Health inspection·November 2, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 20) were treated with dignity by failing to provide privacy during medication administration. This deficient practice resulted in exposure to Resident 1 and Resident 20's abdomens (belly) and could have resulted in a psychosocial decline to Resident 1 and Resident 20 due to feelings of humiliation, embarrassment, and being ashamed. Findings: During a review of Resident 1's Detailed Summary (DS, admission record), the DS indicated, Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial flutter (a type of abnormal heart rhythm when the heart beats faster than normal and not always in coordination), encounter for attention to gastrostomy (a surgical opening into the stomach for feeding through a tube) and dysphagia (swallowing difficulties). During a review of Resident 1's History and Physical Examination (H&P), dated 8/27/23, the H&P indicated, Resident 1 did not have the capacity to understand and/or sign forms. During a review of Resident 1's Minimum Data Set (MDS, an assessment and screening tool), dated 9/13/23, the MDS indicated Resident 1's cognitive (ability to think and process information) status was severely impaired. The MDS indicated Resident 1 was totally dependent for intake of nourishment by other means such as tube feeding. During a review of Resident 1's Physician Orders (PO), dated 11/2/23, the PO indicated, current orders that included famotidine (a medication used to treat and prevent ulcers in the stomach and intestines) 20 mg (milligrams, unit of measurement) tablet administered through the gastrostomy tube (G-tube) once daily ordered, dated 7/27/22 and Metoprolol tartrate (a medication that lowers the blood pressure and heart rate) 75 mg by G-tube every twelve hours, dated 7/14/23. During a review of Resident 1's Medication Record (MAR), dated 11/2023, the MAR indicated, the medications Famotidine and Metoprolol were administered via G-tube on 11/1/23. During a review of Resident 20's DS, the DS indicated, Resident 20 was admitted on [DATE] with multiple diagnoses including unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), type 2 diabetes mellitus (a disease in which your blood glucose or blood sugar levels are too Page 1 of 29 555503 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0550 high) and essential hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 20's MDS, dated 8/4/23, the MDS indicated, Resident 20's cognitive status was intact. Residents Affected - Some During a review of Resident 20's H&P, dated 8/29/23, the H&P indicated, Resident 20 had the capacity to understand and/or sign forms. During a review of Resident 20's PO, dated 11/2/23, the PO included an order dated 6/28/23, Victoza (an injectable prescription medicine that may improve blood sugar levels in adults with type 2 diabetes) 1.2 mg subcutaneous (administered under the skin) once daily for type 2 diabetes mellitus. During a review of Resident 1's MAR, dated 11/2023, the MAR indicated, the medication Victoza was administered on the left quadrant on 11/1/23 at 9 a.m. During a concurrent observation and interview on 11/1/23 at 8:34 a.m. with Licensed Vocational Nurse (LVN) 2, during medication administration, LVN 2 did not close Resident 20's privacy curtain located around Resident 20's bed and lifted Resident 20's gown. Resident 20's abdomen was exposed during administration of Victoza in the left quadrant of the abdomen (belly). LVN 2 stated, LVN 2 should have drawn the curtain for privacy, we get stuck in the routine. During a concurrent medication administration observation on 11/1/23 at 9:45 a.m. with LVN 2, LVN 2 did not close the curtain around Resident 1's bed and lifted Resident 1's gown to access Resident 1's G-tube. Resident 1's roommate (Resident 20) was sitting up in Resident 1's wheelchair that was positioned facing Resident 1. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights Guidelines for All Nursing Procedures, revised 10/2010, the P&P indicated, prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including resident dignity and respect. The P&P indicated, for any procedure that involved direct resident care, one of the steps to follow was to close the room entrance door and provide privacy to the resident. During a review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, residents are treated with dignity and respect at all times and staff were to promote, maintain, and protect resident privacy including bodily privacy during assistance with personal care and during treatment procedures. 555503 Page 2 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an assessment was conducted to self-administer medications for one of one sampled resident (Resident 27). Residents Affected - Few This failure had the potential to result in a decline for Resident 27's physical well-being. Cross Reference F760 Findings: During a review of Resident 27's Detail Summary (DS, admission record) indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack (a stroke-like attack), diffuse large B-cell lymphoma (a type of cancer), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), and gastroesophageal reflux (stomach acid or bile irritates food pipe lining). During a review of Resident 27's History & Physical (H&P), dated 10/13/23, the H&P indicated Resident 27 did not have the capacity to understand and/or sign any forms. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/18/23, the MDS indicated Resident 27 had moderate impaired cognition (ability to understand and process information) and required set up and clean-up assistance with eating and oral hygiene and partial/moderate assistance with sit to stand and chair/bed to chair transfers, and toilet transfers. During an observation and concurrent interview on 10/31/23 at 10:41a.m., Resident 27 was lying in bed in Resident 27's room. Seven pills were observed inside a clear medication cup and were on top of Resident 27's bedside table. Resident 27 stated the nurse (unidentified) brought the medication cup with the pills inside the cup this morning and placed the cup on top of Resident 27's bedside table. Resident 27 stated he was sitting on the wheelchair when the nurse left the cup with pills and left. Resident 27 stated Resident 27 did not take the pills because Resident 27 didn't know if Resident 27's physician prescribed them. During an interview, on 10/31/23, at 10:58 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated LVN 1 was new at the facility and was on orientation. LVN 1 stated LVN 1 thought Resident 27 took the seven pills because LVN 1 looked at Resident 27's throat and it looked like Resident 27 swallowed the pills. LVN 1 stated in the future LVN 1 could look inside a residen'ts mouth. During an observation, interview, and concurrent record review on 10/31/23, at 11:05 a.m., LVN 2 stated medications were not to be left at a resident's bedside or left for resident self-administration. The Medication Administration Record (MAR) dated 10/31/23 was reviewed with LVN 2 and observation of the 7 pills in the cup was conducted. The MAR indicated, 1)Carvedilol (treats high blood pressure) 6.25 milligrams (mg, unit of measurement) one tablet, twice a day (BID). This pill was identified in the cup. 2) Plavix (can prevent stroke and heart attack) 75mg once daily, one tablet. This pill was 555503 Page 3 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0554 identified in the cup. Level of Harm - Minimal harm or potential for actual harm 3) Losartan (treats high blood pressure) 50mg once daily. This pill was identified in the cup. Residents Affected - Few 4) Mucinex (temporary coughs and other breathing illnesses) 600mg one tablet. This pill was identified in the cup. 5) Pantoprazole (treats gastroesophageal reflux-GERD) 40mg one tablet, once daily. This pill was identified in the cup. 6) One orange circular pill could not be identified by LVN 1 and LVN 2. 