Golden Haven Care Center

F-F635

Findings:

During a review of Resident 1 ' s GACH 1 record, titled, Inpatient Progress Notes, dated [DATE REDACTED], indicated Resident 1 had a diagnosis of DM. The GACH 1 record indicated a plan to continue Resident 1 ' s insulin medication to maintain a blood sugar goal of less than 180.

During a review of Resident 1 ' s GACH 1 record titled Discharge Documentation dated [DATE REDACTED], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management upon admission in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1 ' s last blood

sugar result in GACH 1 on [DATE REDACTED] was 157.

During a review of Resident 1 ' s Facility Admission Record indicated the resident was admitted to the facility

on [DATE REDACTED], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process] abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0711 During a review of Resident 1 ' s Facility Nursing Admission Assessment, dated [DATE REDACTED], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE REDACTED] at around 5:10 P. Level of Harm - Minimal harm or M. The Nursing Admission Assessment indicated Resident 1 had a diagnosis of DM Type 2. potential for actual harm

During a review of Resident 1 ' s care plan titled, initiated on [DATE REDACTED] and revised on [DATE REDACTED], indicated to Residents Affected - Few prevent complications related to diabetes, Resident 1 will be monitored and will document, and report signs and symptoms of hyperglycemia and hypoglycemia to the physician.

During review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated [DATE REDACTED], indicated the resident had severely impaired cognition (ability to remember and process information). The MDS also did not indicate that Resident 1 had a diagnosis of DM. The MDS also indicated Resident 1 did not have an order for insulin (a type of hormone that is used as an injectable medication to control the blood sugar for a person with DM).

During a review of Resident 1 ' s History and Physical (H&P), dated [DATE REDACTED], signed by MD, indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of DM. The H&P did not indicate to administer insulin to the resident or to monitor blood sugar level.

During a review of Resident 1 ' s, Order Summary Report (a list of physician ' s orders), dated [DATE REDACTED] included an order to administer Insulin Lispro (medication that lowers blood sugar) Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] (Insulin Lispro) Inject as per sliding scale. The report indicated

the order for Insulin Lispro was discontinued on [DATE REDACTED]. The record indicated the reason for discontinuing was clarification of order. There was no documented evidence in Resident 1 ' s physician orders the reason to discontinue Lispro and the clarification needed.

During a review of Resident 1 ' s clinical record titled, Discontinue Order, dated [DATE REDACTED], timed at 11:17 PM, indicated Insulin Lispro was discontinued on [DATE REDACTED], timed at 11:16 PM. The record indicated the reason for discontinuing was clarification of order, but did not indicate what was clarified with the physician. The record also indicated the discontinuation was ordered by MD and there was indication for the reason the insulin was discontinued or not ordered.

During a review of Resident 1 ' s Interdisciplinary Team Conference Record (IDT, a multidisciplinary meeting), dated [DATE REDACTED], indicated Resident 1 had a diagnosis of DM. The IDT did not have documented evidence that Resident 1 ' s DM was discussed during the IDT and did not discuss that the MD ordered the resident to receive insulin and blood sugar to be monitored.

During a review of Resident 1 ' s Medication Administration Record (MAR) for February 2024, [DATE REDACTED], and [DATE REDACTED], did not have documented evidence that Resident 1 was administered Insulin Lispro, the blood sugar level was monitored. and that staff monitored Resident 1 for signs and symptoms of hypoglycemia or hyperglycemia, as indicated in the resident ' s care plan.

During a review of Resident 1 ' s Transfer Form, dated [DATE REDACTED], timed at 6:42 PM, indicated Resident 1 was transferred to GACH 2, due to altered mental status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0711 During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE REDACTED], indicated Resident 1 was found with labored breathing and blood sugar level of 500 (mg/dL). The CIC also indicated Resident 1 Level of Harm - Minimal harm or had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The potential for actual harm CIC also indicated Resident 1 was transferred via 911 to GACH 2.

Residents Affected - Few During a review of Resident 1 ' s Emergency Department Reports from GACH 2, dated [DATE REDACTED], indicated the resident was admitted to the Emergency Department (ED) on [DATE REDACTED] at 6:48 PM with chief complaint of altered mental status and the blood sugar was high. The report indicated on [DATE REDACTED] at around 5:50 PM, [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated by [facility staff], they noted that she was breathing heavily and not speaking. The report also indicated the facility staff tried to measure [Resident 1 ' s] sugar, their glucometer (a device used to measure

the blood sugar) read as high. Additionally, the laboratory blood test conducted in the ED indicated the following:

1. Arterial Blood Gas (ABG)- pCO2 level of 17.0 (pCO2, partial pressure of carbon dioxide, the measure of carbon dioxide within the blood, normal levels fall between 35 to 45) a sign indicating ketoacidosis.

