Health inspection·October 27, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the needs four of four sampled residents (Residents 1, 2, 3, and 4 ) in accordance with the facility's Policy and Procedure (P&P) by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was functioning during the power outage for 11 hours from 10/16/2025 at 9:30 PM to 10/17/2025 at 8:30 AM.These deficient practices had the potential for Residents 1, 2, 3, and 4 who were assessed as high risk of falls to not be able to call the facility staff for help or assistance and placed the residents at risk for harm/injury.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/23/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, toileting hygiene and shower/bathing self. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1's Care Plan (CP) related to risk for falls revised 9/5/2025, the CP indicated facility staff should ensure Resident 1's call light was within reach and encourage the resident to use it for assistance as needed. During an interview on 10/22/2025 at 3:26 PM with Resident 1, Resident 1 stated the call light system was not working from 10/16/2025 after 9:30 PM to 10/17/2025 at 8:30 AM during the power outage in the facility. Resident 1 stated Resident 1 did not get any call bell to ring for help and had to yell for help when Resident 1 needed assistance. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to facility on 10/25/2024 with diagnoses including hemiplegia (partial or total paralysis on one side of body) and hemiparesis (weakness on one side of the body), left hip and knee osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and epilepsy (a long-term disease that causes repeated seizures). During a review of Resident 2's History and Physical (HP) dated 10/28/2024, the HP indicated Resident 2 was alert and oriented. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was dependent on (helper does all the effort) with toileting hygiene and shower/bathing self, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene. During a review of Resident 2's CP related to risk for falls, revised 8/14/2025, the CP indicated facility staff should ensure the call light was within reach and for Resident 2 to get prompt response to all requests for assistance. During an interview on 10/22/2025 at 3:15 PM with Resident 2, Resident 2 stated the call light system was not working during the night the power in the Residents Affected - Some Page 1 of 5 055259 055259 10/27/2025 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility was off, Resident 2 stated Resident 2 did not receive any call bell or device to request assistance if needed. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), hypertension (high blood pressure), and epilepsy. During a review of Resident 3's CP related to risk for falls, revised 5/21/2025, the CP indicated facility staff should ensure Resident 3's call light was within reach and for Resident 3 to get prompt response to all requests for assistance. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills were intact. The MDS indicated Resident 3 was dependent on toileting hygiene and shower/bathe self and putting on/taking off footwear. The MDS indicated that Resident 3 required substantial/maximal assistance with personal hygiene and lower body dressing. During an interview on 10/22/2025 at 3:02 PM with Resident 3, Resident 3 stated the call light system was not working during the night the power was off for more than ten hours in the facility. Resident 3 stated Resident 3 did not receive any call bell or device to request assistance. 4. During a review of Resident 4's AR, the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs cannot supply enough oxygen to the blood), end stage renal disease (ESRD -irreversible kidney failure) and cerebral infarction (disrupted blood flow to the brain). During a review of Resident 4's HP dated 6/18/2025, the HP indicated Resident 4 had intact cognition including orientation, attention, and memory, and had normal insight and judgment. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 was dependent on toileting hygiene and shower/bathing self, and lower body dressing. The MDS indicated Resident 4 required substantial/maximal assistance with putting on/taking off footwear and upper body dressing. During a review of Resident 4's CP related to risk for falls, revised 1/31/2025, the CP indicated facility staff should ensure Resident 4's call light was within reach and for the resident to get prompt response to all requests for assistance. During an interview on 10/22/2025 at 2:34 PM with Resident 4, Resident 4 stated the call light system was not working during the night that the power was off in the facility. Resident 4 stated Resident 4 did not receive any call bell or device to request assistance. During an interview on 10/23/2025 at 9:51 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the call light system was not working when the facility had power outage. During a concurrent interview and record review on 10/23/2025 at 10:09 AM with the Maintenance Director (MD), the facility's Generator Weekly Run Report was reviewed. The MD stated the facility had a power outage on 10/16/2025 at 9:30 PM, and the power was back on 10/17/2025 at 8:30 AM. The MD stated the power outage lasted for 11 hours. During an interview on 10/23/2025 at 4:38 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the call light system was not working when the facility had power outage on the night of 10/16/205. During a concurrent observation and interview on 