out of 10 (on a pain scale from 0 to 10, where 0 is no pain and 10 is the worse pain possible).

Ensure LVN 1 notified Physician 1 of Resident 53 ' s pain level of 7 to determine if other assessment and interventions are needed to determine the source of pain and to relieve the pain.

Ensure LVN 2 immediately notified Physician 1 when Resident 53 ' s was noted unresponsive to tactile and verbal stimuli, blood pressure could not be read and obtained, respiration was diminished respirations of 8 breaths per minute and stopped breathing after 13 minutes.

Ensure LVN 1 and/or LVN 2 reassessed, monitored by rechecking the BP, HR and respiratory rate (RR) and documented in Resident 53 ' s clinical record the resident ' s repeat pain level assessment, heart rate, BP and respiratory status including the oxygen saturation (amount of oxygen circulating in the blood) rate when Resident 53 ' s BP decreased, and HR increased from resident ' s baseline.

Ensure to develop a plan of care for Resident 53 to address the interventions for the management of CVA, A-fib, MI and hypotension.

During a concurrent interview and record review on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 555839

F-F684

Findings:

A review of Resident 53 's Admission Record indicated resident was originally admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included aftercare following surgery on the digestive system, insertion of gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), and dysphagia (difficulty swallowing) following cerebral infarction.

A review of Resident 53's History and Physical Examination dated [DATE REDACTED] indicated resident did not have the capacity to understand and make decisions.

A review of the Minimum Data Set (MDS) dated [DATE REDACTED], Resident 53 had severe cognitive (ability to process information) impairment and required set up and clean up help with eating and maximum assistance with personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 A review of Resident 53's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient Level of Harm - Immediate wants in the event of a medical emergency) signed by the responsible party for Resident 53 on [DATE REDACTED] and jeopardy to resident health or signed by Physician 1 but not dated, indicated the medical interventions to be performed if the resident was safety found with no pulse and not breathing. The POLST indicated to do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure used to restart a person's heartbeat and breathing after one or both have Residents Affected - Few stopped), instead selected to receive care for comfort to relieve pain and suffering with medication, use oxygen, suction, and manual treatment of airway obstruction.

A review of the General Acute Care Hospital (GACH) Discharge Summary, dated [DATE REDACTED] indicated, Resident 53 was admitted to the GACH on [DATE REDACTED] for evaluation of the resident's altered mental status after a fall at

the facility. The GACH record indicated at baseline Resident 53 was able to answer yes or no but at the time of the assessment in the GACH Resident 53 was nonverbal (unable to talk) and unable to provide medical history. The GACH record indicated Resident 53 had acute to subacute small infarct in the brain likely due to atrial fibrillation, myocardial infraction (MI-) which most likely due to hypotension (low blood pressure) causing the fall.

A review of Resident 53's care plans dated from [DATE REDACTED] to [DATE REDACTED] indicated no documented evidence that a care plan was developed to address interventions related for CVA (stroke also called ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced), Atrial fibrillation and hypotension.

A review of Resident' 53's Order Summary Report from [DATE REDACTED] to [DATE REDACTED] indicated the following:

1. On [DATE REDACTED] at 5:22 PM a physician order for Tylenol (Acetaminophen) 325 mg 2 tablets via G-tube every 4 hours as needed for mild pain (,d+[DATE REDACTED]) not to exceed 3 grams ([gm] unit of measure) every 24 hours of Acetaminophen.

2. On [DATE REDACTED] at 6:13 PM a physician order for Ativan (Lorazepam) one?tablet by mouth every 4 hours as needed for anxiety for 60 days manifested by physical aggression towards staff.