2. ABG- pO2 level of 306 (pO2, partial pressure oxygen level, the amount of oxygen gas dissolved in the blood, normal levels fall between 75 to 100) high pressure of oxygen in the lungs that could cause lungs to collapse.

3. ABG- HCO3 level of 9.6 (HCO3, bicarbonate, concentration of bicarbonate in arterial blood, normal levels fall between 22 to 26) indication of metabolic acidosis (the body produces too much acid that could be caused by ketoacidosis).

4. Blood Sugar of 810 mg/dL (Normal levels fall between 70 to 100)

During a review of the Emergency Department Reports from GACH 2, dated [DATE REDACTED], indicated the resident had a diagnosis of DKA. The ED report also indicated the resident was started on insulin drip (insulin that is administered directly through a person ' s vein) and was admitted to the Intensive Care Unit (ICU, a specialized unit in a hospital that caters to patients that are critically ill) for DKA.

During a review of Resident 1 ' s Discharge Summaries Notes from GACH 2, dated [DATE REDACTED], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person ' s heart stopped and basic life support was provided] and expired on ,d+[DATE REDACTED] while in the ICU. The notes indicated the final diagnoses of:

1. Diabetes Mellitus Type 2

2. Hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time)

3. Diabetic Ketoacidosis

4. Sepsis (a serious condition in which the body responds improperly to an infection)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0711 During a review of Resident 1 ' s Certificate of Death indicated Resident 1 expired on [DATE REDACTED] at 6:45 AM in GACH 2. The certificate indicated the immediate cause of death as Diabetic Ketoacidosis and sequentially, Level of Harm - Minimal harm or Diabetes Mellitus Type 2. potential for actual harm

During a concurrent interview and record review on [DATE REDACTED] at 1:28 PM with MDS Nurse, Resident 1 ' s Residents Affected - Few clinical records, including the progress notes, were reviewed. The MDS Nurse stated there is no documented evidence in Resident 1 ' s clinical record that the physician ordered insulin or to monitor the Resident 1 ' s blood sugar. The MDS Nurse also indicated there was no documented evidence that the staff administered insulin to Resident 1 and monitored Resident 1 ' s blood sugar. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored.

During the same concurrent interview and record review of Resident 1's Order Summary Report, dated [DATE REDACTED] on [DATE REDACTED] at 1:28 PM, the MDS Nurse stated the report had a signature but did not indicate who signed it and when it was signed. The MDS Nurse stated there should be a name and a date along with the signature. The MDS Nurse stated the signature is an indication that Resident 1 ' s medications were reviewed by the physician who signed it. The MDS Nurse stated the Order Summary Report did not have an order for insulin or blood sugar monitoring.

During a phone interview on [DATE REDACTED] at 1:19 PM with MD 1, MD 1 stated he does not recall Resident 1 but he was the primary physician for the resident since admitted to the facility. MD 1 stated residents admitted to the facility from a hospital usually continues medications at the facility because the medications had been reviewed and optimized for the resident. MD 1 stated Resident 1 ' s insulin should have been continued to be administered in the facility and there should have been an order for blood sugar monitoring because if sugar is not checked the resident could develop hyperglycemia and DKA could lead to septic induced hyperglycemia. MD 1 stated the DKA cause Resident 1 to become dehydrated, acidotic, ketosis and death if

the resident does not get immediate help. MD 1 stated he was not sure why Resident 1 ' s insulin was discontinued and why there was no order for the blood sugar to be monitored. MD 1 stated he was not aware that the blood sugar of Resident 1 was not being checked. MD 1 stated the doctors have the final say and oversee discontinuing the medications.

During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Care, revised [DATE REDACTED], indicated blood [sugar] levels will be monitored at specific intervals as ordered by the attending physician.

During a review of the facility ' s P&P titled, Admission and Orientation of Residents, revised [DATE REDACTED], indicated the following:

1. The resident ' s physician will provide medical orders, including a medical condition or problem associated with each medication.

2. The resident ' s physician will provide routine care orders to maintain or improve the resident ' s function.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0711 During a review of the facility ' s P&P titled, Physician Services & Visits, revised [DATE REDACTED], indicated the physician is to provide advice, treatment, and determination of appropriate level of care needed for each Level of Harm - Minimal harm or [resident]. The P&P also indicated for the physician ' s participation in the resident ' s assessment and care potential for actual harm planning and monitoring changes in resident ' s medical status. The P&P also indicated for the physician to participate in an evaluation of the [resident] and review of orders for care and treatment. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48854

Residents Affected - Few Based on interview and record review, the facility failed to ensure the facility ' s pharmacy consultant thoroughly reviewed and reported irregularities to the attending physician and the facility ' s medical director and Director of Nursing (DON) during Medication Regimen Review (MRR-a structured, critical examination of

a person's medicines of the residents to ensure they receive the right medications and monitoring needed to optimize the impact of medicines) for one of one sampled residents (Resident 1) who was admitted to the facility from [DATE REDACTED] to [DATE REDACTED] (total 2 months), with diagnosis of Diabetes Mellitus Type 2 (DM, a chronic disease where a person has high blood sugar [glucose] levels) and did not receive insulin that was discontinued without clear indication and blood sugar was not monitored.

