Health inspection·February 28, 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 of one out of four sampled residents (Resident 31) by ensuring the resident's call light (a device used to alert staff to the resident's room) was within their reach (within arm's reach) as indicated in the resident's plan of care. Residents Affected - Few This deficient practice had the potential for Resident 31 not to receive or receive delayed care and services that could result in accidents and falls. Findings: During a review of Resident 31's admission Record indicated the resident was admitted on [DATE] with diagnoses that included difficulty in walking, muscle weakness, and diabetes type 2 (ability to process thoughts). During a review of Resident 31's History and Physical (H&P), dated 12/15/2025, indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/29/2025, indicated the resident has no impairment in cognition (ability to process thoughts). The MDS also indicated the resident requires moderate assistance (helper does less than half the effort) for self-care activities such as upper body dressing, oral hygiene, and personal hygiene. The MDS also indicated the resident requires touching assistance (helper provides verbal cues and/or touching/steadying assistance as the resident completes the activity) for mobility such as lying to sitting on the side of the bed, sit to lying, and rolling left and right. During a review of Resident 31's care plans included a care plan for heart disease, at risk for falls/injuries, initiated on 12/23/2024. The care plan indicated for staff to encourage the resident to use the call light for assistance. The resident ' s care plans also included a care plan for decline in [activities of daily living] and bed mobility, initiated on 1/23/2025. The care plan indicated for staff to ensure care equipment are within reach. During an observation and interview on 2/25/2025 at 10:27 AM inside Resident 31 ' s room, Resident 31 stated he needed help, but cannot find the call light. Resident 31 ' s call light was observed stuck behind the resident ' s bed and on the floor. During a concurrent observation and interview on 2/25/2025 at 10:33 AM inside Resident 31 ' s room, Registered Nurse (RN) 3 stated Resident 31 is not able to reach the call light because it is on the Page 1 of 30 055899 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor. RN 3 stated Resident 31 would not be able to call for help if he is not able to reach the call light. RN 3 stated the call light is a care equipment that should be accessible to the resident and within the resident ' s reach (within arm ' s length). During a concurrent interview and record review on 2//27/2025 at 9:49 AM with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Answering the Call Light, revised 9/2022, was reviewed. DON stated call lights must be accessible to the resident and the resident should be able to reach the call light. DON stated if the call lights are not accessible to the resident, the resident would not be able to ask for assistance and could potentially have accidents such as falls. During a review of the facility ' s P&P titled, Answering the Call Light, revised 9/2022, indicated staff must ensure the call light is accessible to the resident when in bed. The P&P indicated staff must ensure the call light is plugged in and functioning at all times. The P&P also indicated for staff to answer the call system immediately. 055899 Page 2 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 follow up a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) evaluation for one of three sampled residents (Residents 10) who was assessed as having a positive level I screening on 11/15/2023, that indicated a level II mental health screening. Residents Affected - Few This failure had the potential to result in Resident 10 not to receive care and services in the most integrated setting appropriate to his mental needs, which can negatively affect his quality of life. Findings: During a review of Resident 10's admission Record, indicated the facility originally admitted Resident 10 on 5/21/2021 and readmitted on [DATE] with diagnoses that included psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), schizoaffective disorder (a mental health condition where someone experiences symptoms of both schizophrenia like hallucinations and delusions (a false perception of objects or events and an unshakable belief in something that's untrue) and a mood disorder like mania (a period of abnormally elevated, extreme changes in your mood or emotions)and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily). During a review of Resident 10's History and Physical Examination (H&P), dated 1/29/2025, indicated Resident 1 was alert and interactive. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2025, indicated Resident 10 required substantial/maximal assist (helper does more than half the effort) with eating and roll left and right, and dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. A review of Resident 10's letter from Department of Health Care Services (DHCS) - PASRR Section, dated 11/15/2023, indicated, Resident 10 had positive PASRR Level 1 Screening and required a PASRR Level II mental health evaluation. During a concurrent observation and interview on 2/25/2025 at 11AM with Certified Nurse Assistant (CNA) 1 in Resident 10 ' s room, Resident 10 was observed frowning (to wrinkle the forehead [as in anger or thought]) trying to pull the string for his overhead light. CNA 1 stated, Resident 10 have episodes of agitation when he gets frustrated. A review of Resident 10's Order Summary Report (OSR), dated 2/27/2025, indicated; a)to give Risperdal (medication used to treat certain mental/mood disorders) 2 mg (a unit of mass measurement) one tablet two times a day for schizoaffective disorder manifested by sudden outburst of anger) to give Sertraline (medication used to treat depression) 100 mg one tablet daily for depression manifested by persistent agitation. During a concurrent interview and record review, on 2/27/2025, at 11:11 AM, with MDS Nurse (MDSN), 055899 Page 3 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Assistant Director of Nurses (ADON), Resident 10 ' s, Physical Chart, and Electronic Health Record up to 2/27/2025 was reviewed. The documents did not indicate Resident 10 was not referred for a PASRR level II mental health evaluation. MDSN stated, she was responsible in following up the PASRR II requirement, but she just missed to refer Resident 10. The ADON stated, moving forward she will help in following up PASRR II requirement for all residents. ADON stated, it was important to have a level II evaluation for residents who needs it to ensure proper care, physical, psychological, and mental would provide in accordance with the recommendation. During an interview on 2/27/2025 at 11:30 AM with Director of Nurses (DON), DON stated, the facility did not have a system to follow up PASRR II, moving forward the responsible party would be MDS nurse and ADON and DON. DON stated, PASRR II evaluation and recommendation is important to ensure Resident 10's physical, mental, and psychological needs are being met, otherwise it had the potential to negatively affect Resident 10's quality of life. A review of the facility's policy and procedure (P&P) titled, Subject : PASRR, dated 9/26/2023, indicated; a) the purpose is to ensure compliance with California State PASRR ( Pre-admission Screen and Resident Review) rules and requirements, and b) all residents are required to have a PASRR level I screen completed prior to nursing facility admission, PASSRR level I and II (when applicable will be kept of file in the resident ' s medical record and be kept accurate according to the OBRA and state regulations. 