Health inspection·June 16, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the attending physician and the resident's representative for one 1 of 3 sampled residents (Resident 1) who was not administered and refused to take Zyprexa (an antipsychotic [a medication used to stabilize mood and behavior for residents with severe mental health conditions]) for seven times in May 2023. As a result of this deficient practice on 6/7/23 Resident 1 was transferred to a General Acute Care Hospital (GACH) due to severe agitation, blocking entry to the room for two days, becoming violent when approached, hitting staffs, and paranoid (false belief or disconnection to reality, and was placed on 51/50 hold ( a 72 hold to monitor a resident in the hospital or controlled environment with behavior that post danger to him/herself and others). Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included diabetes (a health condition that the body has excess sugar in the blood), psychosis (a mental disorder characterized by a disconnection from reality), and schizoaffective disorder (a mental health problem when the person experience psychosis and mood symptoms). A review of Resident 1's physician order, dated 2/14/2023, timed at 2:01 PM, indicated the psychiatrist (a physician specialized in treating behavioral and mental disorder) indicated to administer Zyprexa 5 milligrams (mg, unit of measure) 1 tablet by mouth at bedtime to Resident 1 for schizophrenia (a serious mental disorder in which people interpret reality abnormally) as manifested by episodes of loud verbal outburst to staff. A review of the physician's order, dated 6/7/23, timed at 11:59 AM, indicated to transfer Resident 1 to the hospital vis 51/50 hold for further evaluation. A review of the police report, dated 6/7/23, timed at 1:15 PM, indicated Resident 1 was placed on a 51/50 hold, due to severe agitation, blocking entry to the room for two days, becoming violent when approached, hitting staffs, refused to take medications and paranoid that staff was poisoning him. During an interview on 6/16/2023 at 12:45 PM, the Administrator (ADM) stated Resident 1 had an episode of behavior issue by attacking staff on 6/4/23. During an interview on 6/16/2023 at 1:34 PM, the Acting Director of Nursing (ADON) stated, Resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555755 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Green Acres Healthcare Center 8101 E Hill Drive Rosemead, CA 91770 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)