A review of Resident 53's Weight and Vitals Summary Report from [DATE REDACTED] to [DATE REDACTED] indicated Resident 53 had a blood pressure and heart rate as follows:

1. On [DATE REDACTED] at 4:55 AM Resident 53 BP was ,d+[DATE REDACTED] and a HR of 82 beats per minute (BPM)

2. On [DATE REDACTED] at 6:27 AM Resident 53's BP was ,d+[DATE REDACTED] and a HR of 61 BPM.

3. On [DATE REDACTED] at 7:24 AM Resident 53's BP decreased to ,d+[DATE REDACTED] and HR increased to 101 BPM.

4. On [DATE REDACTED] at 5:47 PM, the BP decreased to ,d+[DATE REDACTED] and HR increased to 106 BPM.

No documented evidence in Resident 53;s clinical record that Physician 1 was notified of the resident's significant change in the BP and HR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 5. On [DATE REDACTED] at 4:11 AM, Resident 53 was unresponsive to tactile stimuli and no BP when checked and RR was 8 breaths per minute. After 13 minutes on [DATE REDACTED] Resident 53 had no pulse and not breathing. Level of Harm - Immediate jeopardy to resident health or 6. On [DATE REDACTED] at 7:09 AM, Resident 53 was pronounced dead by the paramedic and taken to the morgue. safety 7. On [DATE REDACTED] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death. Residents Affected - Few

A review of Resident 53's Medication Administration Record (MAR) for ,d+[DATE REDACTED], indicated on [DATE REDACTED] at 9:03 PM, Resident 53 was given Tylenol 325 mg for a pain level of 7 out of 10.

A review of Resident 53's Progress notes indicated the following:

On [DATE REDACTED] timed at 3:51 AM LVN 2 wrote Resident 53 will try to interfere with staff when attending to G-Tube, seen putting hands out trying to keep staff from accessing G-tube. Vital Signs obtained and within normal limits, needs met and anticipated. Will reach out to Medical Doctor for stronger pain medication. Will continue to monitor.

On [DATE REDACTED] timed at 11:56 PM, LVN 2 wrote Resident 53 received in bed, eyes open, appearing weak, no moaning during initial rounds. Per LVN 1, Resident 53 had been moaning earlier in her shift.

On [DATE REDACTED] timed at 4:11 AM, LVN 2 wrote at 12:30 AM LVN 2 assessed Resident 53's vital signs and noted Resident 53 had diminished respirations at 8 breaths per minute with an oxygen saturation level of 95% in room air. Resident 53's eyes were closed, and resident was not responding to tactile stimuli or verbal commands. The note indicated LVN 2 was not able to obtain Resident 53's blood pressure and so raised the foot of the bed and re-checked Resident 53's blood pressure several times and provided oxygen therapy 2 liters (L, unit of measure) via nasal cannula. The note indicated after about 13 minutes, LVN 2 noted Resident 53's respirations ceased and resident did not have a pulse. The note indicated LVN 2 sent immediately for crash cart, applied CPR board to Resident 53's back, and began CPR (due to POLST not being signed by Physician 1, Resident 53 was still considered a full code despite it having been marked as do not resuscitate (DNR), at LVN 3 called 911. The note indicated LVN 2 continued to perform CPR until paramedics pronounced Resident 53 expired at 12:43 AM. The note did not indicate Physician 1 was notified of Resident 53 change in condition.

On [DATE REDACTED] timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Resident 53's death.

A review of the Death Certificate indicated Resident 53 expired on [DATE REDACTED] at 00:43 AM, with the primary cause of death of cerebrovascular disease, atrial fibrillation and hypertension.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During a telephone interview on [DATE REDACTED] at 1:46 PM, LVN 2 stated on [DATE REDACTED] at around midnight she checked Resident 53 in her room to give the resident her medications. LVN 2 stated she took Resident 53's Level of Harm - Immediate blood pressure and the blood pressure did not register a BP reading on the pressure gauge (the part of the jeopardy to resident health or blood pressure device that show the measurement of the BP reading). LVN 2 stated Resident 53 was staring safety at the ceiling and was not responsive when spoken to or touched, and the resident's breathing was diminished. LVN 2 stated when she could not obtain Resident 53's blood pressure, she elevated Resident Residents Affected - Few 53's legs. LVN 2 stated she called LVN 3 to help, and then she placed a pulse oximeter (a non-invasive medical device to measure the amount of oxygen in the blood) on Resident 53's finger which read oxygen saturation level read of 100%, and the heart rate was 70 bpm, but resident's breathing continued at less than 12 breaths per min. LVN 2 stated she used an electrical and manual BP checking device to check Resident 53's blood pressure and she could not get a BP reading. LVN 2 stated she gave Resident 53 an oxygen therapy via nasal cannula because it was one of our (the facility's) protocols. LVN 2 stated the biggest thing was how I could not get her blood pressure and after 13 minutes, Resident 53's respirations ceased and went full on cardiac arrest. LVN 2 stated she did not immediately notify Physician 1 of Resident 53's change

in condition because I was doing my nursing interventions.

During an interview on [DATE REDACTED] at 3:32 PM, LVN 1 stated during the 3 PM to 11 PM shift on the night of [DATE REDACTED], 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 REDACTED] at 4:37 PM with LVN 1, LVN 1 stated Resident 53's last blood pressure was at ,d+[DATE REDACTED] on [DATE REDACTED] 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 REDACTED] 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 REDACTED]. 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During a telephone interview on [DATE REDACTED] at 2:07 PM, RN 1 stated if she was notified by LVN 1 of Resident 53's pain level of 7 out of 10, she would check Resident 53's orders to see what medication covered the pain Level of Harm - Immediate level of 7. RN 1 also stated when the physician did not prescribe a pain medication to Resident 53 to control jeopardy to resident health or the pain level of 7, she could let Physician 1 know. RN 1 stated if she was notified of Resident 53's safety significant change in condition, she would have done a full head to toe assessment and reassessed and monitored the VS of Resident 53 herself. Residents Affected - Few

During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 5:48 PM, the DON stated a significant change of condition was anything that was not normal or not at the resident's baseline condition. The DON stated if there was a significant change of condition on the resident's baseline status, the nurses need to assess and do a full head to toe assessment on the resident, notify the physician, document a change of condition, and initiate a care plan. The DON stated LVN 1 should have checked Resident 53's stomach and checked for bowel sounds since resident had a new G-tube. The DON stated if Resident 53 was already restless, sometimes you need to think further, why is resident doing this? She was probably in pain and required further assessment. The DON stated the physician should be informed of the results of the assessment and document the assessment that was conducted.

During an interview with the DON and concurrent record review [DATE REDACTED] at 6:01 PM, Resident 53's vital signs and pain levels, the DON stated for Resident 53's blood pressure of ,d+[DATE REDACTED] and heart rate of 106 bpm on [DATE REDACTED] at 5:47 PM, the vital signs should have been rechecked. The DON stated if the vital signs remained

the same, the nurse should have called Physician 1 because the pulse was high and the diastolic (measures

the pressure the blood is pushing against the artery [blood vessel that distributes oxygen-rich blood to the entire body] walls while the heart muscle rests between beats) was low and that Resident 53 was in distress.

The DON stated LVN 1 should have called RN 1, to perform a full body assessment. The DON stated when Resident 53's pain level was assessed at a 7 out of 10, it was considered moderate to severe pain, and the licensed nurse should have notified Physician 1 because there was no medication ordered for the pain level of 7 and that the resident was moaning and in distress.

During a concurrent interview and record review of Resident 53's Progress Note written by LVN 2 dated [DATE REDACTED] timed at 4:11 AM with the DON on [DATE REDACTED] at 6:08 PM, the DON stated LVN 2 did not notify Physician 1 as soon as possible. The DON stated LVN 2 needed to notify the Physician 1 and RN 1 so RN 1 could assess Resident 53. The DON stated LVN 2 should have had LVN 3 call Physician 1 to get an order for further care. The DON stated she could not find documented evidence in Resident 53's progress notes from [DATE REDACTED] to [DATE REDACTED] for a change of condition.