055899 Page 4 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and implement a resident centered care plan for one of three residents (Resident 29) who was admitted to the facility with pressure developed a left upper buttock Stage 1 pressure injury (an intact skin with non-blanchable redness [meaning the area doesn't turn white when pressed] that developed due to prolonged unrelieved pressure and friction). This deficiency practice had the potential to result in the development of new and worsened pressure injury for Residents Findings: A review of Resident 29's admission Record (AR), the AR indicated Resident 29 was readmitted to the facility on [DATE], with diagnoses that included quadriplegia (a condition that causes a person to lose all ability to move all part of the body) and contracture (when muscle shorten causing a deformity) of the lower right and left leg. A review of Resident 29's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the Patient's health status) signed by the attending physician on 12/11/2024, the HPE indicated that Resident 29 does have the capacity to understand and make decisions. A review of Resident 29's Minimum Data Set (MDS, a resident assessment and screening tool) dated 2/4/2025, the MDS indicated the Resident 29 cognition (thought process) was intact. The MDS indicated Resident 29 was dependent care for rolling left to right, sit to lying, bed to chair transfer and toileting hygiene. A review of Resident 29's Care Plan titled The resident has potential for pressure ulcer development related to (r/t) immobility. The care plan indicated on 2/3/2023 Resident 29 would have intact skin, free of redness, blisters or discoloration. The care plan indicated on 2/3/2023 the facility will follow polices for the prevention of skin breakdown by keeping Resident 29 body parts from excessive moisture, keep skin clean, dry and use lotion on dry skin. A review of Resident 29's Care Plan titled Episodes of being non-compliant with care and treatment. The care plan indicated on 2/21/2025 Resident 29 will maintain clean and intact skin and will be free of injury by assessing for pain prior to activities of daily living (ADL) care, checking on the air-loss mattress settings are correct, and to educate Resident 29 on how to prevent skin injuries. A review of Resident 29's COC [Change in Condition]/SBAR [Situation, Background, Assessment, Recommendation] dated 2/21/2025 time at 1:39PM, indicated Resident 29 was noted with a new left upper buttock Stage 1 pressure injury. During an interview on 2/27/2025 at 7:50AM, Treatment Nurse (TN 1) stated that Resident 29 was admitted to the facility with no skins issues and Resident 29 developed at Stage 1 pressure ulcer left upper buttock on 2/21/2025 and had orders for treatment. During an interview on 2/27/2025 at 9:55AM, Registered Nurse (RN 4) stated Resident 29 was admitted on 6/2015, Resident 29 had developed the PI stage 1 at the facility on 2/21/2025. RN 4 stated 055899 Page 5 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 29 skin breakdown care plan was not updated regarding the PI on 2/21/2025. RN 4 stated had there been an updated care plan it would have prevent the PI from developing. During a concurrent record review of Resident 28 care plan titled The resident has potential for pressure ulcer development r/t immobility and interview on 2/27/2025 at 9:55AM, Director of Nursing (DON) stated that Resident 28 care plan for skin breakdown was not updated regarding the PI on 2/21/2025. DON that had her licensed nurses updated the care plan for the PI on 2/21/2025 it would have prevented the PI. DON stated that Resident 29 was now at risk for developing an infection. A Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated identifying problem areas and their causes, and developing interventions. 055899 Page 6 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 11) care plan was revised and updated according to the residents current plan of care for the use of Febuxostat (an oral medication used to control gout [a disease that causes inflammation of the joints that causes pain and swelling]). This deficient practice had the potential for facility staff to not monitor the effectiveness or ineffectiveness of Resident 11's health status. Findings: A review of Resident 11's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gout, low back pain, and spinal stenosis (a condition where the spinal canal, the bony tunnel that contains the spinal cord and nerve roots, becomes narrowed, often causing pain, numbness, and weakness). A review of Resident 11's History and Physical (H&P), dated 12/31/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, indicated the resident had moderately impaired cognition (ability to process thoughts). The MDS also indicated in the section titled, Pain Assessment Interview, that the resident had pain during the last 5 days at the time of the assessment. The interview also indicated that the resident occasionally feels pain and the pain interferes with the resident ' s sleep, therapy, and day-to-day activities. A review of Resident 11's Order Summary Report (OSR), dated 2/27/2025, indicated a physician ' s order, with a start date of 12/31/2024, for Febuxostat Oral Tablet 40 mg (mg, milligram, a unit of measuring weight) Give 1 tablet orally one time a day for Gout. A review of Resident 11's Medication Administration Report (MAR) for the months of 1/2025 and 2/2025, indicated the resident was taking Febuxostat. A review of Resident 11's Care Plans for pain related to gout, initiated on 11/12/2024 indicated a goal that the resident will not have discomfort related to side effects of medications. The interventions for the care plan did not indicate Resident 11 ' s medication Febuxostat. During a concurrent interview and record review on 2/27/2025 at 12:40 PM with Registered Nurse (RN) 1, Resident 11's care plans were reviewed. RN 1 stated the resident ' s care plans was not updated to indicate Resident 11's medication, Febuxostat. RN 1 stated Resident 11's care plan should have been revised to indicate the use of Febuxostat since it was part of the interventions to control the resident's pain. RN 1 stated care plans were used by staff to monitor if the current treatment for the resident ' s pain was effective. RN 1 stated the resident ' s pain could worsen if staff were not monitoring and evaluating the effectiveness of the interventions. During an interview on 2/28/2025 with the Director of Nursing (DON), DON stated care plans must be updated when new treatments are ordered, such as new medications. DON stated if care plans are not 055899 Page 7 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few updated, staff would not be able to monitor if the current interventions were effective. DON further stated if care plans were not updated, the facility would not be able to meet the resident ' s goals and needs. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated care plans describes the services that are to be furnished for the resident. The P&P indicated the interdisciplinary team reviews and updates the care plan. The P&P also indicated assessments of residents are ongoing, and care plans are revised as information about the resident and residents ' conditions change. 055899 Page 8 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide a communication tool or device that translate to a language the resident could understand for one of three residents (Resident 28) who does not speak the formal language in the facility. Residents Affected - Few This deficient practice prevented Resident 28 from communicating with the staff the necessary needs that could delay in the resident receiving appropriate care/treatment the resident needed. Finding: A review of Resident 28 ' s admission Record (AR), the AR indicated Resident 28 was readmitted to the facility on [DATE], with diagnoses that included dementia (mental decline that affects memory and thinking) and Alzheimer ' s disease (brain disorder that slowly destroys memory and thinking). AR indicated Resident 28 primary language was listed as other than the formal language in the facility. A review of Resident 28's History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) signed by the attending physician on 12/24/2024, the HPE indicated that Resident 28 did not have the capacity to understand and make decisions. A review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 12/31/2024, the MDS indicated the Resident 28 cognition (thought process) was severely impaired. The MDS indicated Resident 28 was dependent care for eating and toileting hygiene. During an observation on 2/25/2025 at 9:59AM, Resident 28 room did not have any communication tool or device, or translation material posted around her living area. During a concurrent resident room observation and interview on 2/25/2025 at 11:25AM, Certified Nursing Assistant (CNA 2) stated that she did not see any translation or communication tool or device and material in Resident 28 living area. CNA 2 stated that Resident 28 does not speak the formal language in the facility. CNA 2 stated it was important to have translation material at bedside for residents that don't speak English so the resident will be able to communicate her needs for any type of assistance and while providing ADL care. During an interview on 2/25/2025 at 11:45AM, Director of Nursing (DON) stated that residents that speak a different language than the formal language spoken in the facility and the residents need a communication tool at their bedside. DON stated that Resident 28 need a communication tool to be able to communicate her needs. A review of the facility's P&P titled Translation and/or Interpretation of Facility Services revised 5/2017, indicated the facility ' s language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 055899 Page 9 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary care and services to residents who was dependent with the staff to carry out activities of daily living (ADL) for one of one sampled resident (Resident 10) who had communication problems related to slurred (speech are weak or are hard to control) and was at risk for fall by not ensuring Resident 10 ' s call light was within reach to be used to communicate needs with the staffs. Residents Affected - Few This deficient practice had the potential for Resident 10 not to receive the necessary care and treatments timely especially in an event of emergency. Findings: During a review of Resident 10's admission Record, indicated the facility originally admitted Resident 10 on 5/21/2021 and readmitted on [DATE] with diagnoses that included spastic quadriplegic cerebral palsy (four limbs (arms and legs) are affected by muscle stiffness and tightness, causing difficulty with movement), contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) of left and right knee, and anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 10's History and Physical Examination (H&P), dated 1/29/2025, indicated Resident 1 was alert and interactive. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2025, indicated Resident 10 requires substantial/maximal assist (helper does more than half the effort) with eating and roll left and right, and dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. A review of Resident 10's care plan (CP) for communication problems related to slurring, dated 12/23/2021, indicated; a) anticipate and meet needs, ensure and provide safe environment, and keep call light within reach. A review of Resident 10's care plan (CP) for high risk for fall related to gait and balance problems, poor communication and unaware of safety needs, dated 12/23/2021, indicated anticipate and meet residents needs. During an observation on 2/25/2025 at 11AM in Resident 10's room, Resident 10 was laying on his left side, and noted the call light was wrapped on the bottom of the right siderail, the button was pointing down at the side of the bed that Resident 10 could not reach. Resident 10 frowning (to wrinkle the forehead [as in anger or thought]) trying to pull the string for the overhead light. During a concurrent interview on 2/25/2025 at 11:05 AM with certified nurse assistant (CNA) 1 in Resident 10 ' s room. CNA 1 stated, Resident 10 was able to use his call light for assistance and for his care, but the call light was not within reach to Resident 10. CNA 1 stated Resident 10 needed assistance to turn off his overhead light. CNA 1 stated, the call light should always be within reach for Resident 10, so he can ask for assistance, especially in case of emergency. 055899 Page 10 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/27/2025 at 9:36 AM with Registered Nurse (RN) 1, RN 1 stated, Resident 10 should always have his call light within reach so he can call for assistance in accordance with the facility's policy for ADLs, and especially in case of emergency. RN 1 stated, not having call light within reach had the potential to cause frustration or even harm for Resident 10. During an interview on 2/27/2025 at 10:01 AM with Director of Nurses (DON), DON stated, Resident 10 ' s call light should always be within reach as per policy, so he is able to get assistance with his ADLs and in case of emergency. DON stated, not being able to call for assistance can cause accident or even fall that could affect Resident 10 ' s quality of life. A review of the facility ' s policy and procedure (P&P) titled Activities of Daily Living (ADLs), Supporting, dated 3/2018, The P&P indicated, a) 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, and b) appropriate care and services will be provided for residents who are unable to carry out ADLs independently in accordance with the plan of care including support and assistance with mobility and communication. A review of the facility ' s policy and procedure (P&P) titled Answering the Call Light, dated 9/2022, The P&P indicated purpose to ensure timely responses to resident ' s request and needs. The P&P indicated; a) ensure the call light is accessible to the resident when in bed, and b) answer the resident call system immediately. 055899 Page 11 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

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 observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 9 and Resident 29), received care to prevent the development of pressure injuries (PI, areas of skin and underlying tissue damage caused by prolonged pressure) in accordance with the facility's policy and procedure and care plans by failing to ensure: Residents Affected - Few 1. Resident 9, who had a history of PI and was on a low air loss mattress (LAL- mattress designed to prevent and treat pressure sore [a skin breakdown due to unrelieved pressure and friction to the skin]), had the LAL correctly set at Resident 9's current weight as indicated in the manufacturer ' s guidelines to prevent and/or minimize skin pressure on the bony prominences of the body. 2. Resident 29, who was admitted to the facility without pressure injury does not developed a Stage 1 PI at the left upper buttock on 2/21/2025 and preogressed to Stage 2 PI (an open wound that extends to the bottom layer of the skin) in two days 2/23/25 As a result of these deficient practices, Resident 9 and Resident 29 were at risk for development of new or worsened PI and lead to infection, pain and discomfort. Findings: 1. A review of Residents 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes (lifelong condition that causes a person's blood sugar level to become too high), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and generalized muscle weakness. A review of Resident 9's History and Physical (H&P) dated 2/12/2025, indicated Resident 9 can understand and make own medical decision. A review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 2/18/2025, indicated Resident 9's mental status was intact. The MDS indicated Resident 9 required partial/moderate assistance (helper does less than half the effort) with eating and rolling left and right, and substantial/maximal assist (helper does more than half the effort) with personal hygiene and dressing and dependent (helper does all the effort) with toileting and bathing. A review of Resident 9's care plan (CP) for risk for development of pressure related injuries and other skin breakdown contributing factor includes history of PI stage 4 at Sacro-coccyx area, dated 6/11/2022, the CP intervention included to use an LAL mattress for wound prevention. The CP indicated to check settings were correct per resident ' s weight. A review of Resident 9's facility document titled Braden Scale for Predicting Pressure Sore Risk, dated 2/20/2025, indicated Resident 9 was at risk for developing