Health inspection·February 19, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1), who was receiving Quetiapine (a medication used to treat bipolar disorder [a mental disorder that results in severe sadness and manic or extreme joy or elated behavior) was monitored for the specific behavior of paranoid delusions (false beliefs that someone is being threatened or mistreated) as indicated for use of the medication. This deficient practice placed Resident 1 at risk unnecessary use of medication and for mismanagement of her mental disorder and expose her to potential side effects associated with taking Quetiapine, such as drowsiness that could lead to accidents and falls. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), mood disorders, and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s History and Physical (H&P), dated 1/24/2025, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 1/27/2025, indicated the resident had moderately impaired cognition (the ability to think and process thoughts). A review of Resident ' s Order Summary Report, dated 2/14/2025, indicated a physician ' s ordered for the resident to take Quetiapine Fumarate Oral Tablet 25 MG (MG, milligram, a unit of measuring weight) give 1 tablet by mouth at bedtime for schizophrenia manifested by (m/b) paranoid delusions. A review of Resident ' s Medication Administration Report (MAR) for the months of 1/2025 and 2/2025, indicated the resident was being administered Quetiapine Fumarate. The MAR did not indicate that Resident 1 ' s behavior of paranoid delusions was being monitored by staff. A review of Resident 1 ' s nursing progress notes for the months of 1/2025 and 2/2025, did not indicate documented evidence that the resident ' s specific behavior of paranoid delusions was identified and monitored. Page 1 of 2 056317 056317 02/19/2025 Golden Haven Care Center 409 W. Glenoaks Blvd. Glendale, CA 91202

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1 ' s care plan for the use of Quetiapine, initiated on 1/26/2025, indicated the resident ' s behavior was to be monitored for effectiveness every shift. The care plan also indicated for the resident to be monitored for adverse reactions associated with taking Quetiapine. During a concurrent interview and record review on 2/18/2025 at 1:41 PM, Licensed Vocational Nurse (LVN) 1 stated,Resident 1 ' s entire medical records were reviewed, including the MAR and nursing progress notes. LVN 1 stated Resident 1 ' s records did not have documented evidence that Resident 1 ' s behavior of paranoid delusions was monitored. LVN 1 stated Resident 1 ' s behavior should have been monitored to ensure the medication is effective and Resident 1 ' s behavior is being treated. During an interview on 2/18/2025 at 3:45 PM with Director of Nursing (DON), DON stated Quetiapine is considered a psychotropic medication and its use must be monitored. DON stated psychotropic medications (medication that affects mood and behavior) must be monitored to ensure they are working. DON stated monitoring the behavior aids in determining if the medication needs to be discontinued or reduced in dose. DON stated not monitoring the medication could lead to mismanagement of Resident 1 ' s mental disease. DON further stated if the medication is not effective, taking the medication still exposes the resident to side effects that could be dangerous, such as drowsiness that could lead to falls or tremors (involuntary quivering movement). A review of the facility ' s policy and procedure (P&P) titled, Psychotherapeutic Drug Management, revised 10/24/2022, indicated nurses will monitor psychotropic drug use daily. The P&P also indicated nurses will monitor the presence of target behaviors. The P&P also indicated the weekly nursing summary will include as assessment of the psychotherapeutic drugs administered including manifestations. 056317 Page 2 of 2