During a concurrent interview and record review of Resident 53's Assessments with the DON on [DATE REDACTED] at 6:12 PM, the DON stated she could not find documented evidence of a change of condition assessment from [DATE REDACTED] to [DATE REDACTED] for Resident 53.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated , d+[DATE REDACTED] indicated pain management is a multidisciplinary care process that includes the following: Level of Harm - Immediate assessing the potential for pain; identifying and using specific strategies for different levels and sources of jeopardy to resident health or pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary. The P&P safety 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 Residents Affected - Few 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 ,d+[DATE REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42854 potential for actual harm Based on observation, interview and record review, the facility failed to protect the privacy for one of 12 Residents Affected - Some sampled residents (Resident 35), by ensuring the resident's personal information was disposed in a secure manner in accordance with the facility's policy and procedure titled HIPPA (Health Insurance Portability Act-

a law that protects the residents privacy) Privacy- Basic Do's and Dont's to Remember,

This deficient practice caused Resident 35's personal information readily observable by others not authorized to view information and could be a risk for identify theft (a form of fraud in which the person's personal information is used without the person's permission)

Findings:

A review of Resident 35's Admission Record indicated a readmission to the facility on [DATE REDACTED] with diagnoses that included metabolic encephalopathy (disease of the brain that alters brain function or structure), unspecified severe protein-calorie malnutrition (lack of proper nutrition), and hemorrhage (loss of blood from

a damage blood vessel) of anus and rectum.

A review of Resident 35's latest comprehensive Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/5/2024 indicated Resident 35 had moderately impaired cognition.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish

a grievance policy and make prompt efforts to resolve grievances. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42878

Residents Affected - Few Based on interview and record review and observation the facility failed to ensure prompt efforts were made to resolve grievances verbalized by Resident 32 one of two sampled residents and keep Resident 32 apprised of progress towards resolution

This deficient practice increased the risk for negative psychosocial impact on Resident 32's quality of life.

Findings:

A review of Resident 32 ' s Admission Record indicated the facility had initially admitted Resident 32 on 3/06/202 and then readmitted on [DATE REDACTED] with diagnoses that included acute embolism and thrombosis of unspecified deep veins (is a blood clot that forms within the deep veins) of lower extremity bilateral (both sides) ,essential hypertension (is high blood pressure that doesn't have a known secondary cause).

A review of Resident 32 ' s History and Physical dated 5/24/2023 indicated Resident 32 had the capacity to understand and make decisions.

A review of Resident 32 ' s Minimum Data Set (MDS, an assessment and screening tool) dated 4/28/2024, indicated Resident 32 was cognitively intact.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 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 Level of Harm - Minimal harm or by a resident, a resident ' s representative (sponsor), or another interested family member of a resident potential for actual harm 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 Residents Affected - Few written complaint with the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42878 potential for actual harm Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident Residents Affected - Some assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for three of three sampled residents (Resident 41, 45 and 26).

This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41,45,26 and other potentially affected residents. In addition, the deficient practice could affect the quality-of-care monitoring system to ensure safe, efficient, resident centered care in a timely manner.

Findings:

1.A review of Resident 41's Admission Record indicated the facility admitted Resident 41 on 1/05/2024 and readmitted to the facility on [DATE REDACTED], with diagnoses that included Type 2 Diabetes Mellitus (a condition in which the body blood sugar) facility.

A review of Resident 41 ' s MDS, dated [DATE REDACTED], indicated the resident ' s last submitted MDS assessment was a MDS Admission Assessment.

A review of the facility ' s last CMS Submission Report (undated) indicated Resident 41 ' s MDS Admission assessment was last completed on 3/09/2024 by the facility ' s Director of Nursing.

During a concurrent interview and record review on 6/10/2024 at 7:18 PM, with the Director of Staff Development (DSD), the DSD indicated Resident 41 was admitted to the facility on [DATE REDACTED] and then readmitted back on 1/10/2024. The DSD stated that only an Admission MDS assessment was created on 1/17/2024 for Resident 41 but was not completed or submitted to CMS until 3/09/2024 (43 days late). The DSD stated it was the MDS coordinator responsibility to complete the MDS Admission Assessment, change of condition or discharge MDS ' s for the residents. The DSD stated the facility currently does not have an MDS coordinator due to the previous MDS coordinator (MDS Coordinator 1) resigned from the facility on 6/9/2024. Furthermore, the DSD stated that prior to hiring MDS Coordinator 1, the facility did not have a fulltime or permanent MDS coordinator from January 2024 to about March 2024.