As a result of this failure, Resident 1 ' s blood sugar level was not monitored and did not receive any Lispro (medication to control blood sugar level) from [DATE REDACTED] to [DATE REDACTED]. On [DATE REDACTED] at 6:42 PM, Resident 1 was transferred to General Acute Care Hospital (GACH) 2 via 911 (an emergency number for any police, fire, or medic) due to altered mental status and with a blood sugar reading of 500 (normal levels are between 70 to 100). Resident 1 was admitted to GACH 2 with a diagnosis of Diabetic Ketoacidosis (DKA, a life-threatening problem related to DM in which the body starts breaking down fat too fast) and expired 2 days after on [DATE REDACTED].

Cross reference to

F-F711

Findings:

During a review of Resident 1 ' s GACH 1 record, titled, Inpatient Progress Notes, dated [DATE REDACTED], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1 ' s insulin medication to maintain a blood sugar goal of less than 180.

During a review of Resident 1 ' s GACH 1 record titled Discharge Documentation dated [DATE REDACTED], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management upon admission in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1 ' s last blood sugar result in GACH 1 on [DATE REDACTED] was 157.

During a review of Resident 1 ' s Facility Admission Record indicated the resident was admitted to the facility

on [DATE REDACTED], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process] abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure).

During a review of Resident 1 ' s Facility Nursing Admission Assessment, dated [DATE REDACTED], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE REDACTED] at around 5:10 P. M. The Nursing Admission Assessment indicated Resident 1 had a diagnosis of DM Type 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0756 During a review of Resident 1 ' s facility records titled, Discontinue Order, dated [DATE REDACTED], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1 for Insulin Lispro Sliding Scale to be discontinued Level of Harm - Minimal harm or on [DATE REDACTED], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order. potential for actual harm During the review of the resident ' s physician orders, there was no additional orders or justification for Lispro insulin after it had been discontinued. Residents Affected - Few

During a review of Resident 1 ' s History and Physical (H&P), dated [DATE REDACTED], signed by MD 1, indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of DM.

During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated [DATE REDACTED], indicated the resident had severely impaired cognition (ability to remember and process information). The MDS also did not indicate that Resident 1 had a diagnosis of DM. The MDS also indicated Resident 1 did not have an order for insulin (a type of hormone that is used as an injectable medication to control the blood sugar for a person with DM).

During a review of Resident 1 ' s clinical record from General Acute Care Hospital (GACH) 1 that was provided by the facility titled, Inpatient Progress Notes, dated [DATE REDACTED], timed at 8:51 PM, indicated Resident 1 had DM. The GACH 1 record indicated a plan to continue Resident 1 ' s insulin.

During a review of Resident 1 ' s Order Summary Report (OSR) for all orders during Resident 1 ' s stay at

the facility from [DATE REDACTED] to [DATE REDACTED], included a physician order to administer Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE REDACTED]. The OSR indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE REDACTED].

During a review of Resident 1 ' s Order Summary Report, dated [DATE REDACTED], did not include an order for insulin or blood sugar monitoring. The report was signed but does not indicate the person who the signed the report

on the section right next to the signature. The report did not indicate the date when the report was signed.

During a review of Resident 1 ' s facility records titled, Discontinue Order, dated [DATE REDACTED], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1, for Insulin Lispro Sliding Scale to discontinue on [DATE REDACTED], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order.

During a review of Resident 1 ' s clinical record titled, Discontinue Order, dated [DATE REDACTED], timed at 11:17 PM, signed by LVN 1, indicated the order for Insulin Lispro was discontinued on [DATE REDACTED], timed at 11:16 PM. The

record indicated the reason for discontinuing was clarification of order. The record also indicated the discontinuation was ordered by MD.