7) One white circular pill that could not be identified by LVN 1 and LVN 2. During an interview on 10/31/23 at 3:39 p.m., with LVN 1, LVN 1 stated it was important to ensure Resident 27 took the medication before leaving Resident 27's room. During an interview, on 10/31/23, at 4:19 p.m., with the Director of Nursing (DON), the DON stated nurses are supposed to stand in front of a resident and watch the resident take the medications. The DON stated the nurse should take the medication cup after the resident has swallowed the medication and toss the medication cup. The DON stated the nurse could place the pills on a spoon and watch the resident swallow. The DON stated for residents that were more alert the nurse should take the medication cup after resident takes the medication. During an interview on 10/31/23 at 4:48 p.m., with the DON, the DON stated all residents were not evaluated for self-administration of medications. The DON stated if a resident (in general) was alert and wanted to self-administer an inhaler or eye drops they must be evaluated first. The DON stated Resident 27 did not have a self-administration of medication assessment and had not been assessed to self-administer medications. A review of the facility's policy and procedure (P&P), titled, Administering Medications, dated April 2019, indicated, residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 555503 Page 4 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide copies of medical records within two working days in accordance with the facility's Policy and Procedure (P&P) on Medical Records Requests for one of one sampled resident (Resident 3). This deficient practice had the potential to violate resident's right to have access to own medical records in a timely manner. Findings: During a review of Resident 3's detailed summary (admission record), the admission record indicated Resident 3 was re-admitted to the facility on [DATE] with diagnoses that included major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and hypertension (elevated blood pressure). During a review of Resident 3's History and Physical (H&P), dated 2/16/23, the H&P indicated Resident 3 had the capacity to understand and/or sign any form. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment and care-screening form), dated 10/19/23, the MDS indicated Resident 3 was cognitively intact and was independent with dressing and personal hygiene. During an interview with Resident 3 on 11/2/23 at 2:48 pm, Resident 3 stated she requested a copy of her medical records a month ago. Resident 3 stated she had followed up with her request and had not received a copy of her medical records as of interview date. During a review of Resident 3's Authorization to Release Protected Health Information, dated 10/2/23, the authorization indicated Resident 3 requested and signed the release of her medical records to herself. During an interview with the Administrator (ADM) on 11/2/23 at 4:48 pm, the ADM stated Resident 3 requested the release of her medical records on 10/2/23, however, a copy of her requested medical records had not been obtained by Resident 3. The ADM stated Resident 3's medical records should have been given to the resident within 24 hours of request because it was her right to have her medical records, as requested. During a review of the facility's P&P titled Medical Records Requests, revised 11/29/22, the P&P indicated the facility team members only release medical records when required or permitted by law or with the written authorization of the individual who is the subject of the records . The copy of records must be made available within two (2) working days of the request. 555503 Page 5 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code fall incidents on two Minimum Data Sets (MDS, an assessment and screening tool) for one of one sampled resident (Resident 19). Residents Affected - Few This failure resulted in an inaccurate assessment of Resident 94 and had the potential to affect Resident 19's physical well-being. Cross Reference F689 Findings: During a review of Resident 19's Detailed Summary (DS, admission record), the DS indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unsteadiness of feet, hearing loss to both ears, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). During a review of Resident 19's MDS, dated [DATE], indicated Resident 19 had moderate impaired cognition (ability to understand and process information) and required partial/moderate assistance with going from sitting to standing and substantial/maximum assistance when going from chair/bed to chair transfers. The MDS indicate Resident 19 used a manual wheelchair. During an interview and concurrent record review of Resident 19's quarterly MDS, dated [DATE] and 7/18/23, on 11/1/23 at 11:12 a.m., with the MDS Coordinator (MDS RN), the MDS RN stated the MDS RN missed and did not include Resident 19's falls that occurred on 1/2/23 and 7/2/23 on the MDS dated [DATE] and the MDS dated [DATE]. the MDS RN stated it was the MDS RN's fault. the MDS RN confirmed by review of Resident 19's clinical record that Resident 19 fell on 1/2/23 and a zero to indicate no falls was recorded on MDS dated [DATE]. The MDS RN stated there were zero falls recorded on the MDS dated [DATE]. The MDS RN stated the MDS RN had no idea why the MDS RN missed this. During a review of Resident 19's MDS dated [DATE] and 7/18/23, the MDS indicated a zero under any falls since Admission/Entry or Reentry or Prior Assessment or whichever was more recent. During a review of the facility's Policy and Procedure (P&P), titled, Comprehensive Assessments, dated March 2022, indicated, comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. A significant error is an error in an assessment where: a. the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and the error has not been corrected via submission of a more recent assessment. 555503 Page 6 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 194 and Resident 195) had a baseline (initial) care plan (CP provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]) developed and implemented within forty-eight hours of admission to the facility. This failure had the potential to result in lack of communication among staff members, specific care needs and current treatments not implemented, and a decline in Residents 194 and 195's physical well-being Findings: During a review of Resident 194's Detailed Summary (DS, admission record), the DS indicated, Resident 194 was admitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), elevated white blood cell count (typically reflects the normal response of bone marrow to an infectious or inflammatory process) and pressure injury (PI, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]) of the sacral (a triangular bone located at the base of the spine) region stage 2 (open wound). During a review of Resident 194's History and Physical Examination (H&P), dated 10/14/23, the H&P indicated, Resident 194 had the capacity to understand and/or sign any forms. During a review of Resident 194's Physician Orders (PO), the PO indicated, an order dated 10/14/23 for indwelling catheter (a type of flexible tube used to empty the bladder and collect urine in a drainage bag) for urinary retention (a condition in which you cannot empty all the urine from your bladder). During a review of Resident 194's Minimum Data Set (MDS, an assessment and screening tool), dated 10/17/23, the MDS indicated Resident 194's cognitive (ability to think and process information) status was intact. The MDS indicated, Resident 194 had an indwelling catheter. During a review of Resident 195's DS, the DS indicated, Resident 195 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including benign paroxysmal vertigo (a common inner ear disorder of a spinning sensation or dizziness whenever you move your head) unspecified ear, unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential hypertension (high blood pressure). During a review of Resident 195's H&P, dated 10/18/23, the H&P indicated, Resident 194 had the capacity to understand and/or sign any forms. During a review of Resident 195's MDS, dated 10/23/23, the MDS indicated, Resident 195's cognitive status was intact. The MDS indicated, Resident 195 was adequately able to hear with the use of hearing aids or other hearing appliances. 