During a follow up interview with the DSD on 6/10/2024 at 7:20 PM, the DSD stated Resident 41 ' s Admission MDS should have been completed and transmitted to CMS 14 days after Resident 41 ' s admission to the facility on [DATE REDACTED].

42854

2. A review of Resident 45 ' s Admission Record indicated an admission to the facility on [DATE REDACTED], with diagnoses that included sepsis (life-threatening complication of an infection), bacteremia (the presence of viable bacteria in the circulating blood), and extended spectrum beta lactamase (ESBL, enzymes [proteins that help speed up metabolism , or chemical reactions in the body] produced by some bacteria that may make them resistant to some antibiotics [medication used to treat infections]) resistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 A review of Resident 45 ' s latest comprehensive MDS dated [DATE REDACTED], indicated the resident ' s last submitted MDS assessment was a 5-day MDS assessment. Resident 45 ' s 5-day MDS assessment was not signed by Level of Harm - Minimal harm or the Registered Nurse (RN) assessment coordinator to certify that it was completed until 1/10/2024 (20 days). potential for actual harm

During a concurrent interview and record review of Resident 45 ' s MDS transmissions in the facility ' s Residents Affected - Some electronic records, on 6/11/2024 at 2:50 PM, the DSD stated Resident 45 was discharged to home on 2/6/2024. The DSD stated he could not find documented evidence of a comprehensive MDS assessment and discharge MDS assessment was submitted to CMS for Resident 45.

3. A review of Resident 26 ' s Admission Record indicated an admission to the facility on [DATE REDACTED] with diagnoses that included osteomyelitis, type 2 diabetes mellitus with foot ulcer, and hypertension (high blood pressure).

A review of Resident 26 ' s latest comprehensive MDS dated [DATE REDACTED], indicated the resident ' s last submitted MDS assessment was a Quarterly MDS Assessment. Resident 26 ' s Quarterly MDS Assessment was not signed by the RN Assessment Coordinator to certify that the MDS assessment was complete until 3/6/2024 (51 days).

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44429

Residents Affected - Few Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plans for three of three sampled residents (Residents 1, 44 and 48) by failing to:

1. Ensure to develop a comprehensive resident centered care plan for Resident 48 that included what side effects to monitor for the use of Lexapro (a medication used to treat depression (a constant feeling of sadness and loss interest, which affects your daily normal activities).

2. Ensure to develop a comprehensive resident centered care plan for Resident 48 ' s use of Vistaril (a medication used to treat anxiety) that included what side effects and specific behaviors to monitor.

3. Ensure to develop a comprehensive resident centered care plan for Resident 1 that included specific interventions for the use of Apixaban, Olanzapine and Divalproex.

4. Ensure to develop a comprehensive resident centered care plan for Resident 44 that included the use of Risperdal (medication used to treat certain mental/mood disorders) for schizophrenia (mental health condition that affects how people think, feel, and behave) and specific behaviors associated with auditory hallucinations (seeing things or hearing voices that are not observed by others).

5. Ensure to develop a comprehensive resident centered care plan for Resident 44 for the use of Eliquis (apixaban, an anticoagulant medication used to treat and prevent blood clots) for Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) that included monitoring of side effects or adverse reactions associated with the use of the medication.

This deficient practice had a potential for the psychotropic and anticoagulation medication side effects not being identified and addressed.

Findings:

1. A review of Resident 48's Admission Record indicated the facility was last readmitted to the facility on [DATE REDACTED], with diagnoses that included depression and Type 2 diabetes mellitus (a condition that happens when your blood sugar is too high).

A review of Resident 48's History and Physical assessment dated [DATE REDACTED], indicated Resident 48 had the capacity to understand and make decisions.