pressure sores. During a concurrent observation and interview on 2/25/2025 at 10:45 AM with Treatment Nurse (TN) 1 in Resident 9 ' s room, Resident was observed in bed laying on his back, with the LAL mattress set at 150 pounds (lbs., a unit of measurement). TN 1 stated, the LAL mattress setting was incorrect, since Resident 9 ' s current weight was 117 lbs., and that the LAL mattress was not correctly set 055899 Page 12 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few according to the Resident 9 ' s weight. TN 1 stated, it was important that the LAL mattress was at the correct setting for pressure sore prevention especially for Resident 9 who had history of pressure sore and was at risk for pressure sore to reoccur. During an interview on 2/25/2025 at 11:00 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 9 ' s LAL mattress should be set according to Resident 9 ' s weight, which was 117 lbs. LVN 3 stated when the LAL mattress was set at an incorrect weight, the LAL mattress would not assist in preventing PI. A review of Resident 9's care plan (CP) for potential impairment to skin integrity related to poor mobility, dated 2/25/2025, interventions included to use LAL mattress for skin management and wound prevention and to check settings are correct per resident ' s weight 117 pounds. A review of Resident 9 ' s facility document titled Order Summary Report (OSR), dated 2/27/2025, the document indicated, to use Low Air Loss Mattress for skin management: and to check that settings are correct per resident ' s weight 117 lbs. as of 2/5/2025. During an interview on 2/27/2025 at 9:46 AM with Registered Nurse (RN) 1, RN 1 stated, LAL mattress was used to prevent and/or manage PI, therefore the settings should be set according to Resident 9 ' s weight. RN 1 stated, if the setting was incorrect, the LAL mattress would not do its purpose of managing and/or preventing PI, which can potentially affect negatively Resident 9 ' s quality of life. During an interview on 2/27/2025 at 10:01 AM with Director of Nurses (DON), DON stated, LAL mattress was used for Resident 9 because there was an identified risk, which included a history of PI and poor mobility. DON stated, Resident 9 ' s LAL mattress should always be set according to her weight, otherwise it defeats the purpose of the mattress and the therapeutic effect of PI and /or prevention, which could potentially have negative -affects on Resident 9 ' s quality of life. A review of manufactures guidelines for the LAL mattress (Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System), (undated), the guidelines indicated, operating instructions included to determine the patient ' s weight and set the control knob to the weight setting on the control unit. A review of the facility ' s policy and procedure (P&P) titled, Support Surface Guidelines (undated), indicated; a) provide guidelines for appropriate pressure reducing and relieving devices for resident at risk of skin breakdown, b)any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as alternating air or air-loss device, when lying in bed and monitor for other pressure ulcer risk factors and provide interventions as indicated. A review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised 4/2018, indicated; a) the physician will order pertinent wound treatments, including pressure reduction surfaces, b) the physician will help identify medical interventions related to wound management, and c) the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated. 2. During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was readmitted to the facility on [DATE], with diagnoses that included quadriplegia (a condition that causes a person to lose all ability to move all part of the body) and contracture (when muscle shorten 055899 Page 13 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0686 causing a deformity) of the lower right and left leg. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 29's History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) signed by the attending physician on 12/11/2024, the HPE indicated that Resident 29 have the capacity to understand and make decisions. Residents Affected - Few During a review of Resident 29's Minimum Data Set (MDS, a resident assessment and screening tool) dated 12/31/2024, the MDS indicated the Resident 29 cognition (thought process) was intact. The MDS indicated Resident 28 was dependent for care during eating and toileting hygiene. During a review of Resident 29's Braden Scale for Predicting Pressure Sore Risk (Tool to assess residents at risk of developing a pressure injury) dated 1/31/2025, indicated Resident 29 had a score of 13 and was at a moderate risk for developing a PI. During a review of Resident 29's Care Plan titled The resident has potential for pressure ulcer development related to (r/t) immobility. The care plan indicated on 8/19/2019 Resident 29 would have intact skin, free of redness, blisters or discoloration. The care plan indicated on 8/19/2019 the facility will follow polices for the prevention of skin breakdown. During a review of Resident 29's Care Plan titled Episodes of being non-compliant with care and treatment. The care plan indicated on 2/21/2025 Resident 29 will maintain clean and intact skin and will be free of injury. During a review of Resident 29's COC [Change in Condition]/SBAR [Situation, Background, Assessment, Recommendation] dated 2/21/2025 time at 1:39 PM, the COC indicated Resident 29 was noted with a left upper buttock Stage 1 pressure injury (PI) (damage to skin and soft tissue). During a review of Resident 29's Nursing Progress Notes dated 2/22/2025 timed at 7:15AM, the Progress Notes indicated that Resident 29 was on monitoring for a Stage 1 pressure injury (damage to skin and soft tissue) on the left buttock. During a review of Resident 29's COC/SBAR dated 2/23/2025 timed at 10:53AM, indicated that the TN noted that Resident 29 stage 1 PI progressed to a Stage 2 on the left upper buttock. The COC/SBAR indicated the wound bed measure of the PI measured as follows: 2.0cm (unit of measure) width (unit of measure) x 4.0cm length (unit of measure) x superficial depth (unit of measure). The COC/SBAR indicated the wound had a 90% (unit of measure) red to pink color and 10% yellow color. The COC/SBAR indicated noted a light serosanguinous (pinkish red fluid) drainage (fluid that comes from the wound). The COC/SBAR indicated the Stage 2 wound was fragile (weak skin tissue) and discolored. During a review of Resident 29's Braden Scale for Predicting Pressure Sore Risk (Tool to assess Residents at risk of developing a pressure injury) dated 2/23/2025, indicated Resident 29 had a score of 13 and was at a moderate risk for developing a PI. During an interview on 2/27/2025 at 7:50AM, the Treatment Nurse (TN 1) stated that Resident 29 was admitted to the facility with no skin issues and no PI. TN 1 stated Resident 29 developed at Stage 1 PI to the left upper buttock on 2/21/2025. TN stated that it was reported to him that Resident 29 ' Stage 1 PI had progressed to a Stage 2 on 2/23/2025 and the MD was notified, and Resident 29 was under the care of a wound specialist. 055899 Page 14 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0686 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/27/2025 at 9:55AM, the Registered Nurse (RN 2) stated that Resident 29 was admitted on 6/2015 without any PI. RN 2 stated that Resident 29 had developed the PI Stage 1 at the facility on 2/21/2025 and the PI progressed to a Stage 2 on 2/23/2025. RN 2 stated Resident 29 ' s skin breakdown care plan and treatments were not updated to address interventions when the resident was noted with the Stage 1 PI on 2/21/2025. Residents Affected - Few During a wound treatment observation on 2/27/2025 at 1:01 PM, with TN 1 reviewed treatment orders, washed his hands, gloves placed on and began preparing his sterile field. TN 1 removed the foam dressing then cleansed the wound with saline. TN 1 measured the Stage 2 PI, 2.0 cm was the width x 4.0 cm was the length and the depth was superficial. TN 1 observed some slight sloughing with a yellowish color. During a concurrent interview and record review of Resident 29's Care plan titled The resident has potential for pressure ulcer development related to r/t immobility, the Director of Nursing stated that had her licensed staff updated the care plan and implement treatment interventions for the Stage 1 PI on 2/21/25, the PI would have prevented from developing and becoming a Stage 2. The DON stated that Resident 29 was now at risk for developing a Stage 3 and an infection. During a review of the facility's P&P titled Pressure Ulcer/Injury Risk Assessment revised July 2017, indicated the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. The P&P indicated the purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. The P&P indicated Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. 