Health inspection·August 5, 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 to ensure one of five sampled residents (Resident 1) was provided timely responses to requests and needs according to the facility's policy and procedure (P&P) titled, Answering the Call Light, by failing to ensure:On [DATE], [DATE] and [DATE], Resident 1's call light was fully connected to the wall and was within reach of Resident 1.This failure caused Resident 5 to not be able to get assistance from staff when Resident 1 needed to be changed. Resident 1 was left soiled in Resident 1's briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full loss of vision], that cannot be explained by a medical or neurological condition due to the brain converting psychological distress into physical symptoms) with mixed symptom presentation, aphonia, and generalized anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of an untitled CP, the CP indicated Resident 1 preferred the call light to hang from above Resident 1's head on the trapeze (a mobility aid, often used in healthcare settings, that is suspended above a bed to assist patients with repositioning, transferring in and out of bed, and performing exercises), initiated [DATE]. The CP indicated Resident 1 would continue to be able to use call light by tapping it. The CP interventions indicated educating staff on Resident 1's preference of call light placement, and to ensure Resident 1 was able to reach the call light. During a review of the same untitled CP, the CP indicated Resident 1 was incontinent (inability to control the bladder and bowels) with both bowel and bladder in relation to impaired mobility and inability to alert staff of Resident 1's urges, and was at risk for infection, skin breakdown, and was on a check and change program, initiated [DATE] and revised on [DATE]. The CP goals indicated Resident 1 would be kept clean, dry, and odor free daily for three months. The CP interventions indicated that CNAs were to check Resident 1 for bladder incontinence at least every two hours, as needed, and to increase frequency as needed, keep Resident 1's call light within reach and answer promptly, and to monitor as indicated for redness or skin breakdown, and to report to MD (medical doctor, physician). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had the absence of spoken words. The MDS indicated Resident 1 had seven to 11 days (half or more of the days) feeling down, depressed (common and serious illness that negatively affects how one feels, thinks and acts) or hopeless. The MDS indicated Resident 1 was dependent (helper does ALL the effort to complete the activity) with toileting hygiene and chair/bed-to-chair transfers. The MDS indicated Resident Residents Affected - Some Page 1 of 10 055367 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 required substantial/maximal assistance (helper does more than half the effort to complete activity) with personal hygiene, showering/bathing self, and rolling left and right (in bed). The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to lying, lying to sitting on side of bed, and sitting to standing. The MDS indicated Resident 1 had hereditary (passed down from parent to child) and idiopathic (no identifiable cause) neuropathy (a condition that involves damage to the peripheral nervous system from injury or disease process). During an observation on [DATE] at 9:58 am, inside Resident 1's room, Resident 1 was observed until 10:09 am. Resident 1 was lying in bed with closed eyes. Resident 1's call light was hanging above Resident 1's head on the trapeze. The call light was placed towards the wall on the trapeze, not above Resident 1's head and out of Resident 1's reach. During a concurrent observation and interview on [DATE] at 11 am, in Resident 1's room, Resident 1 was observed. Resident 1 used the surveyor's phone to type Resident 1's responses to questions. Resident 1 typed, I am really wet. I pooped and peed and I can't reach my call light, and I can't communicate with anyone because the tablet they (staff in general) gave me died and no one can understand me. Resident 1 typed that Resident 1's sheets and brief were wet. Resident 1 typed, I am so uncomfortable, and they don't care. During a concurrent observation and interview on [DATE] at 11:27 am, inside Resident 1's room, CNA 1 and CNA 2 were observed with Resident 1. Resident 1 typed on surveyor's phone, I've been wet since 2 am. The night staff wouldn't change and neither of you asked me if I needed to be changed. Resident 1 typed, I need a bath, please. I pooped and peed and I've been asking since you gave me breakfast this morning. I can't reach the call light to ask you two for help, Resident 1 typed, You both are aware of that, and I expressed my concerns, and you don't communicate