555503 Page 7 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/30/23 at 10:42 a.m. Resident 194 was asleep, lying in bed, and easily arousable. Resident 194 had an indwelling catheter draining yellow colored urine with the urinary collection bag inside a black (used to preserve dignity) bag. During a concurrent observation and interview on 10/31/23 at 7:24 a.m. with Resident 195, Resident 195 was awake in bed, looked frustrated, and had trouble hearing. Resident 195 stated, he did not know where his hearing aids were. During an interview on 11/1/23 at 2:05 p.m. with the Social Services Director (SSD), the SSD stated the facility was aware of Resident 195's missing hearing aids. The SSD stated this concern was not care planned and it was important to care plan Resident 195's missing hearing aids for facility to know the plan and execute how to communicate with Resident 195. During a concurrent interview and record review on 11/2/23 at 8:35 a.m. with the Director of Nursing (DON), Resident 194's medical records were reviewed. The medical records did not indicate a baseline care plan to address Resident 194's indwelling catheter. The DON stated a baseline care plan should have been created within forty-eight hours and upon admission to know the baseline of care Resident 194 had to receive, so same sheet of music meaning everyone knows what she [Resident 194] needs. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans - Baseline, revised 12/2016, the P&P indicated, a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The P&P indicated, to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 555503 Page 8 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 94's DS, the DS indicated Resident 94 was admitted to the facility on [DATE] with diagnoses that included fracture of the pelvis (damage to the hip bones, sacral, (a triangular shaped bone at the bottom of the spine), coccyx (tailbone), rheumatic mitral stenosis (commonly caused by rheumatic fever), and pain. During a review of Resident 94's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/26/23, the MDS indicated Resident 94 had intact cognition (ability to understand and process information) and was always bowel incontinent (having no or no voluntary control over defecation [discharge of feces from the body]), was dependent for toileting hygiene, and lying to sitting on side of bed. During a review of Resident 94's History & Physical (H&P), dated 10/21/23, indicated Resident 94 had the capacity to understand and/or sign any forms. During an observation and concurrent interview on 11/02/23, at 9:31 a.m., Resident 94 was heard moaning upon entering Resident 94's room. Resident 94 stated Resident 94 had to have a defecate but it hurt so bad. Resident 94 stated Resident 94 could feel the feces was right there but would not come out. During an interview, on 11/02/23, at 11:20 a.m., Resident 94 stated Resident 94 had one bowel movement (BM) since admission to the facility. During an interview and concurrent record review on 11/2/23, at 2:13 p.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 94 had taken medications that caused constipation. During a concurrent review of Resident 94's clinical record, LVN 3 stated a Care Pan for constipation was initiated 10/20/23 but the Care Plan (CP) was not completed. LVN 3 stated the incomplete CP had a problem and a goal but did not include interventions that addressed Resident 94's constipation. LVN 3 stated the CP needed to have interventions because if Resident 94 was constipated, Resident 94 might have a bowel obstruction (partial or complete blockage of the bowels) that could cause illness and death. During an interview on 11/02/23, at 6:22 p.m., the Director of Nursing (DON) stated Resident 94 did not have a CP in Resident 94's clinical record for constipation. The DON stated a CP was important so that everybody [staff] knew how to manage Resident 94's constipation. The DON stated constipation would not affect Resident 94 in a positive way and could affect Resident 94 psychosocially. During an interview, on 11/02/23, at 6:55 p.m., Resident 94 stated Resident 94 had told the nurse Resident 94 had pain from constipation. Resident 94 stated Resident 94 could not remember if Resident 94 told a nurse (unknown) today or a couple of days ago. During a review of the facility's Policy and Procedure (P&P), titled, Goals and Objectives, Care Plans, dated April 2009, indicated, Care Plans shall incorporate goals ad objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether 555503 Page 9 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0656 or not desired outcomes are being achieved. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered care plan for three of three sampled residents (Residents 11, 94 and145). Residents Affected - Some a. For Resident 11, there was no care plan developed to address Resident 11's retention of urine. b. For Resident 145, there was no care plan developed to address Resident 145's aggressive behavior. c. For Resident 94, there was no care plan developed to address Resident 94's constipation. These deficiencies had the potential to result in inconsistent implementation of care and services and/or missed opportunities in identifying risk for Residents 11, 94 and 145. Findings: a. During a review of Resident 11's Detailed Summary (DS, admission record), the DS indicated Resident 11 was re-admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis (joint pain or stiffness) and spinal stenosis (narrowing of space within the spine). During a review of Resident 11's History and Physical (H&P) dated 9/24/23, the H&P indicated, Resident 11 had the capacity to understand and/or sign any form. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 9/28/23, the MDS indicated Resident 11 required extensive assistance (staff provide weight-bearing support) with one person assist with bed mobility (how resident moves to and from lying position), transfers (to and from bed, chair), toilet use and personal hygiene. During an interview with Resident 11 on 10/31/23 at 9 :00 am, Resident 11 was alert and oriented, Resident 11 stated the previous night (10/30/23), her stomach was big, and she was unable to urinate. During a review of Resident 11's Physician Orders, dated 10/30/23, the physician's order indicated to give Resident 11 Lasix (a medication to induce urination) 40 milligrams (mg- unit of measurement) once daily for retention of urine. During a review of Resident 11's Medication Record for 10/2023 (MR, medication administration record) and MR for 11/2023, the MR indicated Lasix 40 mg was administered to Resident 11 on 10/31/23, 11/1/23 and 11/2/23 for retention of urine. During a concurrent interview and record review on 11/2/23 at 2:20 pm, with the Minimum Data Set Coordinator (MDSC), Resident 11's electronic chart (EC) and paper chart were reviewed. The MDSC stated, there was no care plan developed to address Resident 11's retention of urine in the resident's charts. The MDSC stated a care plan needed to be developed to address Resident 11's retention of urine because care plans were important to plan approaches or interventions to resolve resident's care issues. 