Health inspection·April 25, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 ' s licensed nurses failed to ensure informed consents were obtained from residents or their Responsible Party (RP) prior to administering antipsychotic medications (medication used to treat serious mental health conditions) and/or they failed to ensure informed consents were obtained by the resident ' s provider and not licensed nurses for three of seven sampled residents (Residents 1, 5, and 6). Residents Affected - Some This deficient practice resulted in the administration of anti-psychotic medications to Residents 1, 5, and 6 prior to them being informed of the medications risk versus benefits, alternative treatment and opportunity to refuse. This deficient practice had the potential for the residents to receive unnecessary medications. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, anxiety disorder (a mental condition characterized by excessive worry and fear) and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face Sheet indicated Resident 1 ' s Family Member (FM 1) was the Resident Representative. During a review of Resident 1 ' s History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/4/2025, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. During a review of Resident 1 ' s Order Summary Report (Physician ' s Order), the Physician ' s Order indicated the following: 10/29/2024 – Ativan oral tablet 1 mg every 6 hours as needed for anxiety disorder for 14 days m/b agitation leading to resistance to care. 10/29/2024 – Divalproex Sodium (medication primarily used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and manic phase [mental state of an extreme highs] of bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) oral tablet delayed release 125 mg, one time daily for schizophrenia m/b agitation during activities of daily living ([ADLs] activities such as bathing, dressing and Page 1 of 8 555565 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0552 toileting a person performs daily). Level of Harm - Minimal harm or potential for actual harm 10/29/2024 – Zyprexa (medication used to treat schizophrenia) oral tablet 2.5 mg two times a day for schizophrenia m/b striking out without cause. Residents Affected - Some 11/26/2024 – Ativan (medication used to treat anxiety disorders and severe agitation) 0.5 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) every eight hours for 14 days, as needed for anxiety manifested by (m/b) biting and hitting herself. During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 11/24/2025, the Facility Verification of Informed Consent indicated: Ativan 0.5 mg every eight hours for 14 days, as needed for anxiety m/b hitting and biting herself. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling Resident 1 ' s Family Member 1 (FM 1) by phone on 11/26/2025. During a review of Resident 1 ' s Facility Verification of Informed Consent dated 10/29/2024, the Facility Verification of Informed Consent indicated: Ativan oral tablet one mg for anxiety disorder m/b agitation leading to resistance to care. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025. During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 10/30/2024 the Facility Verification of Informed Consent indicated: Zyprexa oral tablet 2.5 mg for schizophrenia m/b striking out without cause. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025. During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 10/30/2024 the Facility Verification of Informed Consent indicated: Divalproex Sodium oral tablet 125 mg for schizophrenia m/b agitation during ADLs. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025. During an interview on 4/23/2025 at 9:52 a.m., FM 1 stated no one at the facility told him what medications Resident 1 was taking, and they were administering two psychotropic medications (drugs that affect mental functions, behavior, and experience [Zyprexa and Divalproex]) without his knowledge or consent. During an interview on 4/25/2025 at 4:49 p.m., Resident 1 ' s Nurse Practitioner ([NP] an advanced practice Registered Nurse who can diagnose and treat illnesses, prescribe medications, and manage patient care often performing many of the same duties as physicians) 1 stated, if a resident does not have the capacity to make a decision, they will reach out to the next of kin. NP 1 stated, she recalls speaking to FM 2 in 11/2024 when she ordered Ativan 0. 5mg for Resident 1 and stated she did not speak to FM 1 (Resident 1 ' s RP). NP 1 stated licensed nurses can obtain informed consents by educating the residents regarding medication if they (the licensed nurses) feel comfortable doing so. NP 555565 Page 2 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 stated the licensed nurses can have the residents sign the informed consent, and then they (physician, NP) will cosign the informed consent. b. During a review of Resident 5 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including vascular dementia (decline in mental ability caused by reduced blood flow to the brain), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5 ' s H&P dated 12/22/2024, the H&P indicated Resident 5 had the capacity to make medical decisions. During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognitive skills were mildly impaired. During a review of Resident 5 ' s Order Summary Report (Physician ' s Order), the Physician ' s Order indicated the following: 12/20/2024 - Prozac (medication used to treat depression) oral capsule 10 mg, one time daily for unspecified depression m/b verbalization of sadness. 