During a review of Resident 1 ' s Medication Administration Record (MAR) for February 2024, [DATE REDACTED], and [DATE REDACTED], did not have documented evidence that Resident 1 was administered Insulin Lispro. The MAR also did not have documented evidence that Resident 1 ' s blood sugar level was monitored. The MAR also did not have documented evidence that staff monitored Resident 1 for signs and symptoms of hypoglycemia or hyperglycemia, as indicated in the resident ' s care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0756 During a review of Resident 1 ' s Interdisciplinary Team Conference Record (IDT, a multidisciplinary meeting ), dated [DATE REDACTED], indicated Resident 1 had a diagnosis of DM. The IDT did not have documented evidence Level of Harm - Minimal harm or that Resident 1 ' s DM was discussed during the IDT. potential for actual harm

During a review of the facility ' s Medication Regimen Review (MRR, process conducted, usually by a Residents Affected - Few pharmacist , to review a resident ' s medication regimen) MRR for the months of ,d+[DATE REDACTED], ,d+[DATE REDACTED], and , d+[DATE REDACTED], the MRR did not have documented evidence that Pharmacist Consultant (PH) 1 addressed or provided pharmacy recommendations related to Resident 1 ' s diagnosis of DM. The MRR did not indicate recommendations for blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. The MRR did not have documented evidence that PH 1 informed the DON or MD 1 to recommend to check the blood sugar level of Resident 1 to determine if the resident required DM management.

During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE REDACTED], timed at 7:04 PM, indicated Resident 1 was found to have labored breathing and with a blood sugar level of 500 (mg/dL). The CIC also indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD and family were notified. The CIC also indicated Resident 1 was transferred via 911 to GACH 2.

During a review of Resident 1 ' s Emergency Department Reports from GACH 2, dated [DATE REDACTED], indicated the resident was admitted to the Emergency Department (ED) on [DATE REDACTED] at 6:48 PM with chief complaint of altered mental status and the blood sugar was high with laboratory blood test conducted in the ED indicated Resident 1 ' s blood Sugar level of 810 (Normal levels fall between 70 to 100).

During a review of the Emergency Department Reports from GACH 2, dated [DATE REDACTED], indicated the resident had a diagnosis of DKA. The ED report also indicated the resident was started on insulin drip (insulin that is administered directly through a person ' s vein) and was admitted to the Intensive Care Unit (ICU, a specialized unit in a hospital that caters to patients that are critically ill) for DKA. The report also indicated Resident 1 ' s condition as critical.

During a review of Resident 1 ' s MAR from GACH 2 indicated the resident received the following medication between [DATE REDACTED] to [DATE REDACTED]:

1. Insulin drip: Insulin regular 100 units [units, a unit of measure] (1 units/hour) + manufacturer premix 100 mL. The order was started on [DATE REDACTED] at 11:39 PM.

2. Vasopressin: Vasopressin 20 units (0.03 units/min) + manufacturer premix 100 mL. The order was started

on [DATE REDACTED] at 3:00 PM.

During a review of Resident 1 ' s H&P from GACH 2, dated [DATE REDACTED], timed at 1:05 AM, indicated Resident 1 intubated (a person that is intubated underwent a process in which a plastic tube is inserted through the mouth and into the person ' s airway for the purpose of providing artificial breaths) with

During a review of Resident 1 ' s H&P from GACH 2, dated [DATE REDACTED], times at 1:07 AM, indicated Resident 1 ' s MAR from the facility did not include any medications for Resident 1 ' s DM. The notes indicated Resident 1 had a diagnosis of DM and was receiving insulin during a recent hospitalization .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0756 During a review of Resident 1 ' s Discharge Summaries Notes from GACH 2, dated [DATE REDACTED], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person ' s heart stopped and basic life Level of Harm - Minimal harm or support was provided] and expired on ,d+[DATE REDACTED] while in the ICU with the primary diagnosis of DKA and potential for actual harm sepsis.

Residents Affected - Few During a review of Resident 1 ' s Certificate of Death indicated Resident 1 expired on [DATE REDACTED] at 6:45 AM in GACH 2. The certificate indicated the immediate cause of death as Diabetic Ketoacidosis and sequentially, Diabetes Mellitus Type 2.

During a concurrent interview and record review on [DATE REDACTED] at 1:28 PM with the MDS Nurse, Resident 1 ' s entire medical records, including the progress notes, were reviewed. The MDS Nurse stated there is no documented evidence that licensed staff administered insulin to Resident 1 and monitored Resident 1 ' s blood sugar. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored.

During a phone interview on [DATE REDACTED] at 11:45 AM with PH 1, PH 1 stated she only reviews the residents ' current medications and not discontinued medications or the resident ' s diagnoses when making recommendations. PH 1 added she would not have known if a resident was taking insulin if the insulin was discontinued. PH 1 stated if she was aware that Resident 1 had a diagnosis of DM, she would have recommended for the resident to have the blood sugar monitored and for the resident to start receiving medications to control the blood sugar.