with me. Resident 1 attempted to reach for Resident 1's call light but was unable to. CNA 1 stated Resident 1 liked the call light to be on the bar (trapeze) but should be within reach on the bar. During a concurrent observation and interview on [DATE] at 11:46 am, inside Resident 1's room, Resident 1 was observed with CNA 1 and CNA 2. CNA 1 stated Resident 1's sheets and pillow under the left leg were wet with urine. CNA 2 stated Resident 1's gown and bed pad were wet with urine. During a concurrent observation and interview on [DATE] at 3:15 pm, inside Resident 1's room, with CNA 4, Resident 1 and the call light were observed. CNA 4 stated Resident 1's call light was unplugged from the wall. CNA 4 stated, It was not pulled out of the wall completely, just enough so that it won't work. CNA 4 stated, This isn't the first time this happened. CNA 4 stated Resident 1's call light was usually pushed behind Resident 1's head so Resident 1 could not reach it and was currently positioned that way. CNA 4 stated Resident 1 did not currently have the iPad. CNA 4 stated, It's pretty typical that [Resident 1] is soaked through [Resident 1's] brief with urine and/or feces when I come onto my shift. CNA 4 stated Resident 1 was currently soaked through the brief. Resident 1 typed on surveyor's phone, No one has ever used the communication board with me. I don't even know what that is. Resident 1 stated, I'm wet and haven't been offered to be changed since you (points to surveyor) were in here this morning. Resident 1 stated, [CNA 1] and [CNA 2] were supposed to change me, they didn't ask me if I wanted to be changed and I can't reach the call light. During a concurrent observation and interview on [DATE] at 4:13 pm, inside Resident 1's room, with CNA 4, Resident 1 was observed. CNA 4 stated Resident 1's brief was really full and wet all the way through. CNA 4 stated, If [Resident 1] was changed every two hours, [Resident 1] won't be this wet. CNA 4 stated that Resident 1 was able to use the call light with CNA 4 to let CNA 4 know when Resident 1 needed to be changed. CNA 4 stated if Resident 1's call light was disconnected then Resident 1 could not ask for help. CNA 4 repeated, This isn't the first time this happened. CNA 4 stated the call light being disconnected was a Real safety issue. CNA 4 stated if something was really wrong, 055367 Page 2 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1 could not get help because Resident 1's call light was pushed back and unreachable for Resident 1. During a concurrent observation and interview on [DATE] at 4:45 pm, inside Resident 1's room, with the Director of Nursing (DON), Resident 1 was observed. The DON stated, I see your call light is over your trapeze but not over your head. Resident 1 typed, They keep pushing it back so I can't reach it. Resident 1 attempted to reach the call light but was unable to. Resident 1 would not indicate who, They were. During an interview on [DATE] at 1:25 pm, with CNA 1, CNA 1 stated call lights were not supposed to be disconnected or unplugged from the walls and should be within reach. CNA 1 stated if a call light is disconnected and out of reach from a resident it became a safety issue. During an interview on [DATE] at 2:13 pm, with LVN 2, LVN 2 stated LVN 2 was familiar with Resident 1. LVN 2 stated Resident 1 could not move Resident 1's legs or right arm. LVN 2 stated a resident's call light should always be within reach in case they needed assistance. LVN 2 stated if Resident 1's call light was not within reach, then Resident 1 could not ask for help. LVN 2 stated Resident 1 could not talk, so Resident 1's needs would go unmet, which was a safety issue. During an interview on [DATE] at 3:34 pm, with the DON, the DON stated call lights were supposed to be within reach and always connected to the wall so residents could ask for help, otherwise they could not get help timely and their needs could go unmet or there be a delay in their needs being met. The DON stated this was a safety issue, for example, if a resident fell. The DON stated if a resident like Resident 1 was not able to communicate with staff in the way Resident 1 needed and the call light was not reachable, it was possible Resident 1's needs would go unmet or be delayed and that could possibly lead to neglect. During a concurrent observation and interview on [DATE] at 4:20 pm, inside Resident 1's room, with CNA 6, Resident 1 was observed. CNA 6 stated LVN 3 had asked CNA 6 to change Resident 1, but CNA 6 was bathing another Resident. CNA 6 checked Resident 1's call light and CNA 6 stated Resident 1's call light was not working. CNA 6 stated the cord was pulled out of the outlet about halfway, and the call light did not work when it was like that. CNA 6 stated this was not the first time CNA 6 