A review of Resident 48's Order Summary Report dated 4/12/2024, indicated the following physician orders:

Lexapro 5mg (mg, unit of measure) oral tablet by mouth one time a day for depression manifested by feeling like crawling out of her skin and sadness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Vistaril oral capsule 25mg, give one capsule by mouth every 6 hours as needed for anxiety for 30 days (start date 4/12/2024). Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident 48's care plans on 6/11/2023 at 1:56 PM, the Director of Staff Development (DSD) stated he could not find documented evidence of a care plan that Residents Affected - Few indicated how Resident 48 was monitored for the use of Lexapro and Vistaril. The DSD stated he was unable to locate a care plan for Resident 48 in the electronic records. The DSD stated its important to have a care plan to monitor Resident 48 ' s Lexapro & Vistaril for monitoring any side effects or any behavioral changes and having interventions to resolve any side effects.

42878

2. A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 9/23/2020, and was readmitted on [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizoaffective disorder, bipolar type(features bouts of mania and sometimes depression), unspecified dementia (loss of memory, language, problem- solving and other thinking abilities).

A review of Resident 1's History and Physical (H&P) dated 3/7/2024, indicated Resident 1 does not have the capacity to understand and make decisions.

A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of 4/7/2024, indicated the resident had severe cognitive (thought process) impairment. The MDS indicated Resident 1 required partial/moderate assistance (helper does more than half the effort) on task such as oral hygiene.

A review of Resident 1's Order Summary Report with active orders, dated June 2024, indicated the following physician orders:

a. Apixaban Oral tablet 5 milligrams (a unit of measure) give 1 tablet by mouth two times a day for Pulmonary Thromboembolism (a condition in which one or more arteries in the lungs become blocked by a blood clot) with an order start date of 4/01/2024.

b. Divalproex Sodium Capsule Delayed Release Sprinkle 125 milligram, give 4 capsules by mouth every 12 hours for mood disorder manifested by aggressive behavior with an order start date of 4/02/2024.

c. Olanzepine oral tablet 10 milligram, give 1 tablet by mouth at bedtime for Schizophrenia manifested by auditory hallucinations with an order start date of 4/01/2024.

A review of all Resident 1's care plans, did not include a care plan with interventions for Residents use of Apixaban tablet 5 milligrams, Divalproex Sodium Capsule 125 milligrams or Olanzapine 10 milligrams that included management and monitoring of Resident 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview and concurrent record review of Resident 1 ' s care plans on 6/11/2024 at 1:55 PM with

the Director of Staff Development (DSD), the DSD stated Resident 1 ' s care plan should have been Level of Harm - Minimal harm or developed when the resident was initially prescribed Apixaban Tablet 5 milligrams, Divalproex Sodium potential for actual harm Capsule 125 milligrams or Olanzapine 10 milligrams. DSD stated it was important for the staff to know specific goals and interventions for Resident 1 s medication. Residents Affected - Few 42854

3. A review of Resident 44's Admission Record indicated a readmission to the facility on [DATE REDACTED], with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation, and Schizophrenia.

A review of Resident 44's History and Physical assessment dated [DATE REDACTED] indicated Resident 44 did not have

the capacity to understand and make decisions.

A review of Resident 44's Order Summary Report for May 2024, indicated the following physician orders:

Administer Eliquis Oral Tablet 5 milligrams (mg, unit of measure) give 1 tablet via gastrostomy (g-tube, a surgical operation for making an opening in the stomach) dated 5/11/2024.

Administer Risperdal Oral Solution 1 mg per milliliter (ml, unit of measure) give 0.5 ml via g-tube at bedtime for schizophrenia manifested by auditory hallucinations, may mix with food, dated 5/11/2024.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42854 jeopardy to resident health or safety Based on interview and record review, the facility failed to reassess, monitor for the signs and symptoms of Cerebral Vascular Accident (CVA or stroke also called ischemic stroke, occurs when the blood supply to part Residents Affected - Few of the brain is blocked or reduced) and Transient Ischemic Attack ([TIA] a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain),) and exhibited new pain for one of three sampled residents (Resident 53) who was recently hospitalized for change in mental status and was diagnosed with TIA and CVA, in accordance to the facility's policy and procedures, and professional standard of practice the facility failed to:

1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 assessed and monitored Resident 53 for signs and symptoms of TIA and Stroke such as change in mental status, baseline BP, HR, RR and mental status such

2. Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 assessed and monitored Resident 53 for lower than baseline Blood Pressure) (BP) and increased Heart Rate (HR), change in mental status and decreased respiratory rate (RR) from baseline.

