Health inspection·January 29, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to participate in the resident's treatment when the facility failed to give Resident 1's Pramipexole Dihydrochloride (medication used to treat Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) at Resident 1's requested time. This failure had the potential for Resident 1 to experience an increase in tremors (involuntary, rhythmic shaking movements that can affect various parts of the body). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/20/2025, with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and need for assistance with personal care. During a review of Resident 1's physician order (PO) dated 1/20/2025, the PO indicated an order for Pramipexole Dihydrochloride oral tablet one (1) milligrams (mg, unit of measurement), give 1 tablet by mouth three times a day for Parkinson's disease. During a review of Resident 1's History and Physical Examination (H&P), dated 1/21/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an interview on 1/28/2025 at 11:05 a.m. with Resident 1, Resident 1 stated her Parkinson's medication (Pramipexole Dihydrochloride) was being given to Resident 1 daily at 9 a.m. Resident 1 stated Resident 1 wanted the medication to be given to her at 7:30 a.m. because the medication being given at that time helped Resident 1 to not shake from her Parkinson's disease. Resident 1 stated Resident 1 spoke to facility staff (unidentified) about changing the medication time from 9 a.m. to 7:30 a.m. but facility staff continued to give Resident 1 the medication at 9 a.m. Resident 1 stated the medication administration time was finally changed to 7:30 a.m. as Resident 1 requested on 1/27/2025. During a concurrent interview and record review on 1/29/2025 at 10:15 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR), dated January 2025 and Resident 2's IDT (Interdisciplinary Team, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) Care Conference Notes (IDT Notes), dated 1/21/2025 were reviewed. The IDT Notes indicated on 1/21/2025, the IDT met with Resident 1 Page 1 of 4 555416 555416 01/29/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding Resident 1's care and goals while at the facility. The ADON stated the ADON was present at the IDT meeting. The ADON stated Resident 1 requested the facility to administer Resident 1's Pramipexole Dihydrochloride medication to Resident 1 before breakfast at around 6 a.m. to 7 a.m. The ADON stated Resident 1 informed the ADON that Resident 1 would experience tremors when she did not receive the medication before breakfast. The MAR indicated Resident 1 received the morning dose of Pramipexole Dihydrochloride at 9 a.m. from 1/21/2025 to 1/23/2025. The ADON confirmed she was aware of Resident 1's request to change the medication time on the evening of 1/21/2025, and that the medication time was not changed for Resident 1 until 1/24/2025. The ADON stated facility staff should have accommodated Resident 1's request to change the medication administration time of Resident 1's Pramipexole Dihydrochloride from 9 a.m. to 7:30 a.m. on 1/22/2025. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised December 2019, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .be informed of, and participate in, his or her care planning and treatment .choose an attending physician and participate in decision -making regarding his or her care . 555416 Page 2 of 4 555416 01/29/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications for one of three sampled residents (Resident 2) were kept locked in secure storage when Resident 2's morning medications were observed to be unattended at Resident 2's bedside. This failure had the potential for Resident 2 to not receive Resident 2's scheduled medications and had the potential to cause harm to other residents who could access and swallow the unattended medications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/29/2024, with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), transient cerebral ischemic attack (a temporary interruption of blood flow to the brain), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/2/2024, the MDS indicated Resident 2 was severely impaired (never/rarely made decisions) in cognitive skills. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) from staff for oral, toileting, and personal hygiene and dressing. During a concurrent observation and interview on 1/28/2025 at 11:46 a.m. with Resident 2, in Resident 2's room, a medication cup containing three pills (unidentified) was observed on the dresser next to Resident 2's bed. Resident 2 stated Resident 2 did not know how long the cup of medicine had been sitting on the dresser. During a concurrent observation and interview on 1/28/2025 at 11:47 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed there was a medication cup containing three (unidentified) medications at Resident 2's bedside, unattended. LVN 1 stated LVN 2 was the nurse responsible to give medications to Resident 2 and that LVN 2 was currently on a lunch break. LVN 1 stated the unattended medications were unsafe because another resident (in general) could have taken/swallowed the medications. LVN 1 removed the medications from the Resident 2's room. During a concurrent observation and interview on 1/28/2025 at 12:13 p.m. with LVN 2, LVN 2 had the cup of three medications at LVN 2's medication cart. LVN 2 confirmed the three medications were from the morning med pass (on 1/28/2025). LVN 2 stated LVN 2 should have remained at Resident 2's bedside after LVN 2 gave Resident 2 her (Resident 2's) medications. LVN 2 stated LVN 2 needed to ensure Resident 2 had swallowed the medications before leaving Resident 2's room. During an interview on 1/28/2025 at 1:58 p.m. with the Director of Nursing (DON), the DON stated LVN 2 had left medication at another resident's (unidentified) bedside previously. The DON stated nursing staff (in general) are required to stay by the resident (in general) during medication pass and ensure residents (in general) have swallowed the residents' medication/s. The DON stated nursing staff (in general) were not permitted to leave residents' (in general) medications at the bedside. 555416 Page 3 of 4 555416 01/29/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised December 2019, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. During a review of the facility's P&P titled, Storage of Medications, revised November 2020, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P indicated: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 555416 Page 4 of 4