had seen Resident 1's call light cord partially disconnected from the wall. CNA 6 stated, It happens more often than not when I come onto my shift. CNA 6 stated Resident 1 was, Pretty soaked through with urine and blood in [Resident 1's] briefs. CNA 6 stated Resident 1's gown and sheets were wet too. During a review of the facility's undated P&P titled, Answering the Call Light, the P&P indicated the purpose of the procedure was to ensure timely responses to the resident's requests and needs. The P&P indicated to be sure the call light was plugged in and functioning at all times, and to ensure the call light was accessible to the resident when in bed, from the toilet, from the shower, or bathing facility, and from the floor. 055367 Page 3 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received activities of daily living care according to the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, by failing to: Ensure Resident 1 was not left soiled of urine, feces, and/or menstruation fluid on 7/12/2025, 8/1/2025, and 8/5/2025. As a result of these failures, Resident 1 was left soiled in Resident 1's brief (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. Cross Reference: F558Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2023 with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full loss of vision], that cannot be explained by a medical or neurological condition due to the brain converting psychological distress into physical symptoms) with mixed symptoms and suffered from aphonia (a medical condition characterized by the complete loss of voice), with mixed symptom presentation, aphonia, and generalized anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of the same untitled CP, the CP indicated Resident 1 was incontinent (inability to control the bladder and bowels) with both bowel and bladder in relation to impaired mobility and inability to alert staff of Resident 1's urges, and was at risk for infection, skin breakdown, and was on a check and change program, initiated 10/14/2023, revised on 7/31/25. The CP goals indicated Resident 1 would be kept clean, dry, and odor free daily for three months. The CP interventions indicated that CNAs were to check Resident 1 for bladder incontinence at least every two hours, as needed, and to increase frequency as needed, keep Resident 1's call light within reach and answer promptly, and to monitor as indicated for redness or skin breakdown, and to report to MD (medical doctor, physician). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/7/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had the absence of spoken words. The MDS indicated Resident 1 had seven to 11 days (half or more of the days) feeling down, depressed (common and serious illness that negatively affects how one feels, thinks and acts) or hopeless. The MDS indicated Resident 1 was dependent (Helper does ALL the effort to complete the activity) with toileting hygiene and chair/bed-to-chair transfers. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort to complete activity) with personal hygiene, showering/bathing self, and rolling left and right (in bed). The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to lying, lying to sitting on side of bed, and sitting to standing. The MDS indicated Resident 1 had hereditary (passed down from parent to child) and idiopathic (no identifiable cause) neuropathy (a condition that involves damage to the peripheral nervous system from injury or disease process). During a telephone interview on 8/1/2025 at 2:55 pm, with CNA 3, CNA 3 stated that CNA 3 worked the 3 pm to 11 pm shift that day (7/12/2025) and was assigned to Resident 1. CNA 3 stated when CNA 3 started the shift, Resident 1 was really upset. CNA 3 stated Resident 1 was completely soiled, and there were urine and feces that were completed soaked through Resident 1's brief, bed pad, sheets, and gown. CNA 3 stated CNA 3 had to bathe Resident 1. CNA 3 stated CNA 3 worked the 3 pm to 11 pm shift on 7/13/2025 and again, Resident 1's sheets and gown were wet. CNA 3 stated Resident 1 told CNA 3 that the staff on 7 am to 3 pm shift had not changed Resident 1. CNA 3 stated, The CNA that morning was [CNA 1]. CNA 3 stated Resident 1 was panicked because Residents Affected - Some 055367 Page 4 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they (CNA 1) did not change Resident 1 during the entire day shift (7 am to 3 pm). CNA 3 stated, every shift CNA 3 have Resident 1, CNA 3 had to change Resident 1's brief and bedding because Resident 1 is soaked wet right when the shift starts. CNA 3 stated it was even worse when Resident 1 was on Resident 1's period because they (staff in general) leave Resident 1 wet and do not change Resident 1. During a concurrent observation and interview on 8/1/2025 at 3:15 pm, inside Resident 1's room, with CNA 4, Resident 1 and the call light were observed. CNA 4 stated Resident 1's call light was unplugged from the wall. CNA 4 stated, It's pretty typical that Resident 1 is soaked through Resident 1's brief with urine and/or feces when CNA 4 come onto my shift. CNA 4 stated Resident 1 was currently soaked through the brief. Resident 1 typed on surveyor's phone, No one has ever used the communication board with me. I don't even know what that is. Resident 1 stated, I'm wet and haven't been offered to be changed since you (points to surveyor) were in here this morning. Resident 1 stated, [CNA 1] and [CNA 2] were supposed to change me, they didn't ask me if I wanted to be changed and I can't reach the call light. During a concurrent observation and interview on 8/1/2025 at 4:13 pm, inside Resident 1's room, with CNA 4, Resident 1 was observed. CNA 4 stated Resident 1's brief was really full and wet all the way through. CNA 4 stated, If [Resident 1] was changed every two hours, [Resident 1] won't be this wet. CNA 4 stated that Resident 1 was able to use the call light with CNA 4 to let CNA 4 know when Resident 1 needed to be changed. CNA 4 stated if Resident 1's call light was disconnected then Resident 1 could not ask for help. CNA 4 repeated, This isn't the first time this happened. CNA 4 stated the call light being disconnected was a Real safety issue. CNA 4 stated if something was really wrong, Resident 1 could not get help because Resident 1's call light was pushed back and unreachable for Resident 1. During an interview on 8/5/2025 at 10:06 am, with Resident 1, Resident 1 typed with surveyor's phone, I'm wet. I'm on my period, and I'm so uncomfortable lying here in all of it (urine and blood). Resident 1 typed, I can smell me, and I don't like the way it smells. It smells bad. They (staff in general) haven't changed me yet and haven't asked at any point this morning if I need to be changed. During a concurrent observation and interview on 8/5/2025 at 10:29 am, inside Resident 1's room, with LVN 1, Resident 1 was observed. LVN 1 stated Resident 1's brief was full of urine in the front. LVN 1 stated Resident 1 was on Resident 1's period and the brief was soiled with blood. LVN 1 stated blood was coming out of the back of the brief. During a concurrent observation and interview on 8/5/2025 at 10:39 am, inside Resident 1's room, with CNA 1 and LVN 1, Resident 1 was observed. Resident 1 threw up. Resident 1 typed with surveyor's phone that Resident 1 was stressed, anxious, and Resident 1's chest and head hurt. CNA 1 stated Resident 1's sheets were wet but could not tell if the red on the sheet was vomit or blood. LVN 1 stated Resident 1's vomit was tan, not red. Neither CNA 1 nor LVN 1 are using a communication device with Resident 1. LVN 1 stated, I can't understand you. LVN 1 performed a skin assessment. LVN 1 stated Resident 1's middle buttocks near the crease were red. LVN 1 stated Resident 1's perineum (the area of skin and underlying tissue between the anus and the genitals) where it met the thighs in the front and back were red. LVN 1 stated Resident 1 was soiled through Resident 1's briefs with urine, feces, and blood. During an interview on 8/5/2025 at 1:47 pm, with CNA 5, CNA 5 stated when CNA 1 and CNA 2 were assigned to Resident 1, Resident 1 only got changed once a shift. CNA 5 stated residents were supposed to be changed every two hours and as needed. CNA 5 stated CNA 5 was taught to use the communication board by having Resident 1 point to the letters, but CNA 5 did not use it. CNA 5 stated, When I don't have the communication board or tablet for [Resident 1] I have to guess what [Resident 1] needs. CNA 5 stated that it made it really hard to know what Resident 1 needed. CNA 5 stated if Resident 1 could not reach the call light, then Resident 1 could not tell staff Resident 1 needed to be changed. CNA 5 stated 055367 Page 5 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff must be able to communicate with residents and if staff could not, then staff will not meet residents' needs. CNA 5 stated, This is neglect. Neglect is a form of abuse. During an interview on 8/5/2025 at 2:13 pm, with LVN 2, LVN 2 stated LVN 2 was familiar with Resident 1. LVN 2 stated Resident 1 could not move Resident 1's legs or right arm. LVN 2 stated LVN 2 learned how to use Resident 1's communication board. LVN 2 stated, There's no needs [Resident 1] can point to, it's just letters. Do you know how long it would take to do that? LVN 2 stated, Even then, I'm guessing what [Resident 1] wants. I have to pull my phone out when [Resident 1] doesn't have the tablet. LVN 2 stated, I'd be in [Resident 1's] room for a long time, an hour at least, and I have 21 residents' worth of meds (medication) to give, and my