555503 Page 10 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 145's DS, the DS indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 145's History and Physical (H&P), dated 10/28/23, the H&P indicated Resident 145 did not have the capacity to understand and/or sign forms due to dementia. During a review of Resident 145's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/30/23, the MDS indicated Resident 145 did not speak and rarely/never had the ability to understand others. During a record review of Resident 145's Physician's Order, dated 10/23/23, the physician's order indicated for staff to monitor Resident 145's aggression manifested by striking out, hitting, and scratching others. During a record review of Resident 145's Interdisciplinary Notes, dated 10/26/23, the notes indicated Resident 145 became combative with daily care. During an observation and concurrent interview with Certified Nurse Assistant 1 (CNA 1), on 10/30/23 at 11:02 am, Resident 145 was observed in bed. CNA 1 stated to keep distance from Resident 145 because Resident 145 can be combative at times. During a concurrent interview and record review on 10/31/23 at 10:36 am, with the Minimum Data Set Coordinator (MDSC) of Resident 145's electronic chart (EC) and paper chart, MDSC stated, Resident 145 had behavioral issues and was aggressive with staff. The MDSC stated there was no care plan developed to address Resident 145's aggressive behavior in the resident's chart. MDSC stated, any licensed staff can initiate a care plan for the resident. MDSC stated if Resident 145 had a particular behavioral issue, a care plan should be developed immediately because care plans were important to manage Resident 145's behavior for staff to be aware of the interventions to implement to minimize Resident 145's aggressive behavior. During a review of the facility's Policy and Procedure (P&P) titled, Goals and Objectives, Care Plans, revised 4/2009, the P&P indicated, Care plans shall incorporate goals and objective that lead to the residents' highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives ae entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 555503 Page 11 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a comprehensive Care Plan (CP) for one of one sampled resident (Resident 19) following fall incidents on 7/2/23, 8/23/23, and on 10/29/23. This failure had the potential to result in major injury and a physical decline to Resident 19. Cross Reference F689 Findings: a. During a review of Resident 19's Detailed Summary (DS, admission record), the Detailed Summary indicated Resident 19 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unsteadiness of feet, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). During a review of the Risk Management Interdisciplinary (IDT) notes dated 7/2/23, 8/23/23, and 10/29/23 indicated Resident 19 was found on the floor in Resident 19's room. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/17/23 indicated Resident 19 had moderate impaired cognition (ability to understand and process information) and required partial/moderate assistance with sit to stand and substantial/maximal assistance with chair/bed to chair transfers. During an interview on 10/30/23 at 10:45 a.m., Resident 19 stated Resident 19 fell forward out of Resident 19's wheelchair last night (10/29/23) trying to pick up a piece of paper from the floor. During an interview and concurrent record review of Resident 19's Fall Care Plan (CP) on 11/02/23, at 3:28 p.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 19 had falls on 7/2/23, 8/23/23, and on 10/29/23. LVN 3 stated a Fall CP for Resident 19 was initiated on 7/20/21 and was revised on 11/1/23. LVN 3 stated LVN 3's the Fall CP needed to be revised after every fall. During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated December 2016 indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. 555503 Page 12 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0657 When the resident has been readmitted to the facility from a hospital stay; and Level of Harm - Minimal harm or potential for actual harm d. At least quarterly, in conjunction with the required quarterly MDS assessment. Residents Affected - Few 555503 Page 13 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) received treatment and care in accordance with facility's Policies and Procedures (P&P) by failing to notify Resident's 27 physician regarding Resident 27's refusal to take a prescribed medication, Mucinex (helps loosen congestion [an abnormal or excessive accumulation of a body fluid] in your chest and throat, making it easier to cough out through your mouth) on October and November 2023. Residents Affected - Some This deficient practice had the potential to result in the development of chest congestion and difficulty breathing for Resident 27. Findings: During a review of Resident 27's Detailed Summary (DS, admission record), the DS indicated, Resident 27 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including transient cerebral ischemic attack (TIA, a temporary blockage of blood flow to the brain), dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and essential hypertension (high blood pressure). During a review of Resident 27's History and Physical Examination (H&P), dated 10/13/23, the H&P indicated, Resident 27 did not have the capacity to understand and/or sign any forms. During a review of Resident 27's Medication Record (MAR), dated 10/2023, the MAR indicated Resident 27 refused (documented as R) the 9 a.m., dose of Mucinex medication on 10/29/23 and 10/31/23. During a review of Resident 27's MAR, dated 11/2023, the MAR indicated, Resident 1 refused (R) the 9 a.m., dose of Mucinex medication on 11/1/23. During a concurrent observation and interview on 11/1/23 at 8:52 a.m. with Licensed Vocational Nurse (LVN) 2, during medication administration, LVN 2 was preparing Resident 27's 9 a.m., medications. LVN 2 did not prepare the medication Mucinex and stated Resident 27 had refused. LVN 2 stated Resident 27 refused Mucinex and said, it does not work, doctor don't know what they're talking about. LVN 2 stated, the physician was not notified about Resident 27 refusing Mucinex and a physician was usually notified the first time a resident refused a medication. LVN 2 stated it was important to notify the physician right away so there will be no lapse of care. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billling/payments, resident rights, etc.). During a review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. The P&P indicated, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 555503 Page 14 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent falls and ensure a safe environment for one of one sampled resident (Resident 19). Resident 19 fell on 7/2/23, 8/23/23, and on 10/29/23 and the facility failed to revise Resident 19's Fall Care Plan (CP) after every fall. This failure resulted in multiple falls and had the potential to result in major injuries, hospitalization, and a decline in Resident 19's physical well-being. Cross Reference F657 Findings: During a review of Resident 19's Detailed Summary (DS, admission record), the DS indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infections (an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body]), unsteadiness of feet, hearing loss to both ears, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/17/23, indicated Resident 19 had moderate impaired cognition (ability to understand and process information) and required partial/moderate assistance with going from sitting to standing and substantial/maximum assistance when going from chair/bed to chair transfers. The MDS indicate Resident 19 used a manual wheelchair. During an interview on 10/30/23 at 10:45 a.m., Resident 19 stated Resident 19 fell forward out of Resident 19's wheelchair last night (10/29/23) trying to pick up a piece of paper from the floor. During an interview and concurrent record review of Resident 19's Fall Care Plan (CP) and clinical record review on 11/02/23 at 3:28 p.