12/20/2024 – Seroquel (medication used to treat schizophrenia and depression) oral tablet 50 mg, one time daily for schizoaffective disorder m/b unprovoked agitation towards staff. During a review of Resident 5 ' s Facility Verification of Informed Consents dated 12/22/2024, the Facility Verification of Informed Consent indicated Resident 5 ' s Responsible Party (RP) 5 consented for the administration of Prozac 10 mg once a day for unspecified depression m/b verbalization of sadness and Seroquel 50 mg once a day (200 mg at bedtime/50 mg daily) for schizoaffective disorder m/b unprovoked agitation towards staff on. During a review of Resident 5 ' s Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident)dated 12/1/2024 through 12/31/2024, the MAR indicated Prozac oral capsule 10 mg and Seroquel oral tablet 50 mg was administered to Resident 5 on 12/21/2024, prior to the consent being obtained on 12/22/2024. During an interview on 4/24/2025 at 11:21 a.m., the Assistant Director of Nursing (ADON) stated for psychotropic medications, the psychiatrist should obtain the informed consent from the resident or the resident ' s RP, then the licensed nurses speak to the resident or call the family to verify the physician obtained the informed consent by reviewing the medication and side effects with the resident or RP. The ADON stated informed consents should be obtained prior to administering psychotropic medications. During an interview on 4/24/2025 at 12:49 p.m., after reviewing Resident 5 ' s MAR dated 12/1/2024 through 12/31/2024, the ADON stated the MAR indicated Prozac oral capsule 10 mg and Seroquel 25 mg was administered to Resident 5 on 12/21/2024. The ADON stated the informed consent for Prozac was dated 12/22/2024 after the medication was administered to Resident 5 and should have been obtained prior to the administration of the medications. c. During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated 555565 Page 3 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0552 Resident 6 was admitted to the facility on [DATE] with diagnoses including dementia, and schizophrenia. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6 ' s H&P dated 2/19/2025, the H&P indicated Resident 6 was not capable of making medical decisions. Residents Affected - Some During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 ' s cognitive skills were mildly impaired. During a review of Resident 6 ' s Physician ' s Order, the Physician ' s Order indicated the following: 2/18/2025 - Divalproex Sodium oral tablet delayed release 500 mg, give 1 tablet at bedtime for schizophrenia m/b mood swings. 2/18/2025 - Quetiapine Fumarate oral tablet 25 mg, give 1 tablet two times a day for schizophrenia m/b agitation leading to noncompliance with care. 3/1/2025 - Quetiapine Fumarate oral tablet 25 mg, give 1 tablet at bedtime for schizophrenia m/b agitation leading to noncompliance with care. During a review of Resident 6 ' s Facility Verification of Informed Consent dated 4/15/2025, the Facility Verification of Informed Consent indicated Quetiapine (dose unspecified) for schizophrenia m/b agitation leading to noncompliance with care was obtained from Resident 6 ' s RP on 3/1/2025 and signed by the provider on 4/15/2025. Continued review of Resident 6 ' s clinical record indicated there were no informed consents obtained for Divalproex Sodium 500 mg at bedtime ordered on 2/18/2025 or Quetiapine Fumarate 25 mg two times a day ordered on 2/18/2025. During a review of Resident 6 ' s MAR dated 2/1/2025 through 2/28/2025, the MAR indicated both Divalproex Sodium oral tablet delayed release 500 mg at bedtime and Quetiapine Fumarate oral tablet 25 mg 2 times a day were administered on 2/19/2025, without an informed consent being obtained prior to administration of the medications. During a review of Resident 6 ' s MAR dated 3/1/2025 through 3/31/2025, the MAR indicated Quetiapine Fumarate oral tablet 25 mg 1 tablet at bedtime was administered on 3/1/2025, prior to the consent being obtained. During an interview on 4/25/2025 at 3:43 p.m., and subsequent interviews at 4:33 p.m., and 4:37 p.m., after reviewing Resident 6 ' s Informed Consents the Director of Nursing (DON) stated the dosage, and date was not documented on Resident 6 ' s informed consent for Quetiapine and the providers signature was dated 4/15/2025 when the medication was ordered on 3/1/2025 and the first dose of the medication was administered on 3/1/2025. The DON stated any changes to Resident 6 ' s psychotropic medication order would need a new informed consent. During an interview on 4/25/2025 at 4:37 p.m., after reviewing Resident 6 ' s MAR dated 2/1/2025 through 2/28/2025, the DON stated the MAR indicated Quetiapine Fumarate oral tablet 25 mg by mouth two times a day and the Divalproex Sodium 500 mg at bedtime, both ordered on 2/18/2025 were 555565 Page 4 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered to Resident 6 on 2/19/20025 with a verbal consent from the physician. The DON stated there should have been an informed consent completed by the licensed nurses and signed by the physician prior to administration of the medications. During a review of the facility ' s Policy and Procedure (P&P) titled, Psychotropic Medication Use revised on 2/2025, the P&P indicated prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives. b. the indications and rationale for the recommendation. c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative's right to accept or decline the treatment. During a review of the facility ' s P&P titled, Psychoactive/Psychotropic Medication Use revised on 7/2024, the P&P indicated the prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a Psychotropic medication. Prior to administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. The resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Prior to prescribing a Psychotropic medication, the prescribing clinician must personally examine the resident. Prior to the administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. A licensed nurse must verify informed consent has been obtained from the resident or the resident's representative prior to administering psychotropic medication. 555565 Page 5 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