During a phone interview on [DATE REDACTED] at 1:19 PM with MD 1, MD 1 stated Resident 1 ' s insulin should have been continued and Resident 1 ' s blood sugar should have been monitored. MD 1 stated a resident who has

a diagnosis of DM and who was not receiving insulin could suffer DKA. MD 1 stated DKA could cause death.

During a concurrent interview and record review on [DATE REDACTED] at 5:25 PM with Director of Nursing (DON), the facility ' s Medication Regiment Review (MRR) for February 2024, [DATE REDACTED], and [DATE REDACTED], was reviewed. The DON stated the MRR does not have any recommendations, such as adding insulin to Resident 1 ' s medication regimen or blood sugar monitoring, from PH 1 to address Resident 1 ' s diagnosis of DM.

During a review of the facility ' s job description titled, Consultant Pharmacist, undated, indicated the pharmacist is to:

1. Provide physicians, nurses, and patients with therapeutic recommendations and/or medication information.

2. Report any drug regimen irregularities to the attending physician and Director of Nursing.

During a review of the facility ' s P&P titled, Drug Regimen Review, revised [DATE REDACTED], indicated the following:

1. The pharmacist will review each resident ' s medication regimen at least once a month to identify irregularities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0756 2. Irregularity refers to identification of conditions that may warrant initiation of medication therapy.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 056317

F-F756

Findings:

During a review of Resident 1 ' s GACH 1 record, titled, Inpatient Progress Notes, dated [DATE REDACTED], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1 ' s insulin medication to maintain a blood sugar goal of less than 180.

During a review of Resident 1 ' s GACH 1 record titled Discharge Documentation dated [DATE REDACTED], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further

review of the Discharge Documentation indicated Resident 1 ' s last blood sugar result in GACH 1 on [DATE REDACTED] was 157.

During a review of Resident 1 ' s Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process]) abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure).

During a review of Resident 1 ' s Nursing Admission Assessment, dated [DATE REDACTED], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE REDACTED] at around 5:10 P.M. The Nursing Admission Assessment indicated Resident 1 had a diagnosis of DM Type 2.

During a review of Resident 1 ' s care plan titled, The resident [Resident 1] has DM, initiated on [DATE REDACTED] and revised on [DATE REDACTED], indicated a goal for the resident to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 During a review of Resident 1 ' s Order Summary Report (OSR) for all orders during Resident 1 ' s stay at

the facility from [DATE REDACTED] to [DATE REDACTED], included a physician order to administer Insulin Lispro [a class of insulin Level of Harm - Immediate hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a jeopardy to resident health or guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE REDACTED]. The OSR safety indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE REDACTED].

Residents Affected - Few During a review of Resident 1 ' s facility records titled, Discontinue Order, dated [DATE REDACTED], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1, for Insulin Lispro Sliding Scale to discontinue on [DATE REDACTED], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order.

During a review of Resident 1 ' s Admission MDS, dated [DATE REDACTED], indicated the resident had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The Admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM.

During a review of Resident 1 ' s Admission MDS, dated [DATE REDACTED], indicated the resident had severely impaired cognition (ability to remember and process information). The Admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM.

During a review of Resident 1 ' s IDT Conference Record, dated [DATE REDACTED], signed by different members of the facility ' s IDT from the Nursing Department, Activities Department, and Social Services, participated by Resident 1 ' s family member (FM 1), the IDT Record indicated Resident 1 had a diagnosis that included dementia and DM Type 2. The IDT Record indicated Resident 1 ' s plan of care to receive physical therapy (a healthcare profession that helps an individual ' s body improve and perform physical movements) and occupational therapy (therapy based on engagement in meaningful activities of daily life) while residing at the facility and the discharge goals to go home with FM 1. The IDT Conference Record did not indicate information that IDT addressed Resident 1 ' s plan of care for management of DM.

During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE REDACTED], timed at 7:04 PM, the CIC indicated Resident 1 was found to have labored breathing (a non-medical term used to describe when breathing is difficult or impaired) and with a blood sugar level of 500. The CIC indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Resident 1 ' s family were notified. The CIC indicated Resident 1 was transferred via 911 emergency services to GACH 2 on [DATE REDACTED].

