Griffith Park Healthcare Center

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bedside. The DON stated the facility did not have any documentation of any type of assessment for Resident 1 regarding self-administering medications. The DON stated having the supplements by Resident 1's bedside and Resident 1 verbalizing she takes it herself had the potential to cause an overdose of the supplements that could affect her health. A review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, revised 12/2016, indicated a) Residents had the right to self-administer medications if the interdisciplinary team determined that it was clinically appropriate and safe for the resident to do so, b)as part of the overall evaluation, the staff and practitioner would assess each resident mental and physical abilities whether self-administering medications was clinically appropriate for the resident, c)the staff and practitioner would document their findings who are identified being able to self-administer medications, and d) nursing staff would review the self -administered medication recorded

on each nursing shift and transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Griffith Park Healthcare Center

201 Allen Ave.

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 0636 Level of Harm - Minimal harm or potential for actual harm

intervals designated by OBRA (federal standards for nursing home care to protect residents' rights, safety, and quality of life) requirement, b) OBRA required assessments - conducted for all residents in the facility includes; Initial assessment (Comprehensive) - conducted within fourteen (14) days of the resident's admission to the facility, the result of the assessments were used to develop, review and revise the resident's comprehensive care plan.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Griffith Park Healthcare Center

201 Allen Ave.

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 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), when Resident 1, who was admitted with Moisture-Associated Skin Damage (MASD, skin irritation or breakdown caused by prolonged exposure to wetness from bodily fluids) to the buttocks extending to the groin area, did not have a weekly skin assessment, per facility policy.This deficient practice had the potential to result

in worsening the MASD or infection and could negatively affect Resident 1's quality of life.Findings:During a

review of Residents 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes (blood sugar level to become too high) and anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a

review of Resident 's History and Physical (H&P) dated 8/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), initiated 8/15/2025, the MDS indicated a completion date of 8/25/2025. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting, and personal hygiene. The MDS indicated Resident 1 was frequently incontinent of urine and had occasional incontinence of bowel. During a review of Resident 1's Braden's Scale for Predicting Pressure Risk, dated 8/8/2025, the document indicated Resident 1 had a high risk for pressure injury. During a

review of Resident 1's care plan for Actual Impairment to Skin Integrity of the buttocks extending to the groin area related to MASD dated 8/8/2025, the care plan interventions indicated to monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs of infection etc. and report to the doctor. During a concurrent interview and record review on 8/25/2025 at 10:30 AM, with the Director of Nurses (DON), Resident 1's electronic health record (EHR) dated from admission 8/8/2025 to present 8/25/2025 was reviewed. The record indicated Resident 1 had MASD upon admission but did not have a weekly skin assessment completed per policy. The DON stated Resident 1 did not have a weekly skin assessment for her MASD, that included location, size and if treatment was effective. The DON stated not having a weekly skin assessment of Resident 1's MASD had the potential for further skin breakdown.

During an interview on 8/25/2025 at 2 PM with Treatment Nurse (TN) 1, TN 1 stated Resident 1 had MASD upon admission on [DATE REDACTED], and there was no weekly assessment because it was missed. TN 1 stated it was very important to have a weekly assessment of Resident 1's MASD, due to the resident's occasional refusal of diaper change. TN 1 stated the weekly skin assessment would determine if the current treatment was working or not, and if the MD needed to be notified. A review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised 4/2020, indicated the purpose was to provide information regarding identification of pressure injury factors and interventions to specific risk factors and to assess the resident on admission for existing pressure injury risk factors and repeat risk assessment weekly. The P&P indicated to evaluate, report and document potential changes in the skin, and to review

the interventions and strategies for effectiveness on and ongoing basis.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet