Health inspection·May 15, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided with the necessary behavioral health care and services to address Resident 1's history of suicidal ideation (SI- a range of thoughts, fantasies, or contemplations about ending one's own life) by failing to: 1. Ensure the Social Services Director (SSD) and/or admitting licensed nurse accurately assessed and documented Resident 1's episode of suicidal ideation while Resident 1 was in the General Acute Care Hospital (GACH) 1 on 4/20/2025. 2. Develop a care plan for Resident 1's history of suicidal ideations. 3. Monitor Resident 1 for suicidal ideations. These deficient practices had the potential to worsen Resident 1's mental condition and increase Resident 1's risk for suicide and self-harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought, perceptions, emotional responsiveness, and social interactions), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with reality), generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and major depressive disorder (a mood disorder that causes persistent feeling of sadness, and loss of interest). During a review of Resident 1's physician order (PO) dated 4/16/2025, the PO indicated Resident 1 had an order to transfer to GACH 1 on 4/17/2025 for further evaluation secondary to behavior of increased verbal and physical aggression and destroying facility property. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/17/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making were modified independence (some difficulty in new situations only). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity) with oral, toileting, and personal hygiene, showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The Page 1 of 4 056079 056079 05/15/2025 Glendora Grand, Inc 805 W. Arrow Hwy. Glendora, CA 91740

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS indicated Resident 1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and exhibited verbal behavioral symptoms directed toward others for one (1) to three (3) days of the assessment and other behavioral symptoms not directed toward others daily. During a review of Resident 1's GACH 1 Psychiatric Evaluation (GACH 1 PE) dated 4/20/2025, the GACH 1 PE indicated, He (Resident 1) reported having suicidal thoughts 2 days ago with a plan to overdose (taking more than the recommended amount of a medicine or drug) on his medication. The GACH 1 PE indicated, When asked why he (Resident 1) is in the hospital he replies, I was having suicidal thoughts. The GACH 1 PE indicated Resident 1 reported feeling helpless, hopeless, and worthless because he had been getting abused, and no one would do anything about it. The GACH 1 PE indicated Resident 1 stated Resident 1's hand was broken because Resident 1 punched the wall. The GACH 1 PE indicated Resident 1 stated, I don't remember why I got angry. The GACH 1 PE indicated Resident 1 was positive for hallucinations, talked to himself and stated, The voices keep telling me to go home. The GACH 1 PE indicated Resident 1's mood was labile (easily altered) and unpredictable (something that can change suddenly, unexpected and cannot be planned for). The GACH 1 PE indicated Resident 1 was unable to be managed at a lower level of care at this time. During a review of Resident 1's Nursing Progress Note (NPN) dated 4/29/2025, timed at 10:08 PM, the NPN indicated Resident 1 was transferred to GACH 1 on 4/17/2025 due to Resident 1's increasing verbal aggression when Resident 1's demands were not met, destroying facility property, striking out glass panel of the station, and walking in the hallway with Resident 1's fist clenched on the right hand. The NPN indicated Resident 1 was readmitted from GACH 1 (on 4/29/2025). The NPN indicated Resident 1 was calm and cooperative with staff at this time. During a review of Resident 1's Social Service History & Initial Assessment (SSHIA) dated 4/30/2025, timed at 11:30 AM, the SSHIA indicated, readmitted Resident 1 from acute hospital back to secure unit for wandering behavior, after going out for aggressive behavior here at facility manifested by destroying facility property . The SSHIA indicated Resident 1 remained guarded and did not engage well in conversation. The SSHIA indicated the SSD would monitor Resident 1's care/psychosocial health. The SSHIA indicated, under Psychosocial Adjustment Factors, the SSD did not check off the boxes for history of depression and history of suicidal ideation/gestures. During a concurrent interview and record review on 5/15/2025 at 10:28 AM with the Director of Nursing (DON), Resident 1's admission record was reviewed. The DON stated Resident 1 was readmitted to the facility on [DATE], and did not have a diagnosis of suicidal ideations (SI) on Resident 1's admission record. The DON stated there were no suicidal ideation assessments completed, no care plan developed with interventions, and no monitoring initiated to address Resident 1's report of suicidal ideation while in GACH 1, upon Resident 1's readmission to the facility. During an interview on 5/15/2025 at 11:25 AM with the SSD, the SSD stated the SSD had met with Resident 1 to go over the history interview (on 4/30/2025). The SSD stated, I did notice that he (Resident 1) went out for aggression and when he (Resident 1) came back from the hospital (GACH 1), on the History and Physical (H&P/GACH 1 PE), he (Resident 1) had a history of suicidal ideation. The SSD stated when Resident 1 came back to the facility, the SSD had a talk with Resident 1 and Resident 1 wanted to call Resident 1's mom. The SSD stated the SSD asked how Resident 1 felt and Resident 1 stated Resident 1 felt fine. The SSD stated the SSD asked Resident 1 twice if Resident 1 felt like Resident 1 wanted to hurt himself or if Resident 1 had ever tried to hurt yourself. The SSD stated Resident 1 answered, No. 056079 Page 2 of 4 056079 05/15/2025 Glendora Grand, Inc 805 W. Arrow Hwy. Glendora, CA 91740