During a review of Resident 1 ' s Transfer Form, dated [DATE REDACTED], the Transfer Form indicated Resident 1 was transferred to GACH 2 on [DATE REDACTED]. The Transfer Form indicated the reason for the transfer was due to altered mental status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 During a review of Resident 1 ' s GACH 2 Emergency Department [ED] Reports dated [DATE REDACTED], indicated the resident was admitted to the ED on [DATE REDACTED] at 6:48 PM with a chief complaint of altered mental status and Level of Harm - Immediate having a blood sugar of High [a glucometer (a portable device used to measure blood sugar levels) reading jeopardy to resident health or that means a very high blood sugar level above 600]. The GACH 2 ED Report indicated At around 5:50 PM, safety [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated they [facility staff], noted that she [Resident 1] was breathing heavily [difficulty breathing] and not Residents Affected - Few speaking. The GACH 2 ED Report indicated the facility staff tried to measure [Resident 1 ' s] [blood] sugar, and the glucometer read as high. The GACH 2 ED Report indicated Resident 1 ' s blood sugar level taken at

the GACH 2 upon arrival to the ED was 810.

During the same review of Resident 1 ' s GACH 2 ED Report dated [DATE REDACTED], indicated a diagnosis of DKA.

The GACH 2 ED Report indicated the resident was started on insulin drip (insulin that is administered directly through a person ' s vein) and was admitted to the ICU for management of the DKA.

During a review of Resident 1 ' s GACH 2 Medication Administration Records (MAR), the GACH 2 MAR indicated GACH 2 started Resident 1 on insulin drip (insulin given through an intravenous [IV-through the vein] to get into the body more quickly to bring down high blood sugar) on [DATE REDACTED].

During a review of Resident 1 ' s GACH 2 records titled Discharge [DC] Summaries Notes, dated [DATE REDACTED], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person ' s heart stopped and basic life support was provided] and expired on [DATE REDACTED] while in the ICU. The GACH 2 DC Summary indicated Resident 1 ' s final diagnoses included DM Type 2, hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time),

DKA, sepsis (a serious condition in which the body responds improperly to an infection), and altered mental status .

During a review of Resident 1 ' s Certificate of Death indicated Resident 1 expired on [DATE REDACTED] in GACH 2.

The Certificate of Death indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated Diabetes Mellitus Type 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 During a concurrent interview on [DATE REDACTED] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE REDACTED] to [DATE REDACTED], the MDS Nurse stated there were no Level of Harm - Immediate documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for jeopardy to resident health or Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE REDACTED]. The MDS Nurse stated there safety was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed Residents Affected - Few staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE REDACTED], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE REDACTED]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s Admission MDS [on [DATE REDACTED]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE REDACTED] and revised on [DATE REDACTED].

During a concurrent interview on [DATE REDACTED] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE REDACTED] to [DATE REDACTED], the MDS Nurse stated there were no documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE REDACTED]. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE REDACTED], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE REDACTED]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s Admission MDS [on [DATE REDACTED]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE REDACTED] and revised on [DATE REDACTED].

During the same interview, on [DATE REDACTED], at 1:28 PM, the MDS Nurse stated that she had reviewed the GACH 1 records, provided to the facility upon Resident 1 ' s admission on [DATE REDACTED]. The MDS Nurse stated the GACH 1 records indicated Resident 1 was receiving insulin from the GACH. The MDS Nurse stated the facility should have continued Resident 1 ' s blood sugar monitoring and insulin because it was the GACH 1 ' s discharge plans for Resident 1, prior to facility admission. The MDS Nurse stated there was no documented evidence the facility ' s licensed nurses monitored Resident ' s blood sugar from [DATE REDACTED] to [DATE REDACTED]. The MDS Nurse stated the only blood sugar result she found for Resident 1 was taken on [DATE REDACTED], with a blood sugar result of 500.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 During a concurrent interview and record review of Resident 1 ' s entire facility records, from [DATE REDACTED] to [DATE REDACTED], and the facility ' s policy and procedure on Admission Assessment and Admission and Orientation of Level of Harm - Immediate Residents on [DATE REDACTED] at 2:48 PM, LVN 2 stated there was no documented evidence that another licensed jeopardy to resident health or nurse, reviewed Resident 1 ' s medication orders the next day after the resident ' s admission to the facility. safety LVN 2 reviewed the policy and procedures on Admission and Orientation of Residents, that indicated a registered nurse will conduct the initial assessment of the resident. LVN 2 stated when a resident is admitted Residents Affected - Few during the evening or night shift by an LVN, an RN must re-assess the resident again the next day, which should include the verification of the resident ' s medication orders. LVN 2 stated there was no documented evidence that another licensed staff (RN or another LVN) conducted a drug review of Resident 1 ' s medication orders and re-assess Resident 1 the next day, which should include verification of the resident ' s medication orders, as indicated in the facility ' s policy titled Admission Assessment and Admission and Orientation of Residents to ensure all the required orders were included.