residents are alert and need a lot of things. LVN 2 stated a resident's call light should always be within reach in case they needed assistance. LVN 2 stated if Resident 1's call light was not within reach, then Resident 1 could not ask for help. LVN 2 stated Resident 1 could not talk, so Resident 1's needs would go unmet, which was a safety issue. During an interview on 8/5/2025 at 4:12 pm, with Resident 1, Resident 1 typed with surveyor's phone, I haven't been changed since you were in here earlier today and saw me be changed. Resident 1 stated Resident 1 asked LVN 3 to change Resident 1 at 3 pm but was told LVN 3 would get the CNA. Resident 1 stated, I'm on my period and I'm so uncomfortable. I'm lying in my own blood and it's disgusting. Resident 1 cried. Resident 1 typed, When is all this torture going to be over? During an interview on 8/5/2025 at 4:15 pm, with LVN 3, LVN 3 stated Resident 1 had asked LVN 3 to change Resident 1 at 3 pm. LVN 3 stated LVN 3 asked CNA 6 to change Resident 1 because LVN 3 was needed in the facility huddle (meeting to review residents' status), but CNA 6 was giving another resident a bath. LVN 3 stated, I could have changed [Resident 1] after the huddle. [Resident 1] should not have waited an hour and 15 minutes for a brief change. During a concurrent observation and interview on 8/5/2025 at 4:20 pm, inside Resident 1's room, with CNA 6, Resident 1 was observed. CNA 6 stated LVN 3 had asked CNA 6 to change Resident 1, but CNA 6 was bathing another Resident. CNA 6 stated Resident 1's call light was not working. CNA 6 stated the cord was pulled out of the outlet about halfway, and the call light did not work when it was like that. CNA 6 stated this was not the first time CNA 6 had seen Resident 1's call light cord partially disconnected from the wall. CNA 6 stated, It happens more often than not when I come onto my shift. CNA 6 stated Resident 1 was, Pretty soaked through with urine and blood in [Resident 1's] briefs. CNA 6 stated Resident 1's gown and sheets were wet too. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, revised 89/2022, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 055367 Page 6 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its past plan of correction regarding providing means of communication for one of five sampled residents (Resident 1).This deficient practice had the potential for facility staff to inappropriately communicate with residents that could lead to a delay in care, needs being unmet, or neglect. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full loss of vision], that cannot be explained by a medical or neurological condition due to the brain converting psychological distress into physical symptoms) with mixed symptom presentation, aphonia, and generalized anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 1's untitled care plan (CP) initiated [DATE], the CP indicated Resident 1 had a communication problem related to aphonia, dysarthria (a motor speech disorder that makes it difficult to pronounce words clearly) and anarthria (a severe speech disorder characterized by the complete loss of the ability to articulate speech), non-verbal, and utilized Resident 1's phone to make needs known and types responses, usually understands others with episodes of asking staff to repeat questions multiple times, episodes of refusing communication board (a tool that helps residents who have difficulty speaking or understanding spoken language to express themselves), and pen and paper as alternative means of communication. The CP indicated on [DATE], Resident 1 asked the (unknown) Certified Nurse Assistant (CNA) to bring Resident 1 the community phone so Resident 1 could call and talk to Resident 1's parent. The CP indicated on [DATE], Resident 1 refused white communication board as alternative means of communication when [tablet (electronic tablet device)] was low battery. The CP goal indicated Resident 1 would maintain current level of communication function (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages) through the review date of [DATE]. The CP interventions indicated Resident 1 preferred communicating face to face, while family was present to translate with the cellphone facetime (video call), ensure availability and functioning of adaptive communication equipment, message bard, and telephone, in the event the [tablet] is dead, offer communication board, offer pen and paper, and offer the communication board, and to use [tablet] as means of communication- resident (1) types in and shows it to be ready by other person. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 1 had the absence of spoken words. The MDS indicated Resident 1 had seven to 11 days (half or more of the days) feeling down, depressed (common and serious illness that negatively affects how one feels, thinks and acts) or hopeless. The MDS indicated Resident 1 was dependent (helper does ALL the effort to complete the activity) with toileting hygiene and chair/bed-to-chair transfers. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort to complete activity) with personal hygiene, showering/bathing self, and rolling left and right (in bed). The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to lying, lying to sitting on side of bed, and sitting to standing. The MDS indicated Resident 1 had hereditary (passed down from parent to child) and idiopathic (no identifiable cause) neuropathy (a condition that involves damage to the peripheral nervous system from injury or 055367 Page 7 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disease process). During a concurrent observation and interview on [DATE] at 11 am, in Resident 1's room, Resident 1 was observed. Resident 1 used the surveyor's phone type Resident 1's responses to questions. Resident typed, I am really wet. I pooped and peed and I can't reach my call light, and I can't communicate with anyone because the tablet they (staff) gave me died and no one can understand me. Resident 1 typed that Resident 1 was not provided with the charger to the [tablet] so Resident 1 was unable to charge it when Resident 1 used the [tablet]. Resident 1 typed, the [tablet] did not have the capability to send messages or have a place to type for Resident 1 to communicate with family and with staff. Resident 1 typed that Resident 1 was told Resident 1 would have the [tablet] every day from 2 pm to 10 am the next day. Resident 1 typed that there were days Resident 1 would not receive the [tablet], and times when staff would put the [tablet] on the bedside tray but push the tray away so Resident 1 could not reach it. Resident 1 typed, They (staff) think they know what I need with gestures, but they don't. They don't listen. Resident 1 typed that the [tablet] had been taken away around 9 am that morning. During a concurrent observation and interview on [DATE] at 11:04 am, inside Resident 1's room, CNA 1 was with Resident 1. CNA 1 asked Resident 1 if Resident 1 needed anything. Resident 1 lipped words to CNA 1 and was pointing with Resident 1's left hand. CNA 1 stated, What do you need? Do you need something? Are you good? Resident 1 continued to lip words and point at things with Resident 1's left hand. CNA 1 stated CNA 1 was usually able to understand Resident 1's gestures when Resident 1 did not have the [tablet]. CNA 1 stated, I can't read them right now. CNA 1 stated Activities usually took the [tablet] at 10 am and gave it back in the afternoon. During an interview on [DATE] at 11:09 am, with the Activities Supervisor (AS), the AS stated Resident 1 got the [tablet] from 2 pm until 10 am the next day so the AS could charge it for other residents to use. The AS stated the AS could not ensure the [tablet] was fully charged before giving to Resident 1 to use. The AS stated the AS did not give Resident 1 the charger and did not know how to ensure the [tablet] was charged for Resident 1 during the time Resident 1 used it. During a concurrent observation and interview on [DATE] at 1120, outside of Resident 1's room, a communication board was observed with CNA 2. CNA 2 stated the communication board was supposed to be used for residents who did not speak English and that the items on the board were in both English and Spanish. CNA 2 stated Resident 1 could point to the letters of the alphabet from the to tell staff what Resident 1 was trying to say. CNA 2 stated Resident 1 had to make words from the letter and, We could try and guess what [Resident 1] wants. During a concurrent observation and interview on [DATE] at 11:27 am, inside Resident 1's room, CNA 1 and CNA 2 were observed with Resident 1. CNA 1 stated, The communication board doesn't work. CNA 1 stated CNA 1 usually used the [tablet] in the afternoon before the end of CNA 1's shift but if the tablet was not charged in the morning or the AS took it away before 10 am, CNA 1 had to read Resident 1's lips, but it was not one hundred percent successful. CNA 1 and CNA 2 asked Resident 1 questions. Resident 1 was gesturing and pointing and using Resident 1's lips, but both CNA 1 and CNA 2 stated they could not understand Resident 1. Resident 1 typed on surveyor's phone, I've been wet since 2 am. The night staff wouldn't change and neither of you asked me if I needed to be changed. Resident 1 typed, I need a bath, please. I pooped and peed and I've been asking since you gave me breakfast this morning. It's hard to communicate when I don't have the tablet. I can't reach the call light to ask you two for help, Resident 1 typed, You both are aware of that, and I expressed my concerns, and you don't communicate with