Health inspection·July 9, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 3) who was unable to speak would have a communication board to assist her to communicate with the facility staff as indicated in the care plan. This deficient practice had the potential for the resident's inability to express her needsFindings: During a review of Resident 3's nursing care plan dated 10/14/2024, the care plan indicated Resident 3 had communication problem. The care plan goal was for Resident 3 to maintain current level of communication by (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions, using communication board, writing messages). The care plan interventions were to ensure availability and functioning of adaptive communication equipment message board, telephone. Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. During an observation on 7/9/2025 at 12:55 PM, in the presence of Certified Nurse Assistant 3 (CNA 3), Resident 3 was observed sitting on the bed. Resident 3 was not able to verbally communicate but able to nod and shake her head when spoken to. During an interview on 7/9/2025 at 1 PM with Certified Nurse Assistant 3 (CNA 3), the evaluator requested CNA 3 to look for Resident 3's communication board. CNA 3 was unable to locate the communication board, was not available for the use of Resident 3, to ensure there was continued communication. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 2021, indicated 'The resident's individual needs and preferences are accommodated to the extent possible,' and includes access to assistive and adaptive devices. Residents Affected - Few Page 1 of 4 055367 055367 07/09/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 follow the facility's Use of Restraints policy and procedure (P&P) to ensure one of two sampled residents (Resident 1) freedom from physical restraint (any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body) not required to treat the resident's medical symptoms (an indication or characteristic of a physical or psychological condition) by using a gown to confine Resident 1 on Resident 1's wheelchair to prevent resident's falling on 6/26/205.This deficient practice violated Resident 1's right and had the potential to result in impairing Resident 1's physical and psychosocial wellbeing.Findings:During an interview on 7/9/2025 at 2:12 p.m. with Licensed Vocational Nurse (LVN)/Treatment Nurse (TN) 1, LVN/TN 1 stated on 6/26/2025 around 1:30 p.m., when a clinical team (members including LVN/TN 1, a physician, case manager [CM], social worker, a Certified Nurse Assistant [CNA]) were making round, they found Resident 1 was tied on the wheelchair by using a gown across Resident 1's waist and Resident 1 could not lift from the wheelchair. LVN/TN 1 stated it is a physical restraint to tie a resident on wheelchair and need to be reported right away.During an interview on 7/9/2025 at 2:57 p.m. with the Director of Nursing (DON), the DON stated on 6/26/2025 around 1:30 p.m., the Case Manager (CM) reported that the clinical team found Resident was found be tied on the wheelchair by using a gown when doing rounds. The DON stated it was a restraint if a resident was tied on wheelchair by using a gown.During an interview on 7/9/2025 at 3:05 p.m. with the Administrator, the Administrator stated on 6/26/2025 around 1:30 p.m., the case manager reported to the Administrator that Resident 1 was found tied on the wheelchair by using a gown. The administrator stated the facility suspended CNA 1 who tied Resident 1 on the wheelchair right away and terminated CNA 1 after the investigation. The administrator stated tying a resident on a wheelchair was a physical restraint and physical restraint was a type of abuse.During a concurrent interview and record review on 7/9/2025 at 4:10 p.m. with the DON, Resident 1's Order Summary Report (OSR), dated 7/9/2025, and Resident 1's Care Plan (CP) were reviewed. The DON stated there were no orders and no CP for using physical restraint. Resident 1's Minimum Data Set (MDSa resident assessment tool) dated 6/28/2025, was reviewed. The DON stated the MDS indicated restraints were not used for Resident 1. Resident 1's Change in Condition Evaluation (CICE) dated 6/26/2025 was reviewed. The DON stated The CICE indicated that Resident 1 was noted having a hospital gown around Resident 1's waist and tied behind the wheelchair on 6/26/2025 around 1:20 p.m. Resident 1's Multidisciplinary Care Conference (MCC), dated 6/26/2025 was reviewed. The DON stated the MCC indicated that Resident 1 was found with a hospital gown lace tied around the wheelchair which prevented the resident from moving freely on 6/26/2026 at around 1:20 p.m. and was considered restraint. The DON stated the MCC indicated there was no physical and chemical restraint order for Resident 1 at that time. Resident 1's Post-Event Review (PER) dated 6/26/2025 at 2:09 p.m. was reviewed. The DON stated the PER indicated that Resident 1 was found confined to wheelchair with a hospital gown on 6/26/2025 at 1:30 p.m. Resident 1's Progress Note (PN) dated 6/2025 and 7/2025 were reviewed. The DON stated the PN dated 6/26/2025 at 5:07 p.m. indicated that Resident was on monitoring for being a victim of alleged abuse. The DON stated the facility needs a physician's order, a consent from patient or family for permission and tried other less restrictive measures to use a restraint. The DON stated it was abuse if using a physical restraint without physician order and family and patient's consent.During a review of resident 1's History and Physical (H&P), dated 6/1/2025, the H&P indicated Residents Affected - Few 055367 Page 2 of 4 055367 07/09/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 had the fluctuating capacity to understand and make decisions.