055899 Page 15 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure two out of four sampled residents (Residents 116 and 69) received oxygen treatment as defined in the facility ' s policy and procedures when: Residents Affected - Few 1. Resident 116's nasal cannula (a thin plastic tube that is placed in the nostril) was observed on the floor, and not on the resident's nostril. 2. Resident 69 was administered oxygen without a physician's order. This deficient practice had the potential to place Resident 116 at risk for inadequate oxygenation that could lead to (a serious medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide in the blood) and for Resident 69 to receive excessive oxygen which could result in oxygen toxicity (develop toxins in the body and result in lung damage due breathing in too much oxygen). Findings: 1 A review of Resident 116 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs), sleep apnea (a disorder in which breathing stops and starts repeatedly during sleep), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in fluid build-up in the lungs which makes breathing difficult). A review of Resident 116's History and Physical (H&P), dated 11/15/2024, indicated the resident had the capacity to understand and make decisions. The H&P indicated the resident had a diagnosis of respiratory failure. A review of Resident 116's Minimum Data Set (MDS - a resident assessment tool), dated 2/17/2025, indicated the resident had intact cognition (ability to process thoughts). The MDS indicated the resident required substantial assistance (helper does more than half the effort) for self-care activities such as upper body dressing, oral hygiene, and personal hygiene. The MDS also indicated the resident required moderate assistance (helper does less than half the effort) for mobility such as lying to sitting on the side of the bed, sit to lying, and rolling left and right. A review of Resident 116 ' s Order Summary Report (OSR), dated 2/27/2025, indicated an order for Oxygen at 2-3 L/min (liters per minute, L/min, a unit of measuring the amount of oxygen delivered) via nasal cannula. A review of Resident 116 ' s Care Plan for shortness of breath (SOB), wheezing, and congestion, initiated on 11/18/2024, indicated interventions to administer oxygen at 2 L/min to maintain oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) to more than 92%. During a concurrent observation and interview on 2/25/2025 at 9:18 AM, inside Resident 116 ' s room, Resident 116 ' s nasal cannula was observed on the floor to the left side of Resident 116 ' s bed. Licensed Vocational Nurse (LVN) 2 stated Resident 116 was not receiving oxygen because the nasal cannula was on the floor. LVN 2 stated the resident could have a hard time breathing since Resident 055899 Page 16 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0695 116 was not being administered oxygen. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/25/2025 at 9:31 AM with LVN 4, LVN 4 could not state the last time seeing Resident 116 receiving oxygen via nasal canula. LVN 4 stated not checking on Resident 116 at the beginning of her shift at 7:30 AM. Residents Affected - Few During a concurrent interview and record review on 2/27/2025 at 9:49 AM with Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, was reviewed. DON stated staff must ensure the resident ' s nasal cannula was placed correctly to ensure the resident receives oxygen. DON also stated staff must periodically check the resident to ensure of the nasal cannula ' s placement. DON stated if the resident does not receive oxygen for a prolonged period, the resident could become distressed and become short of breath. A review of the facility ' s P&P titled, Oxygen Administration, revised 10/2010, indicated for staff to check the nasal cannula to be sure they are in good working order and are securely fastened. The P&P also indicated for staff to observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 2. A review of Resident 69 ' s admission Record, indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Huntington ' s disease (a rare, inherited brain disorder that causes nerve cells to break down over time), atherosclerotic heart disease (a buildup of plaque in the arteries that hardens and thickens them), and diabetes (lifelong condition that causes a person's blood sugar level to become too high. A review of Resident 69's MDS, dated [DATE], indicated Resident 69 ' s cognitive status was moderately impaired. The MDS indicated Resident 69 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with eating, rolling left and right, partial/moderate assistance with personal hygiene, toileting, bathing and dressing. During an observation on 2/25/2025 at 10:00 AM in Resident 69's room, Resident 69 was observed in bed with the head of bed elevated, receiving oxygen via nasal cannula at 3 liters per minute. During a concurrent interview and record review, on 2/25/2025, at 10:02 AM, with Licensed Vocational Nurse (LVN) 2, Resident 69's electronic health records (EHR) dated 2/1/2025 to 2/25/2025 was reviewed. The EHR did not indicate a physician ' s order for oxygen. LVN 2 stated, Resident 69 did not have an order for oxygen, though she does use oxygen sometimes. LVN 2 stated, she should have made sure Resident 69 had a supplemental oxygen order. LVN 2 stated, supplemental oxygen should have an order prior to administration because too much oxygen could result in oxygen toxicity. During a concurrent observation and interview on 2/25/2025 at 10:07 AM with LVN 2 in Resident 69 ' s room. LVN 2 was observed obtaining Resident 69 ' s pulse oximeter reading (noninvasive method of measuring the saturation of oxygen in a person's blood) with results indicating 94 percent. LVN 2 then proceeded to turned off Resident 69 ' s supplemental oxygen. LVN 2 stated, Resident 69 did not need supplemental oxygen at that time. A review of Resident 69's facility document titled O2 sats Summary, dated 2/1/2025 to 2/25/2025, indicated, Resident 69 was administered oxygen on 2/9/2025, 2/11/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2,22,5,2/23/25, and 2/25/2025 without a physician ' s order. 055899 Page 17 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 69's facility document titled Order Summary Report, dated 2/27/2025, did not indicate an order for supplemental oxygen until 2/25/2025 (date Resident 69 was observed receiving oxygen without a physician order). During an interview on 2/27/2025 at 9:40 AM with RN 1, RN 1 stated, unless Resident was in distress, prior to administering oxygen a physician order was required, and Resident 69 should have been assessed. RN 1 stated, providing supplemental oxygen without a physicians ' order had the potential to cause oxygen toxicity. During an interview on 2/27/2025 at 10:05 AM DON, DON stated, prior to providing oxygen, there must be a clinical assessment, and a physician ' s order. DON stated, providing supplemental oxygen without a physician ' s order had the potential to give too much oxygen and could result in oxygen toxicity. A review of the facility's P&P titled, Physician Orders, 4/1/2023, indicated: a) to ensure that all physician orders are complete and accurate, b) the Licensed Nurse receiving the order will be responsible for documenting and implementing the order and c) medication orders will be transcribed onto the appropriate resident administration record. A review of the facility ' s P&P titled, Oxygen Administration, dated 10/2010, indicated: a) the purpose is to provide guidelines for safe oxygen administration, b) preparation includes to verify that there is a physician order for the procedure, review the physician orders or facility protocol for oxygen administration c) before administering oxygen and while the resident is receiving oxygen assess for signs or symptoms of oxygen toxicity and vital signs. 