Health inspection·September 10, 2025

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 Based on interview and record review, the facility failed to ensure that Resident 1, a resident with dementia (loss of thinking, memory, and social abilities), was safely escorted to an outside appointment at GACH 1 for one of five sampled residents.This deficient practice resulted in the resident's safety being put at risk.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in the brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required substantial/maximal assistance with walking 10 feet and was dependent for transfers. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated Resident 1 had an appointment on 9/2/2025 at 12:30 p.m. at GACH 1. FAM 1 stated FAM 1 arrived at GACH 1 at 12:20 p.m. FAM 1 stated when FAM 1 arrived at GACH 1, Resident 1 was with provider and Resident 1's wheelchair was there, but no escort was there. FAM 1 stated Resident 1 had another appointment across the street at another office on the same day to have staples removed from Resident 1's head. FAM 1 stated FAM 1 did not see an escort. FAM 1 felt it was unsafe for Resident 1 to be left alone because Resident 1 has dementia. FAM 1 stated Resident 1 was left at the appointment site with Resident 1's medical documents. During an interview on 9/10/2025, at 3:26 p.m., with the Licensed Vocational Nurse (LVN 1), LVN 1 stated the facility will always send an escort, but they also ask the family if family will be available. LVN 1 stated, We don't send them without an escort. LVN 1 stated the only reason that residents will go without an escort is if the family meets them at the appointment or family will meet at the facility and then they go to an appointment. LVN 1 stated it is important to make sure the resident is safe, and that they come back, or there is not an incident of losing the resident and the resident arrives safely. LVN 1 stated LVN 1 is unsure if there is a written Policy stating that, but this is what LVN 1 hopes they're doing it and it's the protocol. During an interview on 9/10/2025, at 4:04 p.m., with the Social Services Director (SSD), the SSD stated staff escort the resident to the appointment and back, if needed. The SSD stated if the resident had a dementia diagnosis, the resident would need an escort. The SSD stated most of the residents in the facility go with an escort. The SSD stated the escort remains at the appointment and returns with the resident unless the family is going to meet them there and the family is okay with taking care of the resident. The SSD stated they must wait for the family before leaving and they can't just leave them there. The SSD stated it is important for safety. The SSD stated that when the Director of Staff Development (DSD) arranges for transportation and an escort, the DSD looks for if the resident needs physical help, a wheelchair, and if the resident is confused Residents Affected - Few Page 1 of 3 555729 555729 09/10/2025 Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or forgetful. During an interview on 9/10/2025, at 4:14 p.m., with the DSD, the DSD stated that Resident 1 was called in to see the doctor and the escort, Escort (ESC 1) stated to the nurse Resident 1's daughter would be coming. During an interview on 9/10/2025, at 5:56 p.m., with Social Services Assistant (SSA), the SSA stated it was determined by email communication, dated 8/28/2025, that Resident 1 needed an escort to ride with her because Resident 1's daughter would meet them at the appointment. The SSA stated that most likely they wait for the family to meet them at the appointment before leaving. The SSA stated if the escort needs to leave, they will call family for an estimated time of arrival (ETA) to the appointment. The SSA stated for the most part escort remains with the patient. The SSA stated it is important for the safety of the resident, so the resident is not alone. During a phone interview, on 9/10/2025, at 6:27 p.m., with ESC 1, ESC 1 stated that Resident 1's daughter was not there. During a review of the facility's Policy and Procedure (P&P), titled, Transportation and Appointments, revised December 2023, the policy and procedure indicated our facility will assist residents in arranging transportation and escort (as indicated for resident with cognitive impairment, diagnosis of Dementia and/or resident's needing physical assistance with transfers and mobility) to/from appointments including when necessary. A member of nursing staff or social services will accompany the resident when the resident's family is not available. 555729 Page 2 of 3 555729 09/10/2025 Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt. This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline). During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required supervision and touching assistance with eating. A review of the Order Summary Report, dated 8/31/2025, the Order Summary Report indicated that Resident 1's diet order was CCHO (Controlled Carbohydrate/NAS (no additional sodium/salt), regular texture, and regular liquid. During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated the Dietary Supervisor (DS) told FAM 1 that Resident 1 requested additional salt with meals and Resident 1 was provided with salt packets. FAM 1 stated Resident 1 had high blood pressure and should not receive salt. During a phone interview on 9/10/2025, at 1:01 p.m., with FAM 2, FAM 2 stated Resident 1 has a seizure when Resident 1's blood pressure is high. FAM 2 stated Resident 1 should not be given salt. During an interview on 9/10/2025, at 3:08 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated to follow physician diet orders. During an interview, on 9/10/2025, at 4:55 p.m., with the Dietary Supervisor (DS), the DS stated that Resident 1's diet orders were a regular diet, and no added salt. The DS stated Resident 1 always asks for additional salt. The DS stated Resident 1 was so mad. The DS stated Mrs. Dash (salt free seasoning) was offered as an alternative and Resident 1 refused it. The DS stated resident 1's preferences were followed. During a subsequent interview on 9/10/2025, at 5:10 p.m., with the DS, the DS stated that the DS did not have documentation that the DS communicated with FAM 1 or FAM 2 that additional salt packets were provided to resident. The DS stated the DS did not have documentation that the DS informed the physician that Resident 1 requested additional salt packets. The DS stated Resident 1's diet order indicated do not give Resident 1 no additional salt. During a review of the facility's Policy and Procedure (P&P), titled, Diet/Therapeutic Diets, revised October 2017, the policy and procedure indicated diets and therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives. 555729 Page 3 of 3