During a phone interview on [DATE REDACTED] at 4:25 PM with LVN 1, LVN 1 stated when a resident is admitted to the facility, the admitting nurse calls the physician and asks if the attending physician would like to continue everything [medication orders from the GACH]. LVN 1 stated she does not verbally read over the resident ' s entire medication list to the physician. LVN 1 stated she could not remember if she spoke to MD 1 on [DATE REDACTED], when she admitted Resident 1 to the facility. LVN 1 stated she could not remember discontinuing any insulin medications or blood sugar monitoring for Resident 1 on [DATE REDACTED]. LVN 1 stated discontinuing an insulin order required a valid reason such as supporting the discontinuation with laboratory results such as a Hemoglobin [Hb] A1C (a common blood test used to diagnose type 1 and type 2 diabetes) laboratory result. LVN 1 stated the facility practice was for the MDS Nurse to review a newly admitted resident ' s GACH records and for the RN supervisor to review the admission orders for accuracy.

During an interview on [DATE REDACTED] at 6:45 PM with the DON, the DON stated it is the licensed nurse ' s responsibility to notify the physician if a resident ' s medical diagnosis was not addressed, such as not having medications for a resident ' s diagnosis of DM. The DON stated for a resident with a diagnosis of DM, the expectation is for the licensed nurse to ask the physician to add an order for blood sugar monitoring. The DON stated discontinuing insulin must be supported by enough justification such as blood sugar trends or laboratory values like the Hemoglobin A1C.

During a concurrent interview and record review of Resident 1 ' s IDT Conference Record dated [DATE REDACTED], and

the resident ' s entire records from [DATE REDACTED] to [DATE REDACTED], on [DATE REDACTED] at 9:55 AM with the DON, the DON stated

the IDT Record did not show evidence that Resident 1 ' s DM was addressed. The DON stated the IDT

record did not indicate a plan for Resident 1 ' s DM such as adding an order for insulin or blood sugar monitoring. The DON stated he could not find documented evidence the facility ' s IDT addressed Resident 1 ' s DM plan of care interventions on [DATE REDACTED], to meet care plan goals to prevent complications related to diabetes that included monitoring, documenting, and reporting signs and symptoms of hyperglycemia and hypoglycemia. The DON stated the standard of practice for residents with DM should include blood sugar monitoring or a Hemoglobin A1C result and visual monitoring of signs and symptoms of DM. The DON stated there was no evidence in Resident 1 ' s records that the facility ' s licensed nurses monitored the resident for signs and symptoms of hypoglycemia, hyperglycemia and other signs and symptoms of DM such as frequent urination or increased thirst. The DON stated there was no laboratory order made by the physician (MD 1) that included Hb A1c during the resident ' s stay in the facility from [DATE REDACTED] to [DATE REDACTED]. The DON stated that Resident 1 ' s MAR from [DATE REDACTED] to [DATE REDACTED] did not indicate Resident 1 was monitored for blood sugar levels and DM signs and symptoms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 During a review of the facility ' s MRR for the months of ,d+[DATE REDACTED], ,d+[DATE REDACTED], and ,d+[DATE REDACTED], the MRR did not have documented evidence that Pharmacist Consultant (PH) 1 addressed or provided pharmacy Level of Harm - Immediate recommendations related to Resident 1 ' s diagnosis of DM. The MRR did not indicate recommendations for jeopardy to resident health or blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. safety

During an interview, on [DATE REDACTED] at 11:45 AM, PH 1 stated she comes to the facility on ce a month to review Residents Affected - Few the facility residents ' medications. PH 1 stated she reviews the residents ' current medications only and does not look at a resident ' s diagnoses when making her recommendations. PH 1 stated, she was not part of the medication review when a resident gets admitted to the facility. PH 1 stated, she does not look at admission orders that were not current or had been discontinued. PH 1 stated she would only be able to recommend insulin medication for a resident, if the resident was getting their blood sugars checked and would base her recommendations on the results of the blood sugar checks. PH 1 stated she could not remember Resident 1 and did not check the resident ' s medication records why Resident 1 ' s insulin and blood sugar checks were discontinued on admission ([DATE REDACTED]). PH 1 stated that if she knew Resident 1 had diabetes and did not have any blood sugar checks, she would have recommended for blood sugar checks or a Hemoglobin A1C laboratory test to be done and would have recommended insulin or oral diabetes medications (medications taken by mouth to manage blood sugar levels).

