Health inspection·January 30, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect one of three sampled residents' (Resident 2) right to be free from physical abuse. This failure resulted in Resident 2 slapping Resident 1 on the left side of the face. Findings: During a review of Resident 1's admission Record, the admission Record indicted Resident 1 was admitted by the facility on 8/22/2017 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), polyosteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/24/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision-making was moderately impaired (cues/supervision required). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted by the facility on 10/30/2024 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder (a mental health condition that causes excessive fear and worry). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision-making was moderately impaired (cues/supervision required). During an interview with Certified Nurse Assistant (CNA) 1 on 1/30/2025 at 11:57 a.m., CNA 1 stated Resident 2 became agitated about a week ago and tried to throw a book of files at her while at the nursing station. During an interview with Resident 1 on 1/30/2025 at 12:09 p.m., Resident 1 stated his roommate (Resident 2) hit him on the left side of his face . Resident stated the incident happened around 9:30 p.m. and there was a female nurse with him in the room at that time. Resident 1 stated he was scared when the incident happened. Page 1 of 4 555816 555816 01/30/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Licensed Vocational Nurse (LVN) 1 on 1/30/2025 at 1:02 p.m., LVN 1 stated Resident 2 would have moments of outbursts before the incident, off and on. LVN 1 stated Resident 2 got aggressive to the point he would push things, and he threw a pitcher prior to the incident. During a concurrent interview and record review with the Minimum Data Set (MDS) nurse on 1/30/2025 at 1:33 p.m., the MDS nurse stated Resident 2 was reported berating Resident 1 stating he stole my girlfriend . Resident 2's Medication Administration Record (MAR) dated 1/2025 was reviewed. The MDS nurse stated, there was no documented evidence of the number of episodes of outbursts of anger for Resident 2. The MDS nurse stated staff should have monitored to prevent incidents like resident-to-resident altercations and should have called the doctor to assess the resident and adjust the medications. During a telephone interview with Registered Nurse (RN) 3 on 1/30/2025 at 4:25 p.m., RN 3 stated she was making her rounds when she saw Resident 1 in his wheelchair going to the bathroom. When Resident 1 passed Resident 2's bed, RN 3 saw Resident 2 telling Resident 1 he stole his girlfriend. RN 3 walked into the residents' room to assist Resident 1, that's when Resident 2 slapped Resident 1 . RN 3 stated she witnessed the slapping of Resident 1. During a review of Resident 1's Progress Notes and Interdisciplinary Team (IDT) notes dated 1/21/2025 indicated Resident 2 without provocation, suddenly berated and accused Resident 1 of stealing his girlfriend. This accusation was unfounded and nor based in reality .while Resident 1 was being assisted to the toilet by a staff member, Resident 2 approached and slapped him (Resident 1) in the face. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention and Management, revised on 5/30/2024, the P&P indicated, The facility does not condone any forms of resident abuse, neglect, misappropriation of property, exploitation and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems. 555816 Page 2 of 4 555816 01/30/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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: a. Monitor one of three sampled resident ' s (Resident 2) behaviors while the resident was on Risperidone (a psychotropic medication, used to treat certain mental/mood disorders). b. Document one of three sampled resident ' s (Resident 2) indication for an increased dose of Depakote [medication used to treat (bipolar disorder, a chronic mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels)] These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety (excessive worry). During a review of Resident 2 ' s Minimum Data Set (MDS- resident assessment tool), dated 10/01/2024, the MDS indicated Resident 2's cognitive skills for daily decision-making was moderately impaired (decisions poor; cues/supervision required). a. During a review of Resident 2 ' s Order Summary Report, from1/7/2025 to 1/21/2025, the report indicated: Risperidone 3 milligrams (mg, unit of weight) one tablet by mouth two times a day for mood disorder manifested by behavioral aggression as evidenced by destroying facility property, going into other resident ' s room/belongings and taking them. During an interview with Certified Nurse Assistant (CNA) 1 on 1/30/2025 at 11:57 a.m., CNA 1 stated Resident 2 became agitated about a week ago and tried to throw a book of files at her while at the nursing station. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/30/2025 at 1:02 p.m., LVN 1 stated Resident 2 would have moments of outbursts before the incident, off and on. LVN 1 stated Resident 2 got aggressive to the point he would push things, and he threw a pitcher prior to an incident with his roommate. During a concurrent interview and record review on 1/30/2025 at 1:33 p.m. with the Minimum Data Set (MDS) nurse, Resident 2 ' s Medication Administration Record (MAR), dated 1/2025 was reviewed. The 555816 Page 3 of 4 555816 01/30/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0758 Level of Harm - Minimal harm or potential for actual harm MAR indicated, to monitor target behaviors for use of Risperidone due to schizophrenia manifested by recurrent episodes of outbursts of anger, indicate the number of behavior occurrences. The MDS nurse stated, there was no documented evidence of the number of episodes of outbursts of anger. The MDS nurse stated staff should have monitored to prevent behavioral outbursts and should have called the doctor to assess the resident and adjust the medications. Residents Affected - Some During an interview on 1/30/2025 at p.m., with Registered Nurse (RN) 2 at 5:08 p.m., RN 2 stated, when residents are on psychotropic medications the facility should monitor for behaviors manifested and document the number of episodes on the MAR. RN 2 stated, monitoring behaviors was important to prevent increase in behaviors and track if medication is working. b. During a review of Resident 2 ' s Order Summary Report, from 1/7/2025 to 1/21/2025, the report indicated: Depakote 750 mg by mouth two times a day for mood disorder manifested by sudden mood changes ranging from depressed to euphoric and vice versa. During a concurrent interview and record review on 1/30/2025 at 3:26 p.m., with Registered Nurse (RN) 1, Resident 2 ' s Medication Order Summary Report, dated 1/13/2025 was reviewed. The Medication Order Summary Report indicated an increase in Depakote from 500 mg to 750 mg twice a day. RN 1 stated, the increase in dose was not documented on a Situation, Background, Assessment, and Recommendation (SBAR) form, nor was there documentation on the indications for the increase. RN 1 stated, documentation of the indication was a standard of practice. During a phone interview on 1/30/2025 at 5:06 p.m., with the Nurse Practitioner (NP), the NP stated, the criteria for increasing Depakote were for increased behaviors. The NP stated the medication was adjusted to decrease behavior outbursts. During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management revised 1/25/2024, indicated, Evaluation: a. The Behavior Management/Psychoactive Review Committee will review the following and make recommendations based on resident ' s need: ii) continued use of psychoactive medication; c. Documentation Requirements: i) Monthly. The occurrence of behavior will be tallied and entered on the Monthly Psychoactive Medication Management Form in addition to any occurrence of adverse reaction 555816 Page 4 of 4