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 19 had falls on 7/2/23, 8/23/23, and on 10/29/23. LVN 3 stated a Fall CP for Resident 19 was initiated on 7/20/21 and was revised on 11/1/23. The CP was not revised after every fall. LVN 3 stated Resident 19's Fall CP needed to be revised to include interventions like wheelchair alarm, bed alarm, and bed maintained in a low position. LVN 3 stated the facility should revise CPs to maintain a safe environment and the falling does not happen again. LVN 3 stated to prevent falls from recurring the facility should have had meetings to discuss Resident 19's falls, with charge nurses, certified nursing assistants present, and Resident 19's family should have been involved. LVN 3 stated it was necessary to know the cause of Resident 19's falls. LVN 3 stated visual monitoring and asking Resident 19 if Resident 19 needed to go to the bathroom and aid Resident 19 to avoid Resident 19 going by herself. LVN 3 stated sometimes Resident 19 got confused and tried to get up from the wheelchair by herself, bend over to pick things up, and fall. During a review of Resident 19's Falls CP, initiated 7/20/23, indicated Resident 19 had a history of a fall that occurred on 2/18/20 (no others falls mentioned) and required monitoring and intervention to reduce the potential for self-injury. The CP's interventions included non-skid footwear, 555503 Page 15 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observe non-verbal signs of restlessness, anticipating needs, and Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) to review Activity of Daily Living (ADL, term used in healthcare that refers to self-care activities) status and fall potential. The CP did not indicate revisions or new interventions after the falls that occurred on 7/2/23, 8/23/23, and on 10/29/23. During a review of the Risk Management Interdisciplinary (IDT) notes dated 7/2/23, 8/23/23, and 10/29/23 indicated Resident 19 was found on the floor in Resident 19's room. During a review of Resident 19's post fall Fall Risk Assessment, dated 7/5/23, the Fall Risk Assessment indicated a total score of 10. The assessment indicated Resident 19 was at high risk for falls with a score of 10 or more. The assessment indicated with a score of 10 or more, a Fall Risk Algorhythm had to be completed. A review of the facility's Policy and Procedure, revised March 2018, indicated the staff would evaluate and document falls that occur while the individual is in the facility, begin to try to identify possible causes within 24 hours of the fall. If the fall is unclear or the resident continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident gait, balance, and current medications that may be associated with dizziness or falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is correctable. Based on the assessment, the staff and physician will identify pertinent interventions to try to prevent falls, staff will try the relevant interventions based on the assessment of the nature of category of the fall and until falling reduces or stops or until a reason is identified. The staff and physician will monitor and document the individual's response to the interventions intended to reduce falling. 555503 Page 16 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review reported by the facility's pharmacist on the use of Remeron (a medication to treat depression [feelings of sadness and/or a loss]) were acted upon for one of five sampled residents (Resident 22) in accordance with the facility's Policy and Procedure (P&P) on Pharmacist Medication Regimen Review and Reporting. This deficient practice had the potential to result in unnecessary medication administration and potentially cause harm to Resident 22. Findings: During a review of Resident 22's Detailed Summary (admission record), the admission record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), psychotic disorder (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) and depression. During a review of Resident 22's Physician Orders dated 8/28/22, the physician's order indicated to give Resident 22 Remeron 7.5 milligrams (mg- unit of measurement) by mouth (PO) at bedtime (HS). During a review of the Consultant Pharmacist's Medication Regimen Review (MRR) dated 8/1/23 and 8/23/23, the MRR indicated Resident 22's Remeron carried higher sedative properties and risk of drowsiness and falls and to comment on the risk benefit of continued use - whether to discontinue or decrease the dose of Remeron to 3.75 mg HS. During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 8/17/23, the MDS indicated Resident 22 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for bed mobility (moved to and from lying position), dressing and eating. During a review of Resident 22's History and Physical (H&P), dated 10/5/23, the H&P indicated Resident 22 did not have the capacity to understand and/or sign any form. During a review of Resident 22's Medication Record (MAR, medication administration record) for October 2023, the MAR indicated Resident 22 received Remeron 7.5 mg PO HS from 10/1/23 to 10/30/23. During an interview and concurrent record review with the Director of Nursing (DON), of Resident 22's electronic and paper chart on 11/1/23 at 5:12 pm, the DON stated Remeron 7.5 mg PO HS was ordered on 7/1/23 and discontinued on 8/23/23. The DON stated the same dose and duration of Remeron 7.5 mg PO HS was re-ordered on 8/24/23 and discontinued on 8/28/23. The DON stated Resident 22's current order of Remeron 7.5 mg PO HS was reordered on 8/28/23. The DON stated Resident 22 had been receiving Remeron 7.5 mg PO HS since 7/1/23. The DON stated the Pharmacist's recommendations should be followed because pharmacist reviewed Resident 22's medications and make suggestions to better care for the resident. The DON stated Resident 22's physician needed to be informed of the pharmacist recommendations for the use of Remeron on Resident 22. 555503 Page 17 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's Policy and Procedure, titled Pharmacist Medication Regimen Review and Reporting, dated 9/2008, the P&P indicated MRR is defined as the systematic evaluation of medication therapy viewed within the context of resident-specific data. Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations and respond to in an appropriate and timely fashion. Resident specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. The consultant pharmacist and the nursing care center follows up on the recommendation to verify that appropriate action has been taken. 555503 Page 18 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

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 five sampled residents (Resident 22) who was on Seroquel (medication used to treat mental health condition), received a Gradual Dose Reduction (GDR- tapering a dose of medication) as indicated in the facility's Pharmacist's Recommendation and facility's Policy and Procedure (P&P) on Medication Management. This deficient practice had the potential for Resident 22 to receive unnecessary psychotropic medication (any medicine that affects behavior, mood, or thoughts) and be at risk for harm/injury. Findings: During a review of Resident 22's Detailed Summary (admission record), the admission record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), psychotic disorder (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality) and depression. During a review of Resident 22's Physician's Orders, the physician's order indicated for Resident 22 to receive Seroquel 12.5 milligrams (mg) daily by mouth (PO), ordered on 2/23/22 and Seroquel 25 mg PO at hour sleep (HS) ordered on 4/4/22. During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 8/17/23, the MDS indicated Resident 22 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for bed mobility (moved to and from lying position), dressing and eating. During a review of Resident 22's Medication Administration Record (MAR) for October 2023, the MAR indicated Seroquel 12.5 mg was administered to Resident 22 daily from 10/1/23 to 10/31/23 and Seroquel 25 mg PO at HS was administered to Resident 22 from 10/1/23 to 10/31/23. During a review of Resident 22's Consultant Pharmacist Medication Regimen Review (CPMRR), entered between 8/1/23 to 8/23/23, by the facility's pharmacist, the CPMRR indicated to follow up with Resident 22's physician and recommend trial GDR for Seroquel to 12.5 mg twice a day. During a review of Resident 22's CPMRR entered between 9/1/23 to 9/18/23, by the facility's pharmacist, the CPMRR indicated to consider a GDR for Resident 22 who was taking Seroquel 12.5 mg daily and 25 mg at hours sleep. During a review of Resident 22's Pharmacist Note (PN), printed on 9/18/23, the note indicated to consider a gradual dose reduction of Seroquel 12.5mg daily and 25 mg at hours of sleep for Resident 22. The PN indicated if a GDR was not appropriate, document a rationale for contraindication. The PN note did not indicate any documentation from the Resident 22's physician whether he agreed or disagreed with the GDR. During an interview and concurrent record review of Resident 22's medical record with the Director 555503 Page 19 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0758 Level of Harm - Minimal harm or potential for actual harm of Nursing (DON), on 11/2/23 at 10:34 am, the DON stated the facility pharmacist requested for a GDR for Seroquel for Resident 22 on 9/2023 and 10/2023. The DON stated the PN dated 9/18/23 requesting for a GDR or a rationale to continue the current dose of Seroquel was blank. The DON stated GDR was important for residents on a psychotropic medication to be on the lowest dose possible to address their specific behaviors. Residents Affected - Few During a review of the facility's P&P titled, Medication Management, dated 9/2010, the P&P indicated to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective and safe medication use. Tapering (gradual reduce) of a medication dose/gradual dose reduction (GDR): Within the first year in which a resident is admitted on an antipsychotic medication or after the nursing care center has initiated an antipsychotic mediation the nursing care center must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically indicated. The physician has documented the clinical rationale for why any additional attempted dose reduction at the tie would likely to impair the resident's function or increase distressed behavior. 555503 Page 20 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility's medication error rate was not at five percents (%) or greater. The facility had two errors in 28 opportunities during medication pass which yielded a 7.14% medication error rate for one of three sampled residents (Resident 1). Residents Affected - Few For Resident 1, two medications were crushed, combined, and administered at once via the gastrostomy feeding tube (G-tube or GT, a tube inserted through the belly that brings nutrition directly to the stomach). This failure had the potential to cause chemical incompatibility and incomplete dosage for Resident 1's medications and could cause GT complications such clogging up the tube. Findings: During a review of Resident 1's Detailed Summary (DS), the DS indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial flutter (a type of abnormal heart rhythm when the heart beats faster than normal and not always in coordination) and encounter for attention to gastrostomy. During a review of Resident 1's History and Physical Examination (H&P), dated 8/27/23, the H&P indicated, Resident 1 did not have the capacity to understand and/or sign any form (reasons not indicated). During a review of Resident 1's Minimum Data Set (MDS, an assessment and screening tool), dated 9/13/23, the MDS indicated, Resident 194's cognitive (ability to think and process information) status was severely impaired. The MDS indicated, Resident 1 was totally dependent for intake of nourishment by other means such as tube feeding. During a review of Resident 1's Physician Orders (POS), summary, dated 11/2/23, the POS indicated to administer Famotidine (a medication used to treat and prevent ulcers in the stomach and intestines) 20 mg (milligrams, a unit of measurement) tablet G-tube once daily (ordered on 7/27/22), and Metoprolol tartrate (a medication that lowers your blood pressure and heart rate) 75 mg via G-tube every twelve hours (ordered on 7/14/23). During a review of Resident 1's Medication Record (MAR), dated 11/2023, the MAR indicated, the medications Famotidine and Metoprolol were administered via GT on 11/1/23. During an concurrent observation and interview on 11/1/23 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 2, during medication pass, LVN 2 combined, crushed and administered Resident 1's Famotidine and Metoprolol via the GT at once. LVN 2 stated, the pills should have been crushed individually and administered individually via the GT to avoid contraindications when medications are mixed together. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2018, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated factors that are considered during medication administration included preventing potential medication or food interactions. 555503 Page 21 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0759 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Administering Medications through an Enteral Tube, revised 11/2018, the P&P indicated for staff to administer each medication separately and flush between medications. Residents Affected - Few 555503 Page 22 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents were free from any significant medication error for one out of 16 residents (Resident 27). Residents Affected - Some This failure resulted in a decreased medication efficacy (ability to produce a desired or intended result) for Resident 27 and Resident 27 may have experienced health complications related to incorrect medication administration which could have negatively impacted his health and well-being. Findings: During a review of Resident 27's admission Record indicated he was readmitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack (a stroke-like attack), diffuse large B-cell lymphoma (a type of cancer), atherosclerotic heart disease (damage or disease in the heart's major blood vessels, and gastroesophageal reflux (stomach acid or bile irritates food pipe lining. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 10/18/23, indicated Resident 27 was moderately cognitively impaired (a term referring to an individual's ability to process thoughts and the ability of an individual to perform the various mental activities) and required set up and clean-up assistance with eating and oral hygiene and partial/moderate assistance with sit to stand and chair/bed to chair transfer and toilet transfers. During a review of Resident 27's History & Physical (H&P), dated 10/13/23, the H&P indicated Resident 27 does not have the capacity to understand and/or sign any form. During an observation and concurrent interview, on 10/31/23, at 10:41a.m., with Resident 27, in resident's room, seven pills were observed in a clear medication cup shown by Resident 27 after retrieving the cup from his table/desk. Resident 27 stated, the nurse brought the medication cup in with seven pills this morning and placed the cup with the pills on his bedside table/desk and left medication cup with medicine on bedside table/desk. Resident 27 stated he was up in the chair when the nurse left the seven pills on his table/desk in the medicine cup. He stated he did not take the pills because he didn't know if his regular physician prescribed them. He stated he cannot remember his physician's name because since the stroke he forgets quickly. He stated the pills gives him a headache, although does not know which one and he does not