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 originally on 6/4/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), cognitive impairment, hypertension (HTN-high blood pressure), left lower leg contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle, lack of coordination, history of transient ischemic attack (TIA- is a temporary blockage of blood flow to the brain) and cerebral infarction ( a region or area of brain tissue that dies as a result of reduced or blockage of vessel blood flow).During a review of Resident 1's Change in Condition Evaluation (CICE), dated 6/26/2025 at 1:20 p.m., the CICE indicated Resident 1 was noted having a hospital gown around Resident 1's waist and tied behind the wheelchair.During a review of Resident 1's Multidisciplinary Care Conference (MCC), dated 6/26/2025 at 1:30 p.m., the MCC indicated that Resident 1 was found with a hospital gown lace tied around the wheelchair which prevent the resident from moving freely and was considered restraint. The MCC indicated there was no physical and chemical restraint order for Resident 1 at that time.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/28/2025, the MDS indicated the resident had severe impaired cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, toileting hygiene, and upper body dressing. The MDS indicated the resident is dependent (helper does all of the effort resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with lower body dressing, shower/bathe self, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, and sit to stand). The MDS indicated restraints were not used for Resident 1.During a review of Resident 1's Order Summary Report (OSR), the OSR indicated there was no order for physical restraint.During a review of the facility's Verification of Investigation (VOI) report, dated 6/30/2025, the VOI report indicated that on 6/26/2025, the facility's clinical team found Resident 1 was confined to the wheelchair using a gown during routine rounds. The VOI report indicated that Certified Nurse Assistant (CNA) 1 who tied the resident on wheelchair stated CNA 1 used a gown to secure the resident to the wheelchair with the intent of preventing the resident from leaning forward and falling. The VOI indicated that CNA 1 confirmed that CNA 1 did not follow proper facility protocol to prevent fall.During a review of CNA 1's Employee Termination (ET), dated 7/3/2025, the ET indicated CNA 1 was terminated due to a reported abuse allegation on 6/26/2025 and the investigation findings that CNA 1 did not comply with the facility policies, resident rights, or standard care protocol and had confined a resident to wheelchair using a gown.During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, dated 4/2017, the P&P indicated, Practice that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including placing a resident in chair that prevents the resident from rising. The P&P indicated that Restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. The P&P indicated that Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 055367 Page 3 of 4 055367 07/09/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a physician-ordered diagnostic test (MRI) was scheduled and completed for one of three residents (Resident 3 ) reviewed for follow-up medical care. This failure resulted in a delay in diagnostic testing for Resident 3 and had the potential to result in delayed diagnosis and treatment for the resident. Findings: During a review of Resident 3's admission Record (Face Sheet), the facility admitted Resident 3 on 10/4/2023 with diagnoses including Aphonia (Loss of Voice), Dysarthria and anarthria (refer to a condition that interferes with the muscles that control speech). During a review of Resident 3's History and Physical (H&P), dated 10/4/2024 indicated, Resident 3 had the mental capacity to make medical decisions. During a review of the After Visit Summary (AVS) from the resident's neurology appointment, dated 11/12/2024, the neurologist assessment and plan for Resident 3 was an MRI of the thoracic and lumbar spine (without contrast). During a review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 4/8/2025, indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and needed supervision to extensive assistance from the staff for the activities of daily living. During a concurrent interview and record review on 7/9/2025 at 4:30 PM with the Director of Nursing (DON), Resident 3's AVS was reviewed. The DON stated that the MRI was ordered by the physician but was never scheduled. The DON confirmed this was an oversight and stated corrective measures would be taken. During a review of the facility's policy and procedure (P&P) titled, Request for Diagnostic Services, revised 2007, indicated that orders for diagnostic services will be promptly carried out as instructed by the physician's order. 020Gigi$ Residents Affected - Few 055367 Page 4 of 4