055899 Page 18 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to implement its policy and procedure on Transmitting Medication Orders by failing to reorder a scheduled medication (Finasteride oral tablet, a drug to treat an enlarged prostate [a condition where the prostate gland grows larger than normal]) in a timely manner for one of three sampled residents (Resident 15). As a result, Resident 15 did not receive Finasteride 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) during a medication pass observation because the medicine was not available in the medication cart. This deficient practice had the potential to result in complications related to enlarged prostate such as difficulty with urination and worsen the health condition of the resident. Findings: A review of Resident 15 ' s admission Record indicated that the facility initially admitted the resident on 11/10/2022 and readmitted the resident on 9/23/2024 with diagnoses that included benign prostatic hyperplasia (BPH) without lower urinary tract symptoms (a non-cancerous enlargement of the prostate gland). A review of Resident 15 ' s Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2025, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. A review of Resident 15 ' s Order Summary Report, printed on 2/26/2025, indicated that the physician made an order on 9/24/2024 to administer Finasteride Oral Tablet 5 mg one time a day for BPH. A review of Resident 15 ' s Medication Administration Record (MAR) for 2/2025 indicated that LVN 1 did not administer Finasteride Oral Tablet 5 mg on 2/26/2025 at 9 AM as ordered. During a medication administration observation on 2/26/2025 at 8:40 AM, Licensed Vocational Nurse (LVN) 1 did not administer Finasteride 5 mg to Resident 15. In an interview LVN 1 stated, Finasteride was not available in the medication cart. When LVN 1 realized that the medicine was not available, she immediately called the pharmacy and made a STAT order (designed to give priority to orders that are needed most quickly) to refill the medication. During a concurrent interview with LVN on 2/26/2025 at 8:40 AM, LVN 1 stated the charge nurse should order for a medication refill when there are about 2-3 doses left. LVN 1 stated that she gave the last Finasteride 5 mg tablet to Resident 15 yesterday and called the pharmacy to request for a refill. LVN 1 was not able to provide proof that she ordered Finasteride 5 mg because the request was documented. LVN 1 stated that scheduled medications should always be available in the medication cart because missing a dose may result to serious health problems and lead to hospitalization or death. During an interview with the Director of Nursing (DON) on 2/26/2025 at 11:21 AM, the DON stated that the licensed nurse should request for a medication refill from the pharmacy whenever there are only three medication doses left. The DON stated that the health of the resident could be compromised if the resident does not receive a prescribed medication on time; hence, licensed nurses should 055899 Page 19 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0755 always request for a medication refill in a timely manner. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s undated policy titled; Transmitting Medication Orders indicated that the nurse should reorder medications when a three to five-day supply remains in the medication cart. The nurse shall make a note in the resident ' s medical record the date, time, and the name of the pharmacist to whom the order was made. Residents Affected - Few A review of the facility ' s undated policy titled; Pharmacy Services Overview, revised in 4/2019 indicated that residents should have a sufficient supply of their prescribed medications and should receive medications in a timely manner. The nursing staff should communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident ' s medication is not available for administration. A review of the facility ' s undated policy titled; Administering Medications, version 2.1, revised in 4/2019 indicated that medications should be administered in a safe and timely manner and as prescribed. 055899 Page 20 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (food waste, scraps) properly by not having a lid on one of four metal dumpsters (large trash container designed to be emptied into a truck) which was overflowing with boxes, and garbage area with food waste on the ground and littered with rubbish such as dirty crates, broken chairs, broken carts, broken shelves, etc. Residents Affected - Many This deficient practice had a potential to attract insects and harbor pests, attract birds, flies, insects, pest, rodents, which could spread infection to residents and staffs in the facility. Findings: During a concurrent observation and interview on 2/25/2024 at 8AM with the Director of Nurses (DON) in the facility ' s ' garbage area, observed one of four metal dumpsters without a lid and was overflowing with boxes, and the garbage area with food waste on the ground and littered with rubbish such as dirty crates, broken chairs, broken carts, broken shelves, etc . DON stated, she was not aware that one of the bins did not have a lid, she would immediately talk to maintenance supervisor (MS) and housekeeping supervisor (HKS) to order a lid for the trash bin and make sure the garbage area was clean, because it can bring rats, birds and spread infection. During an interview on 2/26/2025 at 7:59 AM with HKS, HKS stated, he and the MS was responsible in making sure the trash bins were covered and not overflowing with trash, and the garbage area was clean, This was just missed. HKS stated, it was an environmental concern to have the trash uncovered and overflowing because it could cause infestation of rats, insects and birds which can cause infection to residents and staff. During an interview on 2/26/2025 at 8:17 AM with MS, MS stated, HKS and himself are responsible in making sure the trash bin was not overflowing, and that the garbage area was always clean, they just missed it. MS stated, he ordered the lid for the trash bin and will not use it until replaced. MS stated, the kitchen staff also use the trash bin for their trash. MS stated, not having the area clean may cause infestation of insects, birds and rodents that could spread disease and affect everyone. During an interview on 2/26/2025 at 8:25 AM with Dietary Service Supervisor (DSS), DSS stated, the dietary staff also uses the trash bin outside of the facility for our food waste and trash. The DSS stated he was not aware that there was an overflowing trash bin, and the garbage area was not clean. DSS stated, moving forward he will notify MS and HKS, if the trash bin is overflowing, and the garbage is not clean. DSS stated, not keeping the area clean may cause infestation of insects, rodents, and had the potential to spread infection and disease that could affect the residents and staff. During an interview on 2/26/2025 at 8:38 AM with Director of Nurses (DON), DON stated, the trash bin should not be overflowing, always covered with a lid, and the garbage area should always be clean to prevent infestations of insects, rodents, that could cause the spread of diseases and/or infections that had the potential to affect the life and safety of residents and staff. A review of the facility's policies and procedures (P&P) titled Food-Related Garbage and Refuse Disposal, (undated), indicated: a)all food waste shall be kept in containers, b) garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests, and c)outside dumpster 055899 Page 21 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0814 provided by garbage pickup services will be kept closed and free of surrounding