Health inspection·August 29, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document an indication for a psychotropic medication (medication that affects the brain) to be administered to one of three sampled residents (Resident 11) who was given Ativan due to anxiety with no manifestation. This deficient practice resulted in Resident 11 not being monitored for psychiatric behaviors and had the potential to experience unwanted adverse side effects.Findings: During a review of Resident 11’s admission Record (Face Sheet), the admission Record indicated Resident 11 was initially admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), psychoactive substance (such as caffein, alcohol, addictive pain medications) dependence, and Parkinson’s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 11’s history and physical (H&P) dated 5/14/2025, the H&P indicated Resident 11 had no capacity to understand and make decisions. During a review of Resident 11’s Minimum Data Set (MDS: a resident assessment tool) dated 8/19/2025, the MDS indicated Resident 11 was cognitively moderately impaired. The MDS indicated Resident 11’s was dependent on all aspects of performing activities of daily living (ADL: bathing, oral/toileting/personal hygiene, and eating). The MDS indicated Resident 11 had impairments on both sides of the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 11’s care plan (CP) untitled, the CP indicated Resident 11 used anti-anxiety medications (Lorazepam: anti-anxiety medication) as needed (PRN) for anxiety manifested by (m/b) restless and agitation [manifestations clarified: repetitive physical movements as evidenced by (AEB) getting out of bed unattended on 6/11/2025. The CP intervention indicated to administer anti-anxiety medications as ordered, monitor for side effects, monitor resident every shift for safety as the resident is taking anti-anxiety meds that are associated with an increased risk of confusion, sedation, loss of balance, monitor/document/report PRN any adverse reactions to anti-anxiety therapy, and monitor/record occurrence of for target behavior symptoms and document per facility protocol initiated on 6/11/2025. During a review of Resident 11’s Medication Administration Record (MAR: electronic document that indicate medication administration time) dated 8/1/2025 – 8/31/2025, the MAR indicated Resident 11 received Ativan oral Tablet 0.5 milligram (mg: unit of mass) on 8/16/2025, 8/20/2025, and 8/27/2025 for exhibiting a behavior. Page 1 of 3 055918 055918 08/29/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 11’s Order Summary dated 8/26/2025, the order summary indicated Ativan oral tablet 0.5mg (Lorazepam): give one tablet by mouth every 12 hours as needed for anxiety m/b for 14 days ordered on 8/16/2025 to 8/30/2025. During a concurrent interview and record review on 8/29/2025 at 9:03a.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 11’s order indicated Ativan 0.5mg anxiety m/b, however the m/b is not showing up and further indicated Resident 11’s manifestation is for restlessness. RNS 1 stated it was for m/b for 14 days and does not indicate further. RNS 1 stated Resident 11’s MAR dated 8/1/2025 – 8/31/2025, Resident 11 received Ativan on 8/16/2025, 8/20/25, 8/27/2025, and indicated the m/b is not there and should have been written to identify the behavior where the medication is needed. RNS 1 stated whether the medication is routine or as needed, they are supposed to monitor the behavior and side effects, and every shift will observe the residents behavior. RNS 1 stated the order is incomplete as it is missing the manifestation and indicated on the MAR dated 8/1/2025 – 8/31/2025, the behavior observed is documented as YES. RNS 1 stated the monitoring of behavior is documented on the MAR and in the progress note and indicated Ativan was started on 8/16/2025 for Resident 11. During a concurrent interview and record review on 8/29/2025 at 9:22a.m. with RNS 1, RNS 1 stated on the progress note dated 8/16/2025 at 12:47p.m. indicated Ativan oral tablet 0.5mg was given to Resident 11, but indicated during the evening shift (3:00pm to 11:00pm), they did not mention Resident 11’s behavior and night shift (11:00pm to 7:00am) did not document any progress notes for 8/17/2025. RNS 1 stated monitoring of the side effects for Ativan should be on the medication orders but does not see the monitoring of side effects for Ativan. RNS 1 stated they monitor the side effects as if the medication is given, the residents can become groggy and can affect their ADLs and could get too sleepy. During an interview on 9/2/2025 at 4:29p.m. with the Director of Nursing (DON), the DON stated for residents with any mental diagnosis, they will monitor the behavior and will tally the hash marks on a monthly basis to identify whether the medication was effective or not. The DON stated if the behavior is not monitored, they will not know if the medication is effective or not and would have to refer them to psychiatry. The DON stated there are manifestations for psychotropic medications to ensure the medication is appropriate for the behavior they are treating and indicated if there are no indications, they are giving medications not knowing what they are treating. The DON stated the indication and monitoring for adverse reactions are part of the order, and they monitor the side effects as it can cause lethargy and drowsiness, so it is important to monitor to identify if the medication needs to be reduced or changed to a different medication. During a review of the facility’s policy and procedure (P&P) titled, “Medication Orders” dated 9/2/2022, the P&P indicated elements of the medication order: PRN (as needed) orders should also specify the condition, for which they are being administer, (e.g., as needed for sleep). During a review of the facility’s P&P titled, “Behavioral Health Services” dated 12/19/2022, the P&P indicated it is the policy of this facility to ensure all residents receive necessary behavioral health services facility utilizes the comprehensive assessment process for identifying and assessing a resident’s mental and psychosocial status and providing person-centered care. The process includes, but is not limited to: ongoing monitoring of mood and behavior, care plan development and implementation. During a review of the facility’s P&P titled, “Use of Psychotropic Medications” 055918 Page 2 of 3 055918 08/29/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised 3/17/2025, the P&P indicated “adequate indications for use” refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident’s specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident’s response to the medication(s). the resident’s response to the medication(s), including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident’s medical record. The psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident’s medical record. During a review of the facility’s P&P titled, “Documentation in Medical Record” revised 9/2/2022, the P&P indicated licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident’s medical record in accordance with state law and facility policy. 055918 Page 3 of 3