me. CNA 1 stated, CNA 1 and CNA 2 did not know what Resident 1 needed until the surveyor brought out a phone. CNA 1 stated, if CNA 1 and CNA 2 could not communicate with Resident 1 then they would not know what Resident 1 needed and Resident 1's needs could go unmet and make Resident 1 feel bad. During a concurrent observation and interview on [DATE] 055367 Page 8 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 10:17 am, inside Resident 1's room, CNA 1 was observed with Resident 1. CNA 1 stated CNA 1 did not have the tablet to communicate with Resident 1 or the communication board. During a concurrent observation and interview on [DATE] at 3:15 pm, inside Resident 1's room, with CNA 4, CNA 4 stated Resident 1 did not currently have the [tablet]. Resident 1 typed on surveyor's phone, No one has ever used the communication board with me. I don't even know what that is. During a concurrent observation and interview on [DATE] at 4:45 pm, inside Resident 1's room, with the Director of Nursing (DON), Resident 1 was observed. Resident 1 now had the [tablet]. Resident 1 showed the DON that the [tablet] did not have messaging or note taking capabilities. The DON stated, I see what you mean. You don't really have the ability to communicate effectively with the [tablet]. During a concurrent observation and interview on [DATE] at 10:39 am, inside Resident 1's room, with CNA 1 and LVN 1, Resident 1 was observed. Resident 1 threw up. Resident 1 typed with surveyor's phone that Resident 1 was stressed, anxious, and chest and head hurt. Neither CNA 1 nor LVN 1 are using a communication device with Resident 1. LVN 1 stated, I can't understand you. During an interview on [DATE] at 11:48 am, with the DSD, the DSD stated staff were supposed to use the communication board and write down the letters that Resident 1 pointed to and allow Resident 1 to express Resident 1's needs that way, when Resident 1 did not have the tablet. The DSD stated if staff were not communicating with Resident 1 appropriately it could lead Resident 1's needs being unmet and could lead to neglect. The DSD stated if Resident 1 could not tell staff what Resident 1 needed then staff could not properly help Resident 1 and that could affect Resident 1 mentally and emotionally. During an interview on [DATE] at 1:25 pm, with CNA 1, CNA 1 stated there was an in-service for the communication board with Resident 1. CNA 1 stated the DSD did not show staff how to use it but instructed staff to offer it to Resident 1. CNA 1 stated, when Resident 1 was not using the tablet, CNA 1 was just guessing what Resident 1 needs and it took a while. CNA 1 stated the communication board was very time consuming. CNA 1 stated, I guess it could make [Resident 1] feel bad and feel like we don't listen or meet [Resident 1's] needs if we can't communicate with [Resident 1]. CNA 1 stated it was possible Resident 1's needs could go unmet when a communicate device was not being used because Resident 1 got frustrated. CNA 1 stated it was difficult as well because CNA 1 worried about CNA 1's other residents when CNA 1 was in Resident 1's room for so long trying to figure out what Resident 1 needed. During an interview on [DATE] at 3:34 pm, with the DON, the DON stated staff were educated to always offer other means of communication to communicate with residents. The DON stated staff were told to use the communication board or white board when Resident 1 did not have the tablet. The DON stated it was important to communicate with residents in the way they needed or it's possible their needs could go unmet. The DON stated if a resident like Resident 1 was not able to communicate with staff in the way Resident 1 needed, it was possible Resident 1's needs would go unmet or be delayed and that could possibly lead to neglect. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 2/2020, the P&P indicated the facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that was focused on indicators of the outcomes of care and quality of life for the residents. The P&P indicated the objectives of the QAPI program were to provide a means to measure the current and potential indicators for outcomes of care and quality of life, to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. The P&P indicated the QAPI plan described the process for identifying and correcting quality deficiencies where key components included, tacking and measuring performance, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing 055367 Page 9 of 10 055367 08/05/2025 Monrovia Gardens Healthcare Center 615 W. Duarte Rd. Monrovia, CA 91016

F 0867 corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of the corrective action/performance improvement activities, and revising as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055367 Page 10 of 10