litter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 055899 Page 22 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure on charting and documentation by failing to ensure that the resident has signed the POLST (Physician ' s Orders for Life-Sustaining Treatment, a portable medical order form that documents a patient's preferences for end-of-life care) for two of ten sampled residents (Resident 24 and Resident 179) before placing it in the resident ' s chart. This deficient practice can lead to misdiagnoses, inappropriate treatment, and gaps in patient care that could result to adverse health outcomes. Findings: A review of Resident 24's admission Record indicated that the facility initially admitted Resident 24 on [DATE] and readmitted the resident on [DATE] with diagnoses that included peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs). A review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated that Resident 24 ' s cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 24's medical chart indicated that the facility offered the POLST to Resident 24 on [DATE], prepared the form, but failed to obtain the signature of the resident before placing it in the resident's chart. A review of Resident 179's admission Record indicated that the facility admitted Resident 179 on [DATE] with diagnoses that included type 2 diabetes with foot ulcer (a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 179's MDS dated [DATE], indicated that Resident 179 ' s cognition was intact. A review of Resident 179's medical chart indicated that the facility offered the POLST to Resident 179 on [DATE], prepared the form, but failed to obtain the signature of the resident before placing it in the resident ' s chart. During an interview with the Medical Records Director (MRD) on [DATE] at 8:10 AM, the MRD stated that the admission nurse was the person responsible for offering the POLST to the resident. The MRD stated that during the IDT meeting, the team ensures that the staff who admitted the resident offered the POLST to the resident, filled out the form properly, and was signed accordingly. During an interview with the Social Services Director (SSD) on [DATE] at 8:23 AM, the SSD stated that she was responsible for ensuring that the admitting staff offered the POLST to the resident during admission. The SSD stated that the MRD should take the initiative to take the POLST to the physician's office if the physician has not yet signed the form. The SSD stated that an incomplete POLST could delay treatment for a resident during emergency situations since the facility would need to call the physician to confirm if the resident should be resuscitated (revive from unconsciousness or apparent death) or not. 055899 Page 23 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Medical Records Assistant (MRA) on [DATE] at 9:11 AM, the MRA stated that the facility offers the POLST to the resident during admission. The MRA stated that the POLST in the resident's chart may not be the complete form since he maintains a binder that contains the POLST of all residents. During a concurrent record review of Resident 24 and 179's POLST forms with the MRA, he showed that the POLST of Residents 24 and 197, which he took from his binder, were prepared on [DATE] and [DATE] respectively and was signed by the physician. The MRA stated that he should have placed the signed POLST in the chart of Residents 24 and 197 after it has been completed. During an interview with the Director of Nursing (DON) on [DATE] at 9:40 AM, the DON stated that a complete and accurate copy of the POLST should be placed in the chart of the resident since an incomplete POLST could delay treatment for a resident during emergency situations which could lead to harm or death. A review of the directions on how to complete the POLST form, indicated that for a POLST to be valid, the form must be signed by a physician, or by a nurse practitioner, or a physician assistant acting under the supervision of a physician, and by the patient or decision maker. A review of the facility ' s policy titled, Charting and Documentation, Version 1.2, revised in 7/2017, indicated that the documentation in the medical record should be complete and accurate. 055899 Page 24 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, Record review and interview, the facility failed to ensure 40 out of 54 residents' rooms meet the square footage requirement of 80 square feet per resident ' s room. The 40 resident's rooms consisted of 5 two bedrooms and 35 - three bedrooms. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for facility staff. Findings: A review of the facility's letter, dated 2/28/2025, indicated that the Administrator requested a room waiver. The letter indicated that resident ' s rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, and 55 did not meet the minimum requirement of 80 sq. ft. per resident room in a multi-resident room. The Room Waiver request indicated that there indicated the room sizes are in accordance with the needs of each resident and does not adversely affect residents's health and safety. The Room Waiver request letter indicated the following rooms provided less than 80 square feet per resident: Room# Room Size Sq Ft 1 240 X 132 220 (3 beds) 2 240 X 132 220 (3 beds) 3 240 X 132 218.3 (3 beds) 4 240 X 132 218.3 (3 beds) 5 240 X 132 154.4 (2 beds) 6 240 X 132 157.1 (2 beds) 7 240 X 132 218.3 (3 beds) 8 240 X 132 218.3 (3 beds) 9 240 X 132 220 (3 beds) 10 240 X 132 218.3 (3 beds) 11 173 X 129 155.8 (2 beds) 12 240 X 132 220 (3 beds) 14 240x131 218.3 (3 beds) 055899 Page 25 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0912 15 241x131 219.24 (3 beds) Level of Harm - Potential for minimal harm 16 241 X 131 219.24 (3 beds) 18 133 X 174 144.7 (2 beds) Residents Affected - Some 19 241 X 131 219.24 (3 beds) 20 240 X 131 218.3 (3 beds) 21 244 X 132 223.6 (3 beds) 22 240 X 131 218.3 (3 beds) 23 244 X 131 222.7 (3 beds) 24 240 X 131 218.3 (3 beds) 25 242X 131 220 .15 (3 beds) 26 240 X 132 220 (3 beds) 27 240 X 131 218.3 (3 beds) 28 241 X 131 219.24 (3 beds) 29 171 X 131 155.56 (2 beds) 30 174 X 131 158.29 (2 beds) 40 95 X 131 177.39 (2 beds) 41 241 X 131 219.24 (3 beds) 42 41 X 131 219 (3 beds) 43 241 X 131 220.15 (3 beds) 44 241 X 131 219 (3 beds) 45 159 X 131 146 (2 beds) 46 241 X 131 219.24 (3 beds) 47 243 X 131 222 (3 beds) 48 243 X 131 222 (3 beds) 49 209 X 179 259.79 (2 beds) 055899 Page 26 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0912 50 241 X 132 220.9 (3 beds) Level of Harm - Potential for minimal harm 51 178 X 131 145.93 (2 beds) 52 178 X 131 145.93 (2 beds) Residents Affected - Some 53 242 X 131 220.15 (3 beds) 54 242 X 131 220.15 (3 beds) 55 241 x 128 214.2 (3 beds) The minimum square footage for a 2-bed room is 160 sq. ft and for a 3-bed room is 240 sq. Ft. During an interview 2/25/2025 at 9:09 AM with Resident 11, the resident stated the room was big enough for her to go around with her wheelchair and staff to provide care. Per resident, she can even have multiple tables in the room and still have space. During another interview on 2/25/2025 at 10:27 AM with Resident 31, the resident stated the room was spacious for him to allow space to go around on his wheelchair and walker. Per resident, staff do not have difficulty going in and out of the room to help him. During the recertification survey from 2/25/2025 to 2/28/2025, observations of the rooms indicated that nursing staff ' s duties were not hindered by the provided space. Observations did not present deficits in care, privacy, and safety towards residents. During a review of the facility ' s policy and procedure (P&P), titled, Bedrooms, revised 5/2017, all resident are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The P&P indicated bedrooms accommodate no more than two residents at a time. The P&P also indicated bedrooms measure at least 80 square feet of space per resident in [multi-bed rooms]. 