10/27/2025 at 9:28 AM with Registered Nurse 1 (RN 1) at Nurse Stations 1 and 2, there were 16 bells at Nurse Stations 1 and 2, totaling 32 bells. RN 1 stated the facility provided temporary bells for residents to ring for assistance when the facility had power outage. RN 1 states the facility did not have enough bells for every resident in the facility. During a review of the facility's undated P&P titled, Building Systems Electrical and Generator, the P&P indicated, Check and repair as necessary monthly to verify that all connections and mountings are secure and in good working order .electrical service system. During a review of the facility's P&P titled, Call System, Resident revised 9/2022, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting /bathing facilities and from the floor. The P&P indicated, The resident call system remains 055259 Page 2 of 5 055259 10/27/2025 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0558 Level of Harm - Minimal harm or potential for actual harm functional at all times. During a review of the facility's P&P titled, Maintenance Service, revised 12/2009, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Residents Affected - Some 055259 Page 3 of 5 055259 10/27/2025 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P) titled Medication Orders and Receipt Record to ensure three of three sampled residents (Residents 1, 6 and 7)'s medication delivered by the pharmacy were checked, signed, dated and timed by licensed staff upon receiving. This failure had the potential for missing medication or residents receiving wrong medication.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/23/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, toileting hygiene and shower/bathing self. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1's Treatment Administration Record (TAR), dated 8/2025, 9/2025 and 10/2025, the TAR indicated Resident 1 had an order for Ketoconazole (is a drug used in the management and treatment of fungal infections) External Shampoo 2% Topical, apply to scalp topically every day shift every Monday, Thursday, Saturday for Seborrheic Dermatitis (skin disease that cause scaly, oily, and flaky patches, on the scalp, face, ears, and chest), leave in for 5 minutes then wash out. The medication order date was 7/25/2025. 2. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to facility on 2/14/2025 with diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs cannot supply enough oxygen to the blood), end stage renal disease (ESRD -irreversible kidney failure), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 6's History and Physical (HP), dated 2/17/2025, the HP indicated Resident 6 had full mental capacity to make own decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had intact cognition. The MDS indicated Resident 6 required substantial/maximal assistance with lower body dressing, putting on/taking off footwear and shower/bathing self. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 6's Order Listing Report (OLR) dated 7/2024, the OLR indicated Resident 6 had a medication order for Ipratropium-Albuterol (medication used to prevent difficulty breathing, chest tightness, and coughing in people with COPD) Inhalation Solution 0.5-2.5 milligram (MG, a unit of measurement)/3 milliliter (ML, a unit of measurement), one inhalation by mouth via nebulizer (a medical device that turns liquid medication into a fine mist for inhalation, making it easier to deliver medicine deep into the lungs) two times a day for COPD for 12 weeks. 3. During a review of Resident 7's AR, the AR indicated Resident 7 was originally admitted to facility on 5/8/2023 and readmitted on [DATE] with diagnoses including ESRD), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and major depressive disorder (a persistent feeling of sadness and loss of interest). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognitive skill was intact. The MDS indicated Resident 7 required partial/moderate assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 7 required supervision or touching assistance with upper body dressing and personal hygiene. During a review of Resident 7's OLR dated 7/2024, the OLR indicated Resident 7 had an order for 055259 Page 4 of 5 055259 10/27/2025 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Doxycycline Hyclate Oral Tablet 100 MG, one tablet by mouth two times a day for facial redness for 60 Days. The last medication ordered date was 7/17/2025. During a review of Resident 7's H&P dated 8/22/2025, the HP indicated Resident 7 had the capacity to understand and make own decisions. During an interview on 10/23/2025 at 10:59 AM with Treatment Nurse 2 (TN 2), TN2 stated every medication received from the pharmacy should have a receipt with signature, date, and time of pharmacy delivery. During a concurrent interview on 10/27/2025 at 3:32pm with Registered Nurse 3 (RN 3) and record review of the facility's Prescription Delivery Receipt (PDR) as of 7/14/25, RN 3 stated there was no date, time or signature of the licensed nurse who received the medications for Residents 1, 6 and 7. RN 3 stated the licensed nurse should sign, date and indicate the time on the receipt upon receiving the medications, and make a copy of the signed receipt as part of the residents' record. During a review of the facility's undated P&P titled, Medication Orders and Receipt Record, the P&P indicated, .The medication order/receipt record shall contain:g. The date and quantity received; andh. Name and title of the person receiving the order. 055259 Page 5 of 5