Health inspection·August 19, 2025

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 ensure the facility's medical records were complete and accurately documented for one of two sampled residents (Resident 2) by not ensuring licensed nurses1. Documented the number of behavioral episodes on the Medication Administration record (MAR);2. Monitored Resident 2 for behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior);3. Had the knowledge to complete monitoring section in the MAR; and4. Licensed nurses documented Resident 2' s return to the facility.These deficient findings could potentially place other residents in the facility at risk to Resident 2's behavioral episodes. These deficient findings created miscommunication on when and at what time Resident 2 returned to the facility.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 2's diagnosis included schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (intense, excessive and persistent worry and fear about everyday situations).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required moderate assistance (helper does less than half) with oral hygiene, toileting hygiene, lower body dressing and putting on/taking off shoes. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with shower/bathing and personal hygiene.During a review of Resident 2's H&P dated 8/8/2025, the H&P indicated Resident 2 could make needs known but could not make medical decisions.During a review of Resident 2's Order Summary Report dated 8/8/2025, the order summary report indicated Resident 2 had an order for quetiapine (helps regulate mood, behavior and thoughts) oral tablet 100 milligrams (mg- metric unit of measurement), one tablet at bedtime for manic (mental state of an extreme highs or depressive lows) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 2's Medication Administration record (MAR), dated 8/7/2025, the MAR indicated there was an order to monitor Resident 2 for agitation and aggressive behavior every shift for use of quetiapine. The MAR indicated for the shifts of 8/8/2025 from 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m., and for 8/9/2025 from 7 a.m. to 3 p.m., the monitoring for those shifts was not done.During a review of Resident 2's Nursing Progress notes, dated 8/10/2025 at 10:58 p.m., Progress Note indicated Resident 2 displayed mild agitation.During a review of Resident 2's MAR, dated 8/9/2025, the MAR indicated there was an order to monitor Resident 2 for extreme mood swings with intense irritability for the use of quetiapine. The MAR indicated on 8/10/2025, Resident 2 did not display any behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior). The MAR indicated on 8/11/2025 from 7 a.m. to 3 p.m., the word yes was documented under number of episodes of behavior. The MAR Page 1 of 3 056220 056220 08/19/2025 Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated for 8/11/2025 from 3 p.m. to 11 p.m., the behavioral monitoring for that shift was not done.During a review of Resident 2's MAR, dated 8/11/2025, the MAR indicated there was an order to monitor Resident 2 every shift for screaming and yelling for the use of quetiapine. The MAR indicated for 8/11/2025 from 3 p.m. to 11 p.m., the behavioral monitoring for that shift was not done. The MAR indicated on 8/12/2025 from 3 p.m. to 11 p.m., the letter n was documented under number of episodes of behavior.During a review of Resident 2's Nursing Progress notes, dated 8/11/2025 at 6:45 p.m., the Progress Note indicated Resident 2 displayed frustration regarding smoking break policy. The nursing progress note indicated Resident 2 became argumentative with staff. The nursing progress notes indicated Resident 2 voiced concerns in an elevated tone.During a review of Resident 2's Nursing Progress notes, dated 8/11/2025 at 9:15 p.m., Progress Notes indicated Resident 2 became hostile, raised his voice and said demeaning comments to staff.During a review of Resident 2's Order Summary Report dated 8/11/2025, the order summary report indicated Resident 2 had an order for Ativan (slows the activity of the brain and nerves) oral tablet 0.5 mg, every six hours as needed for anxiety.During a review of Resident 2's MAR, dated 8/11/2025 at 4:21 p.m., MAR indicated there was an order to monitor Resident 2 every shift for anxiety manifested by restlessness and agitation while using Ativan. The MAR indicated on 8/11/2025 from 3 p.m. to 11 p.m., behavioral monitoring was not done. The MAR indicated on 8/12/2025 from 7 a.m. to 3 p.m., Resident 2 had two behavioral episodes, and indicated No for behavioral episodes.During a review of Resident 2's Nursing Progress notes, dated 8/12/2025 at 11:30 a.m., Progress Notes indicated Resident 2 had a physical altercation with another resident.During a review of Resident 2's medical record, Resident 2's progress note indicating Resident 2 returned to the facility after leaving the facility was not located.During a concurrent interview and record review on 8/19/2025 at 3:26 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR), dated August 2025 was reviewed. The MAR indicated on 8/8/2025, 8/9/2025, and 8/11/2025 monitoring for behavioral episodes was not performed. The DON stated Resident 2 should have been monitored on those days. The DON stated it was important for residents to get monitored because it was important to know if the medication was working. The DON stated residents must be monitored to inform their doctors if there was a change in their behavior.During a concurrent interview and record review on 8/19/2025 at 3:44 p.m. with the DON, Resident 2's MAR, dated August 2025, was reviewed. The MAR indicated on 8/11/2025 and 8/12/2025 licensed nurses did not accurately document the number of behavioral episodes on the MAR. The DON stated licensed staff must document the number of behavioral episodes and not write the word yes or the letter n. The DON stated if the numbers of episodes were not documented, there was no way of knowing how often the behavioral episodes occurred.During a concurrent interview and record review on 8/19/2025 at 4:00 p.m. with the DON, Resident 2's Nursing progress notes, dated 8/8/2025, were reviewed. The progress notes indicated licensed nurses did not document Resident 2's return to the facility. The DON stated licensed nurses must document when residents return to the facility to set a baseline as to how a resident entered the facility. The DON stated looking at the progress notes there was no way of knowing when Resident 2 returned to the facility. The DON stated licensed nurses must document resident's whereabouts because it served as communication for other licensed nurses.During a review of facility's Policy and Procedures (P&P) titled admission Notes dated 9/2012, the P&P indicated residents' information would be documented upon resident's admission to the facility.During a review of facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated it was the facility's policy for all services provided to the resident, any changes in resident's medical, physical, functional or psychosocial condition shall be documented in residents' medical record. The P&P indicated documentation in the medical record 056220 Page 2 of 3 056220 08/19/2025 Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

F 0842 Level of Harm - Minimal harm or potential for actual harm would be objective (not opinionated or speculative), complete, and accurate/During a review of facility's P&P titled Antipsychotic Medication Use dated 7/2022, the P&P indicated staff would gather and document information to a clarify a resident' s behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. Residents Affected - Few 056220 Page 3 of 3