3. Ensure LVN 1 assessed and notify the Physician 1 and Registered Nurse (RN1) when Resident 53 was observed, decreased BP from ,d+[DATE REDACTED] mm Hg (millimeter mercury) and HR of 82 beats per (BPM) minute to ,d+[DATE REDACTED] mm Hg and HR increased to 101 BPM and to ,d+[DATE REDACTED] mm Hg and HR increased to 106 BPM to provide necessary interventions for the significant change in VS (measurement of the BP, HR, RR and body temperature).

4. Ensure LVN 1 assessed Resident 53's the source of pain resident when the resident exhibited a pain at level of 7 out of 10 (on a pain scale from 0 to 10, where 0 is no pain and 10 is the worse pain possible).

5. Enusre LVN 2 did not wait 13 minutes before calling LVN 3 and the paramedics ( medical personnel who responds to medical emergencies) after Resident 53 was found unresponssive and no BP reading could not be obtained.

6. Ensure LVN 2 immediately notified Physician 1 on [DATE REDACTED] at 12:30 AM, when Resident 53 was found unresponsive to tactile (touch) and verbal stimuli, with no BP reading and diminished respirations of eight (8) breaths per minute.

7. Ensure to develop a plan of care for Resident 53 to address how the resident will be monitored and assessed for TIA and Stroke and A-Fib.

On [DATE REDACTED] at 8:35 PM, during the facility's Recertification Survey, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified regarding significant changes

in Resident 53's vital signs, in accordance with the facility's policy on Change of Condition Notification and assessment for a change of condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 34 555839 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 On [DATE REDACTED] at 8:31 PM, the IJ was removed after the surveyors verified and confirmed the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record Level of Harm - Immediate review. The IJ was removed in the presence of the Administrator (ADM), Director of Staff Development jeopardy to resident health or (DSD), and Compliance Consultant (CC). The acceptable IJ Removal Plan included the following: safety Current licensed nurses will be re-in serviced in person on [DATE REDACTED] regarding assessment, monitoring, Residents Affected - Few evaluation for a history of TIA and stroke. DSD/Designee will in-service licensed staff in person by [DATE REDACTED] to complete a 100% in-service to licensed staff.

DSD/Designee will complete random audits to test knowledge of in-service regarding assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke. Results will be logged on the spot check tool. Audits will be completed 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months.

LVN 1, LVN 2, and RN 1 will be provided an additional 1:1 in-service on assessment, monitoring, and evaluation for a history of TIA and stroke, including documentation for any changes.

Residents with any changes in condition, including those with TIA and stroke will be reviewed in morning meeting by the Interdisciplinary Team (IDT-a team of staff that works in team to develop the plan of care for

the residents).

Any findings on the audit tool will be addressed, 1:1 in-service will be provided as needed.

Review of documentation, including assessment, monitoring, and evaluation for a history of TIA and stroke associated with a change in condition, will be completed at various times weekly by DON/Designee for the next 30 days then semimonthly for 1 month then monthly for 1 month. 1:1 in-service will be provided as needed.

Consultant will review a random sampling of resident charts, based on a list provided by the facility, on a regular basis for 30 days or California Department of Public Health (CDPH) revisit, whichever is longer, to verify that appropriate assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke associated with a change in condition has been documented. Issues noted will be resolved and additional in-services will be provided as needed.

As a result of these deficient practices Resident 53 did not receive the immediate care and emergency interventions to ensure the residents vital signs (measurement of the blood pressure, heart rate, respirations and body temperature) returns to baseline status, thereby increasing the blood supply to the resident's body. Resident 53's vital signs and mental status continued to decline which was no rechecked and was pronounced dead by the paramedics on [DATE REDACTED] at 12:43 AM.

Cross Reference to