055899 Page 27 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain a safe, sanitary and clean homelike environment by ensuring 2 of 2 bathrooms observed (Bathroom [ROOM NUMBER] and Bathroom [ROOM NUMBER]) did not have paint bubbling and peeling off the wall behind the sink and the bathroom sink had no light brown discoloration on grout sealer around sink and a white residue around faucet head. This deficient practice had the potential for the residents to be at risk for the spread of infection. Findings: During an observation on 2/27/2025 at 9:31AM at facility Bathroom [ROOM NUMBER] ' s wall paint was bubbling and peeling off on the back of water faucet. There was a light brown discoloration on grout sealer around sink and a white residue around faucet head. During an observation on 2/27/2025 at 9:39AM at facility Bathroom [ROOM NUMBER] ' s the wall paint was bubbling and peeling off on the back of water faucet, grout sealer was peeling off and there was white residue around the faucet head. During a concurrent facility Bathroom [ROOM NUMBER] and 2 observations and interview on 2/27/2025 at 11:30AM with the Maintenance Super (MS), the MS stated the paint was bubbling and peeling in the back of the faucet for both facility Bathroom [ROOM NUMBER]and 2 which was a potential source for infection control because of the discoloration of the grout and the paint peeling off that could get on the resident hands while handwashing. MS stated the resident could get sick and affect their health. A review of the facility ' s P&P titled Homelike Environment revised 2/2021, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 055899 Page 28 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0926 Have policies on smoking. 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 ensure residents receives adequate supervision to prevent accidents for two of two sampled residents out of 16 smokers (Residents 104 and 79) in accordance with the acility ' s smoking policy and facility document titled smoking/vaping risk evaluation, who were observed with a cigarette lighter in their possession. Residents Affected - Few This deficient practice had the potential to cause a fire or accidents especially in a facility that uses oxygen, which can negatively affect the life and safety of residents and staff. Findings: 1. A review of Resident 104 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (hemiplegia is paralysis on one side of the body) and (hemiparesis is weakness on one side of the body) following cerebral infarction (blockage of blood flow to the brain) affecting right dominant side and left non- dominant side, diabetes (lifelong condition that causes a person's blood sugar level to become too high) and lack of coordination. A review of Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/3/2025, indicated Resident 104 ' s cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Resident 104 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, substantial/maximal assist (helper does more than half the effort) with toileting, bathing, dressing and personal hygiene. A review of Resident 104 ' s care plan (CP), dated 11/5/2024, indicated the resident need supervision when smoking. The interventions included: the resident will be monitored for any unsafe smoking practices; notify charge nurse immediately if it is suspected resident has violated facility smoking policy, and supervision will be provided while smoking. A review of Resident 104 ' s facility document titled Smoking/Vaping Risk Evaluation, dated 2/3/2025, the document indicated; Resident 104 was not to keep a cigarette lighter under personal control possession, and staff must store Resident 104 ' s smoking materials. During a concurrent observation and interview on 2/25/2025 at 3:46 PM, Resident 104 was observed in his room with a cigarette lighter on his bedside table. Resident 104 stated, the cigarette lighter belongs to him and he does not hide the cigarette lighter from anyone. During an interview on 2/25/2025 at 4:00 PM with Registered Nurse (RN) 2, RN 2 stated, Resident 104 does not have an independent smoking privileges and should not have a cigarette lighter in his possession, we should be supervising him better as per our policy. RN 2 stated, having a cigarette lighter in Resident 104 ' s possession potentially can cause fire or accidents, especially we have residents that uses oxygen. 2. A review of Resident 79 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson ' s Disease (causes movement problems, mental health issues, and other health concerns), diabetes, and muscle weakness. A review of Minimum Data Set (MDS, a resident assessment tool), dated 1/18/2025, indicated Resident 055899 Page 29 of 30 055899 02/28/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 79 ' s cognitive skills was moderately impaired. The MDS indicated Resident 79 required partial/moderate assistance (helper does less than half the effort) with eating, toileting, bathing, dressing and personal hygiene. A review of Resident 79 ' s facility document titled Smoking/Vaping Risk Evaluation, dated 12/23/2024, the document indicated; Resident 79 was not to keep a cigarette lighter under personal control possession, and staff must store Resident 79 ' s smoking materials. A review of Resident 79 ' s care plan (CP) for supervised smoker, dated 12/24/2024, intervention included: to monitor the resident for any unsafe smoking practices and to notify charge nurse immediately if it is suspected resident has violated facility smoking policy, supervision while smoking, and smoking supplies were to be stored in Nursing Station 1 and activity locker. During a concurrent observation and interview on 2/26/2025 at 4PM with Resident 79 in smoking patio area, Resident 79 was smoking with a cigarette lighter on top of his walker. Resident 79 stated, it was his cigarette lighter, and he always had it, and no one had taken it away from him. During an observation and concurrent interview on 2/26/2025 at 4:05 PM with Director of Activities (DA), in the smoking patio area, DA stated, she was supervising the residents that are smokers, and she was not aware that Resident 79 had a cigarette lighter in his possession. DA stated, the staff should supervise the smokers better to ensure that they do not have a cigarette lighter in their possession. DA stated, the lighter could cause accident and affect the residents and staff. During an interview on 2/27/2025 at 9:50 AM with Registered Nurse (RN) 1, RN 1 stated, supervised smokers were not supposed to have a cigarette lighter in their possession, and Residents 104 and 79 required to be supervised, as per facility ' s policy and procedure. RN 1 stated, the residents that smokes require better supervision to ensure they do not have a cigarette lighter in their possession. RN 1 stated, it is to prevent accidents and for the health and safety of residents and staff, especially in a facility that uses oxygen. During an interview on 2/27/2025 at 10:15 AM with Director of Nurses (DON), DON stated, according to our initial risk smoking evaluation Residents 104 and 79 should not have a cigarette lighter in their possession and were supervised. DON stated, we need better supervision of the residents who smokes and make sure they do not have a cigarettes' lighter, because it is a life and safety hazard and had the potential to cause fire and accident, especially we have oxygen in the building. A review of the facility ' s policy and procedure (P & P) titled, Safety and Supervision of Residents, dated 7/2017, indicated, a) the facility strives to make the environment as free from hazards as possible, b)Resident safety and supervision and assistance to prevent accidents are facility -wide priorities, and c) employees shall be trained on potential accident hazards and demonstrate competency and how to identify and report accident hazards, and try to prevent avoidable accidents. A review of the facility ' s policy and procedure (P & P) titled, Smoking Policy - Residents, dated 7/2017, indicated, a) the facility shall establish and maintain safe resident smoking practices, b) If a smoker, the evaluation will include ability to smoke safely or without supervision (per completed Safe Smoking Evaluation), and c) Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, tobacco, etc., except when they are under direct supervision. 055899 Page 30 of 30