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the same interview on 5/15/2025 at 11:25 AM with the SSD, the SSD stated the SSD did not document the conversation the SSD had with Resident 1 regarding Resident 1's SI. The SSD stated the SSD should have documented the conversation about SI on Resident 1's Social Service History & Initial Assessment. The SSD stated if Resident 1 had a positive SI answer, the SSD should have notified the nursing department and participated in an Interdisciplinary Team (IDT- a group of healthcare professionals, including nurses, doctors, therapists, and social workers, who collaborate to provide comprehensive care and services to residents) meeting, and considered documenting a change of condition (COC) for Resident 1. The SSD stated in general, upon admission of a resident, the SSD needed to complete the history and physical of the resident including history about family or health issues. The SSD stated in the form the SSD used to complete the resident's H&P (in general), there was a check list for social services staff to check off if there were any issues or concerns with the resident having SI. The SSD stated for Resident 1, the SSD left the area for history of suicidal ideation/gestures blank because of the conversation the SSD had with Resident 1 (on 4/30/2025). The SSD stated the SSD completed the assessment by interviewing Resident 1 and reviewing Resident 1's history and physical. During a concurrent interview and record review on 5/15/2025 at 11:36 AM with DON, Resident 1's medical record was reviewed. The DON stated if a resident (in general) had SI, there should have been an assessment upon admission, CP created with interventions to keep the resident safe, monitoring, COC initiated, and an IDT meeting held. The DON stated the resident's doctor should have been notified, and new orders would have been given. The DON stated the SSD should have checked off the history of SI in the SSD's assessment of Resident 1. The DON stated the SSD should have documented any type of conversation she had with Resident 1 whether Resident 1 verbalized SI or not. The DON stated that because the SSD did not complete the SI assessment, there could have been potential and/or actual harm to Resident 1. During an interview on 5/15/2025 at 12:45 PM with the Administrator (Admin), the Admin stated the facility staff needed to assess Resident 1 for suicide ideations due to Resident 1's history upon admission. The Admin stated it was very important to assess Resident 1 for suicidal ideations to prevent harm and the way to do so was by making sure the steps were put into place where Resident 1 was assessed, monitored, and kept safe. The Admin stated if there was an assessment done specially about suicide, the staff needed to document the assessment. The Admin stated the SSD should have documented the conversation the SSD had with Resident 1 and notified nursing staff right away. During an interview on 5/15/2025 at 4 PM with Registered Nurse (RN) 2, RN 2 stated that if a resident (in general) was suicidal or had history of SI, it needed to be taken very seriously because if it was missed, it could place the resident at risk of danger to himself/herself. RN 2 stated there needed to be documentation of the interview with the resident even if the resident was currently not having SI. RN 2 stated documenting any type of SI information from a resident helped to clarify to the rest of the staff and staff were able to access the information. RN 2 stated if it was not documented, it could affect the care given to the resident and the continuity and quality of care provided. RN 2 stated a missed assessment could cause potential harm to the resident. RN 2 stated there should be a care plan developed to make sure the resident had adequate interventions even if it was just a history of SI. During the same interview on 5/15/2025 at 4 PM with RN 2, RN 2 stated, Undocumented suicidal thoughts mean staff may not be aware of the patient's risk level, leading to inadequate supervision, safety precautions, and a missed opportunity for interventions that could potentially save the residents life. If it's not documented, it wasn't done. RN 2 stated, it was important to document any 056079 Page 3 of 4 056079 05/15/2025 Glendora Grand, Inc 805 W. Arrow Hwy. Glendora, CA 91740

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's history of suicidal thoughts to decrease the resident's risks of injury and even death and that was what we (the staff) were here for. RN 2 stated that even if the resident did not currently have suicidal thoughts, it was important to document the history. RN 2 stated, It doesn't hurt to document it. During a review of the facility's policy and procedure (P&P) titled, Behavior Management Program, undated, the P&P indicated, Residents who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. The P&P indicated, Behaviors shall be identified through the Resident Assessment Instrument (RAI- a process that is used to gather information about residents' needs, strengths, and preferences to create individualized care plans and ensure residents receive quality care and maintain their quality of life) and through staff interaction . Further assessments to identify and manage behaviors may be conducted . Identified behaviors should be evaluated and documented on MAR (Medication Administration Record) or other specified location. The P&P indicated, The Interdisciplinary Team should decide which residents need a behavior management program vs. residents that are care planned with appropriate interventions, by evaluating them. During a review of the facility's P&P titled, Suicide Assessment, undated, the P&P indicated, It is the policy of this facility to assess residents for suicidality. The P&P indicated, Residents will be assessed for suicide risk upon admission and as indicated. The facility social worker or designee will conduct a medical record review and then interview the resident regarding any risk factors that have been identified. Protective factors will be explored with the resident as well. The P&P indicated, Risk factors include, but are not limited to .History of prior suicide attempts or self-injurious behaviors .Current or past psychiatric disorder(s) and/or recent change in psychiatric treatment (change in medication/treatment/ provider or recent discharge from inpatient psychiatric setting) . Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity . The P&P indicated, Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record. During a review of the facility's P&P titled, Baseline Care Plan, undated, the P&P indicated, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The P&P indicated, The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable . Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives . Interventions shall be initiated that address the resident's current needs including . Any health and safety concerns to prevent decline or injury . Any identified needs for supervision, behavioral interventions . During a review of the facility's job description for Social Services Designee (JD SSD) titled, Social Services Designee, the JD SSD indicated, The Social Service Designee will participate in discharge planning, development and implementation of care plans and resident assessments. The Social Service Designee will accurately and completely document social service actions and interactions in each resident's medical record. The Social Service Designee will ensure that residents who display mental illness, or psychosocial difficulties such as coping with grief and loss, have access to appropriate treatment and resources. 056079 Page 4 of 4