During an interview on [DATE REDACTED] at 1:19 PM, MD 1 stated that normally the current medications from the acute hospital are continued when a resident is admitted to the facility. MD 1 stated he could not remember Resident 1, but he signed and performed the resident ' s History and Physical assessment on [DATE REDACTED]. MD 1 stated, generally, unless the discharging physician in the GACH discontinued the GACH medications, the expectation is for current medications to be continued at the facility. MD 1 stated, he reviewed the medications of Resident 1 from GACH 1 and stated that all current medications was supposed to be continued. MD 1 stated Resident 1 ' s insulin medications should not have been discontinued. MD 1 stated Resident 1 ' s insulin should have been continued at the upon admission to the facility on [DATE REDACTED]. MD 1 stated, he does not discontinue insulin medications, once admitted to the facility, but would review for any dosage changes. MD 1 stated, he was not aware Resident 1 ' s insulin was not continued in the facility and that there was no blood sugar monitoring ordered for the resident. MD 1 stated, if insulin is discontinued, the resident could get hyperglycemic [increase blood sugar levels]. MD 1 stated, Resident 1 should have received insulin while in the facility. MD 1 stated, Resident 1's blood sugar levels could go high if not monitored and complication such as DKA could happen and result in death. MD 1 stated, he was not aware Resident 1 did not have an order for blood sugar monitoring, and if he knew that Resident 1 had a diagnosis of diabetes, he would have placed an order for blood sugar monitoring. MD 1 stated he expected the facility ' s licensed nurses to let him know that Resident 1 did not have blood sugar monitoring for the management of DM. MD 1 stated, discontinuing insulin needs documented justification and could not recall if the facility ' s licensed nurses informed him of Resident 1 ' s blood sugar monitoring.

During an interview on [DATE REDACTED] at 5:25 PM, the DON stated that PH 1 did not have any pharmacy recommendations for Resident 1 for the months of ,d+[DATE REDACTED], ,d+[DATE REDACTED], and ,d+[DATE REDACTED].

During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Care, revised [DATE REDACTED], indicated

the following:

1. The purpose of the P&P is to provide a protocol for the immediate treatment of hypoglycemia in residents diagnosed with diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 2. The Licensed Nurse will monitor residents for signs and symptoms (of) hypoglycemia and hyperglycemia. Signs and symptoms will be documented in the resident ' s medical record and the Attending Physician will Level of Harm - Immediate be notified. jeopardy to resident health or safety 3. Notify the Attending Physician of treatment and results and for any possible changes in insulin or oral diabetes medications. Residents Affected - Few

During a review of the facility ' s P&P titled, Admission and Orientation of Residents, revised [DATE REDACTED], indicated the following:

1. The resident ' s physician will provide medical orders, including a medical condition or problem associated with each medication.

2. The resident ' s physician will provide routine care orders to maintain or improve the resident ' s function.

3. A registered nurse will conduct the initial assessment of the resident.

During a review of the facility ' s P&P titled, Admission Assessment, [DATE REDACTED], indicated the the licensed nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues.

During a review of the facility ' s policy and procedure titled Care Planning dated [DATE REDACTED], indicated each resident should have a comprehensive person-centered care plan developed and implemented based on individual assessed needs.

During a review of the facility ' s job description titled, Consultant Pharmacist, (undated) indicated the pharmacist is to:

1. Provide physicians, nurses, and patients with therapeutic recommendations and/or medication information.

2. Report any drug regimen irregularities to the attending physician and Director of Nursing.

During a review of the facility ' s job description titled, Charge Nurse (oversee the operations of their specific nursing unit) dated Year 2003, indicated the Charge Nurse ' s duties and responsibilities include:

1. Report all discrepancies noted concerning physician ' s orders, diet change, charting error, etc. to the Nurse Supervisor.

2. Consult with the resident ' s physician in providing resident ' s care, treatment, rehabilitation etc, as necessary.

3. Review the resident ' s chart for specific treatments, medication orders, diet,[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 056317 Department of Health & Human Services Printed: 09/13/2025 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 056317 B. Wing 08/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

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 0711 Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48854

Residents Affected - Few Based on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) assessed and evaluated the total program of care for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by ensuring the resident ' s blood sugar was monitored [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and Lispro ( a medication that lowers the blood sugar level) to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) was not administered while under the physician ' s care in the facility from [DATE REDACTED] to [DATE REDACTED] ( a total of 61 days).

As a result of this failure, Resident 1 ' s blood sugar was not monitored and did not receive any medication to control Resident 1 ' s blood sugar from [DATE REDACTED] to [DATE REDACTED]. On [DATE REDACTED] at 6:42 PM, Resident 1 was transferred to General Acute Care Hospital (GACH) 2 via 911 emergency services (an emergency number for any police, fire, or medic) due to altered mental status and with a blood sugar reading of 500 (normal levels are between 70 to 100), oxygen desaturation (low oxygen blood level), and hyperglycemia. Resident 1 was admitted to GACH 2 with a diagnosis of Diabetic Ketoacidosis (DKA, a life-threatening problem related to DM in which the body starts breaking down fat too fast) and expired 2 days after admission to GACH 2 on [DATE REDACTED].

Cross reference to