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 observation, interview, and record review, the facility failed to ensure that for one of three sampled residents (Resident 1) who was prescribed and administered anti-psychotic medication (a class of drugs used to treat psychosis [an abnormal condition of the mind that results in difficulties telling what is real and what is not], that the medication was prescribed and administered for appropriate indications for use, detailed evidence of behaviors were documented, non-pharmacological interventions (any type of healthcare action that does not involve the use of medication) were attempted and evaluated prior to the administration/continuance of the medication, adverse reactions associated with the use of the medication, i.e., weight gain, an increase in cholesterol and dizziness were monitored, documented and evaluated, and a comprehensive evaluation was conducted to determine if continued use of the medication was warranted. These deficient practices placed Resident 1 at risk for unnecessary medication administration, adverse reactions associated with the medication's use, chemical restraints, and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia, unspecified (a diagnosis used when a clinician can't specify why a patient's symptoms don't meet the criteria for a specific schizophrenia diagnosis and when there isn't enough information to make a more specific diagnosis). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/4/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. During a review of Resident 1's History and Physical (H&P) dated 10/29/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Progress Notes dated 10/29/2024, the Progress Notes indicated Resident 1 was agitated, crying, and trying to get up from her bed. The Progress Notes indicated Resident 1's physician ordered Zyprexa (an antipsychotic medication used to treat several mental health conditions) 2.5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) on 10/29/2024 and instructed them to call the Nurse Practitioner ([NP] an advance practice registered nurse who can diagnose and treat illnesses, prescribe medications, and manage patient care, often performing many of the same duties as physicians) in the morning. Continued review of Resident 1's Progress Notes indicated no further documented behaviors from Resident 1's and no documented non-pharmaceutical interventions were attempted prior to the administration of Zyprexa. During a review of Resident 1's Order Summary Report (Physician's Orders) dated 10/29/2024, the Physician's Orders indicated to administer the following medications to Resident 1: 1. Divalproex (used to treat certain types of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] as well as the manic phase [mental state of an extreme highs] of bipolar disorder [sometimes called 555565 Page 6 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0758 Level of Harm - Minimal harm or potential for actual harm manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) 125 mg one time a day for schizophrenia manifested by agitation during activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) care. 2. Zyprexa 2.5 mg two times a day for schizophrenia manifested by striking out without cause. Residents Affected - Few During a review of Resident 1's Psychiatric Initial Evaluation Note dated 10/30/2024, the Psychiatric Initial Evaluation Note indicated, Resident 1 was pleasant, and per the treatment team, Resident 1 was compliant with care. The Psychiatric Initial Evaluation Note indicated Resident 1 had no behavioral issues. During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/2024, and 12/2024, the MARs indicated there was no documentation that adverse/side effects were monitored related to Resident 1's use of Divalproex and Zyprexa. On 4/23/2025 Resident 1 was observed to be pleasant but confused, sitting in and self-propelling her wheelchair. There was no observation of Resident 1 striking out or yelling at anyone. During an interview on 4/24/2025 at 11:20 a.m., the Assistant Director of Nursing (ADON) stated, when Resident 1 was admitted to the facility (10/28/2024), she was agitated and disgruntled (unhappy, annoyed and disappointed about something) due to the new environment. The ADON stated, the facility's protocol for new onset behavior included assessing the resident, attempting non-pharmacologic interventions, and monitoring the resident for behaviors. The ADON stated, after reviewing Resident 1's Progress Notes, that there was no documentation to indicate Resident 1 had been assessed, monitored for behaviors or that non pharmaceutical interventions had been attempted prior to administering Divalproex and Zyprexa to Resident 1. During an interview on 4/25/2025 at 3:43 p.m., the Director of Nursing (DON) stated the NP ordered Zyprexa on 10/29/2024 because Resident 1 was agitated, crying and trying to get up from her bed. The DON stated there was no evaluation of Resident 1's psychotropic medications (drugs that affect mental function, behavior, and experience), or monitoring for adverse/side effects of Divalproex and Zyprexa for 11/2024 and 12/2024, and there had been no further behaviors documented for Resident 1. During a telephone interview on 4/25/2025 at 4:48 p.m., Resident 1' Physician and the NP stated, the Zyprexa that was ordered on 10/29/2024 should have been given one time only, not as a routine medication. During a review of the facility's Policy and Procedure (P&P) titled, Psychotropic Medication Use revised 2/2025, the P&P indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident of others and when a resident is exhibiting indications of distress that are significant to the resident. Non-pharmacological approaches have been attempted, but did not relieve the medical symptoms which are presenting a danger or significant distress. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record. Documentation must include that behavioral interventions 555565 Page 7 of 8 555565 04/25/2025 Artesia Palms Care Center 11900 E. Artesia Blvd. Artesia, CA 90701

F 0758 were attempted but not successful, and these interventions were deemed clinically contraindicated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555565 Page 8 of 8