Health inspection·February 19, 2025

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 one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) titled Psychotropic Medication Use, by failing to ensure: A. Resident 1 have indication for a specific target behavior such as sudden striking or hitting another resident in the physician's order dated 2/17/2025 for the use of Risperdal (medication to treat certain mental/mood disorders). B. Resident 1 have an order to monitor and / or record occurrence of target behavior such as sudden striking for the use of Risperdal. C. Resident 1 have an order to monitor and document/report any adverse (harmful) reactions to Risperdal. These deficient practices had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) status. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a type of mental health condition). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/8/2024, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision Page 1 of 3 555825 555825 02/19/2025 San Marino Healthcare Center 6812 N. Oak Avenue San Gabriel, CA 91775

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated presence of mood symptoms such as little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired or having little energy, and poor appetite or overeating. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 received antipsychotic medication (any drug that affects brain activities associated with mental processes and behavior) on a routine basis. During a review of Resident 1's Order Summary Report dated 2/19/2025, timed 3:23 PM, indicated an order of Risperdal oral tablet 1 milligram, give 1 tablet by mouth two times a day for schizophrenia, with order date of 2/17/2025, and start date of 2/18/2025. During an observation on 2/19/2025 at 12:48 PM with Resident 1, in the activity room, Resident 1 is sitting in a chair, Resident 1 is staring at the floor, Resident faced the wall when approached, and Resident 1 refused to be interviewed. During an interview on 2/19/2025 at 12:50 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated she witnessed Resident 1 punched another resident for the first time on 2/5/2025. During an interview on 2/19/2025 at 3:06 PM with CNA 2, CNA 2 stated Resident 1 sometimes has a different mood wherein Resident 1 is hard to approach and Resident 1 just want to be left alone. During a concurrent record review and interview on 2/19/2025 at 3:12 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's active orders as of 2/19/2025 were reviewed. LVN 1 stated Risperdal for schizophrenia that was ordered on 2/17/2025 is incomplete because there is no specific targeted behavior indicated in the physician's order such as sudden striking or hitting another resident. LVN 1 stated including specific target behavior for the use of Risperdal is important to know what behaviors to monitor and to know what the medication is for. LVN 1 stated Resident 1 has no order for monitoring of specific behavior for the use of Risperdal and no order to monitor adverse reaction of Risperdal. During a concurrent record review and interview on 2/19/2025 at 3:38 PM with Registered Nurse (RN) 1, Resident 1's active orders as of 2/19/2025 were reviewed. RN 1 stated Resident 1's Risperdal order on 2/17/2025 did not and should have a specific behavior such as sudden striking or hitting another resident to be monitored for its use. RN 1 stated it was important to include the specific target behavior so the licensed nurses would know what the Risperdal is for. RN 1 stated Resident 1 did not have and should have an order to monitor adverse reaction to Risperdal. RN 1 stated that antipsychotic medication needs monitoring of specific target behavior so the facility would know if the medication was effective to manage the behavior or not. RN 1 stated specific behavior manifestation such as hitting another resident or physically aggressive behavior should have been in Resident 1's order for Risperdal, and an order of behavior monitoring that to be documented and tallied by the end of the month should be active to have validation for the effectiveness or the need of medication adjustment. During a concurrent record review and interview on 2/19/2025 at 4 PM with Interim Director of Nursing (DON), Resident 1's active orders as of 2/19/2025 were reviewed. The Interim DON verified Resident 1's has an order of Risperdal for schizophrenia, she added it was an incomplete order since there 555825 Page 2 of 3 555825 02/19/2025 San Marino Healthcare Center 6812 N. Oak Avenue San Gabriel, CA 91775

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is no specific target behavior for the use of Risperdal. The Interim DON also stated monitoring of specific behavior for the use of Risperdal and monitoring of adverse reaction was not ordered for Resident 1. The Interim DON stated Risperdal order with a specific target behavior was necessary, so the staff know what the medication is for. The Interim DON stated that psychotropic drugs need monitoring of specific target behavior so the facility would know if the behavioral management was effective or not. The Interim DON stated Resident 1 has a behavior of being physically aggressive to another resident. The Interim DON verified that this behavior was not indicated in Resident 1's Risperdal order. During a review of the Facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated July 2022, indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. It also indicated consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Residents receiving psychotropic medications are monitored for adverse consequences (negative outcomes or effects). 555825 Page 3 of 3