know if all the pills are necessary. He stated he has not taken the pills three to four times but, has taken the medication at a later time. He stated he does not throw away the medication. But, if his daughter says take them, he'll take them. During an interview, on 10/31/23, at 10:58 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated, she was on orientation. LVN 1 stated she thought Resident 27 took them because she saw his throat and it looked like he swallowed them. She stated in the in the future she can make him open his mouth. LVN 1 stated she is new and didn't know he had that behavior. She thought she saw him take the pills and he did not refuse. LVN 1 stated the nurse has to make sure that they take the medication. During a concurrent interview with LVN 2, LVN 2 stated, we do not leave medication for them to take on their own. During an interview and concurrent record review, on 10/31/23, at 11:05 a.m., with LVN 2, the Medication Administration Record (MAR), dated 10/31/23, found in the Electronic Health Record (EHR) was 555503 Page 23 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0760 reviewed. The MAR indicated Resident 27 was given: Level of Harm - Minimal harm or potential for actual harm 1)Carvedilol (treats high blood pressure) 6.25 milligrams (mg) one tablet, twice a day (BID) 2) Plavix (can prevent stroke and heart attack) 75mg once daily, one tablet Residents Affected - Some 3) Losartan (treats high blood pressure) 50mg once daily, 4) Mucinex (temporary coughs and other breathing illnesses) 600mg one tablet BID 5) Pantoprazole (treats gastroesophageal reflux-GERD) 40mg one tablet, once daily 6) Orange circular pill- LVN 1 or LVN 2 was not able to identify the pill. LVN 2 stated thinks it is a multivitamin. 7) [NAME] circular pill- LVN 1 or LVN 2 did not identify pill. During an interview, on 10/31/23, at 11:05 a.m., LVN 2 stated she thinks one of the pills is a Vitamin C. LVN 2 stated a multivitamin and Vitamin C are not a part of Resident 27's medication regimen so he shouldn't be taking something that is not on his list. She stated this is important because Resident 27 could be allergic and have adverse effects to the medication. LVN 2 stated it is definitely not the proper protocol of the facility to give medication that is not prescribed by the resident's physician, and she is not sure what happened. LVN 2 stated five Resident Rights are right patient, right time, right medication, right dose, and right route and medications given twice a day are given at 9:00 a.m. and 5:00 p.m. During an interview with, on 10/31/23, at 11:30 a.m., with LVN 2, LVN 2 stated, giving medication not prescribed is not following patient rights- it is the wrong medication and wrong patient. LVN 2 confirmed on the MAR five medications were given and she stated they were not. During an interview, on 10/31/23, at 3:39 p.m., with LVN 1, LVN 1 stated, it is important to ensure the resident has taken the medication before she leaves the resident's room because as a result of not taking the medication the patient could have a change in condition or his blood pressure (BP). During an interview, on 10/31/23, at 4:19 p.m., with the Director of Nursing (DON), the DON stated nurses are supposed to prepare the medications, identify the resident (picture on MAR), if no picture ask resident their name, administer the medications, if there is a blood pressure medication put in a separate cup (if there are parameters for BP medication), and stand there and watch the resident take the medication. The DON stated nurse stands there and watches the resident take the medication and takes the medication cup after the resident has taken the medication and tosses the medication cup. She stated spoon it and watch them swallow and for a more alert resident the nurse can take the cup after resident takes the medication. The DON stated the nurse can watch the resident take the medication with some kind of fluid and watch him swallow. She stated if we know the resident pockets the medication (gets in mouth and puts on side of cheek or keeps on the tongue) in his mouth or keeps medications at the back of his throat, then the nurse can ask the resident to open their mouth so she can visually check resident's mouth. The DON stated the nurse should do everything she can to ensure the resident has taken the medication. She stated it is important to ensure the resident has taken the medication because it is ordered from the physician for a particular reason and the nurse needs to know if the resident has been taking the medication, and if the resident has not been taking 555503 Page 24 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the medication, in the event there is a change in condition, we can assess it properly. The DON stated an example of a BP or a diabetic medication. She stated BID meds are given at 9:00 a.m. and 5:00 a.m. The DON stated it is important for residents to take medications on time because if the resident is used getting their medication and 9:00 a.m. and 5:00 p.m. that's what their body is used to and let's say he took it at 1:00 p.m. and ten he took the 5:00 p.m., that would have an effect on his blood pressure, it could bottom out (get too low). During an interview on, 10/31/23, at 4:48 p.m., with the DON, the DON stated all residents are not evaluated for self-administration of medication. She stated if the resident is alert and has inhaler or eye drops, they may be evaluated to self-administer. The DON stated Resident 27 does not have a self-administration of medication assessment and had not been assessed to self-administer medication. During an interview, 11/01/23, at 4:43 p.m., with the DON, the DON stated it is unacceptable to administer medication that is not on the resident's MAR or on the Physician's Order. She stated if he's supposed to be getting five pills and he's getting seven, he's getting two more pills than he is supposed to. She stated the nurse should not administer a medication that is not on resident's MAR and ordered by the physician. She stated we as nurses, we are not pharmacists, and we don' know how these medications can affect the resident. The DON stated we work off of a Physician's Order and we should not administer a medication to a resident without a Physician's Order. During a review Resident 27's Physician's Orders, dated 11/2/23, the Physician's Orders indicated Resident 27 was given five daily medications at 9:00 a.m. The medications given to Resident 27 were Carvedilol 6.25 milligrams (mg), Plavix 75mg, Losartan 50mg, Mucinex 600mg, Pantoprazole 40mg, and the Physician's Orders did not indicate Resident 27 was taking a multivitamin or Vitamin C. During a review of Resident 27's MAR, dated, 10/31/23, indicated Resident 27 was given five daily medications at 9:00 a.m. The medications given to Resident 27 were Carvedilol 6.25 milligrams (mg), Plavix 75mg, Losartan 50mg, Mucinex 600mg, Pantoprazole 40mg, and the MAR did not indicate Resident 27 was given a multivitamin or Vitamin C. A review of Resident 27's clinical record did not show any evidence that Resident 27 had been evaluated and approved for self-administration of medication. A review of the facility's policy and procedure (P&P), titled, Administering Medications, dated April 2019, indicated, only persons licensed or permitted by the state to prepare, administer, and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including any required time frame. 555503 Page 25 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when, Residents Affected - Some a. the liquid, in one of three red buckets (Bucket 1), used to sanitize contact surface areas in the kitchen was maintained at the correct concentration of 200-400 parts per million (ppm, unit of measurement). b. foods in one of one nourishment room refrigerator (Refrigerator 1) were not covered or labeled. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and the spread of food borne illnesses (food poisoning) amongst the residents residing at the facility. Findings: a.During an observation of the facility kitchen and interview on 10/31/23 at 10:20 a.m., with the Director of Dining Services (DDS), the sanitation (J-512 ) liquid inside three red buckets were checked for proper concentration. Bucket 1 was tested with a test strip (indicated concentration in ppm) and indicated 0 ppm and orange in color. Bucket 1's concentration was checked a second time (different test strip) and indicated 0 ppm and orange in color. The DDS stated the correct concentration for the liquid in the red buckets was 200 ppm. The DDS stated red buckets were to be checked, dumped, and refilled every two-hours or checked as needed. The DDS stated a concentration of 0 ppm indicated the liquid was not strong enough to sanitize [kitchen counter] surfaces. During a review of the Red Bucket Log dated October 2023, the Red Bucket Log indicated red buckets were checked and 10 a.m. by Kitchen Staff 2 (KS 2) and at 12 p.m. by KS 1. During an interview on 10/31/23 at 10:30 a.m., KS 2 was asked the reason why the Red Bucket Log indicated the sanitizing liquid was checked on 10/31/23 at 12:00 p.m. when the current time was 10:30 a.m. KS 2 did not respond, shook KS 2's head left to right to indicate no, and shrugged KS 2's shoulders. During an interview on 10/31/23 at 10:32 a.m., KS 1 stated KS 1 usually tested the liquid for one red bucket only and refilled all three buckets because it was the same chemical going in all the buckets. KS 1 stated KS 1 checked the liquid in one red bucket at about 9:55 a.m., and KS 1 did not remember the concentration but recalled it was within normal limits. A review of the facility's Policy and Procedure (P&P), titled, Sanitation and Infection Prevention/ControlSanitizing Food Contact Surfaces, dated January 2023, indicated a concentration of 200-400 ppm for J-512 sanitizer and a minimum temperature of 75 degrees Fahrenheit. b.During an observation of Refrigerator 1 and concurrent interview on 11/1/23 at 5:05 p.m., with Registered Nurse 1 (RN 1), Refrigerator 1 contained a plastic clear bowl of sliced apples and oranges were uncovered and unlabeled. RN 1 stated the items inside Refrigerator 1 should be covered and labeled to avoid infection [food borne illness], cross contamination, and for the facility to know if the food was still good. 555503 Page 26 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P, titled, Production, Purchasing, and Storage- Food and Supply Storage, dated January 2023 indicated all food, non-food items and supplies used in food preparation areas shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label, and date unused portions and open packages. Residents Affected - Some 555503 Page 27 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Residents 194 and 196) were provided a sanitary environment to help prevent the development and transmission of infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms e.g., fever, redness, heat, purulent exudates, etc.) by failing to properly discard and store the resident's care items. Residents Affected - Some For Residents 194 and 196, the residents shared the same restroom but nursing staff failed to discard the white top hat specimen collector after one use and failed to rinse and store the used graduated cylinder in the drawer located at the bottom of Resident 164's closet. This failure had the potential to result in cross contamination and the transfer of an infectious agent which could compromise Resident 194 and Resident 196's health. Findings: a. During a review of Resident 194's Detailed Summary (DS), the DS indicated, Resident 194 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), elevated white blood cell count (typically reflects the normal response of bone marrow to an infectious or inflammatory process) and pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) of sacral (a triangular bone located at the base of the spine) region, stage 2 (open wound). During a review of Resident 194's History and Physical Examination (H&P), dated 10/14/23, the H&P indicated, Resident 194 had the capacity to understand and/or sign any form. During a review of Resident 194's Physician Orders (PO), dated 10/14/23, the PO indicated, an order to monitor Foley catheter (a type of flexible tube used to empty the bladder and collect urine in a drainage bag) output every shift. During a review of Resident 194's Minimum Data Set (MDS, an assessment and screening tool), dated 10/17/23, the MDS indicated, Resident 194's cognitive (ability to think and process information) status was intact. The MDS indicated, Resident 194 had an indwelling catheter. b. During a review of Resident 196's DS, the DS indicated, Resident 196 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), essential (primary) hypertension (high blood pressure) and anemia (a condition in which the body does not have enough healthy red blood cells that provide oxygen to body tissues). During a review of Resident 196's H&P, dated 10/24/23, the H&P indicated, Resident 196 did not have the capacity to understand and/or sign any form due to acute (severe and sudden in onset) illness. During a review of Resident 196's MDS, dated 10/27/23, the MDS indicated, Resident 196's cognitive status was intact. 555503 Page 28 of 29 555503 11/02/2023 Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive Duarte, CA 91010

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 196's PO, dated 11/2023, the PO indicated, no order for a urine specimen (a sample for medical testing, especially of urine). During an observation on 10/30/23 at 10:42 a.m. Resident 196 was observed asleep in bed and arousable. Resident 196 had an indwelling Foley catheter draining yellow colored urine and with the urinary collection bag inside a dignity bag. Resident 196 was observed awake in bed. During a concurrent observation and interview on 10/30/23 at 10:59 a.m. with Certified Nursing Assistant (CNA) 1, Resident 194 and Resident 196 shared the same restroom. A white top hat specimen collector next to a used urine stained graduated cylinder labeled with Resident 194's room/bed number and name were stored on top of the toilet tank. CNA 1 stated, the white top hat specimen collector was used to collect specimen and since it was not labeled, facility did not know who it belonged to and should have been discarded. CNA 1 stated, Resident 196 was able to get up and use the restroom. CNA 1 stated, the graduated cylinder was used to empty the urine from the Foley catheter. During an interview on 11/1/23 at 2:32 p.m. with the Infection Preventionist (IP), the IP stated, the used graduated cylinder should have been rinsed and stored in the designated separate drawer located at the bottom of resident's closet. The IP stated, the used white hat specimen collector should have been thrown away since it was a single use. The IP stated, clean supplies or resident care items were stored in the Supply Room across from the nursing station. The IP stated, the resident care items should not be kept on top of the toilet since it was cross contamination and for infection control. During a review of the facility's P&P titled, Infection Control Guidelines for All Nursing Procedures, revised 8/2014, the P&P indicated, Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. During review of the facility's P&P titled, Blood or Body Fluids Exposure, revised 7/2016, the P&P indicated, all blood or body fluids should be considered potentially infectious at all times. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, revised 10/2018, the P&P indicated, Standard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, the P&P indicated, single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals). Single use items will be discarded after a single use. 555503 Page 29 of 29