Other·November 6, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Entity Reported Incident (ERI) investigation. ERI Intake Number: CA655775 Representing the Department of Public Health: Health Facilities Evaluator Nurse: # 36535 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for CA00655775.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 10/26/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to modify the care plan for one of two sampled residents (Resident 1) to address the need for supervision during smoking, as indicated on the smoking assessment. This failure had the potential for the resident not to receive specific intervention, which could result to a fall and cause injury to the Resident. Findings: A review of Resident 1's Admission Record indicated the facility readmitted the resident on 11/6/17. Resident 1's diagnoses included displaced fracture of greater tuberosity of left humerus (break in the long bone of the upper arm), displaced intertrochanteric fracture of the left femur (break in the thigh bone), fall from non-moving wheelchair, history of falling, generalized muscle weakness, Alzheimer's disease (a slowly progressive disease of the brain characterized by symptoms like impairment of memory and disturbances in reasoning, planning, language, and perception), and chronic obstructive pulmonary disease (lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review Resident's of the Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated 7/9/19, indicated Resident 1's brief interview of mental status (BIMS, screening which aids in detecting cognitive [ability to process information] impairment) score was 10 (a score of eight to 12 reflected moderate impairment). The MDS indicated Resident 1 required supervision (oversight, encouragement or cueing) for bed mobility, transferring (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), walking, and locomotion (how resident moves between locations). Resident 1 required limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance) with dressing and personal hygiene. A review of Resident 1's Smoking Assessment, dated 7/9/19, indicated Resident 1 was determined as not cognitively alert and does not exhibit independent judgment to maintain own smoking and/or lighting materials. Resident 1 required supervision while smoking/and or using lighting materials. A review of Resident 1's care plan, titled "Resident at Risk for Injury Due to Parkinson's Disease/Alzheimer's," initiated 7/24/18, indicated Resident 1 is a smoker and noncompliant on the smoking schedule. Staff interventions included were to explain to resident the risk of non-complying on scheduled smoking time, smoking risks, hazards and available smoking cessation aids, instruct resident about the facility policy on smoking including locations, times, safety concerns, and to notify Charge Nurse immediately if suspected resident has violated facility smoking policy. Other interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE included were for smoking supplies (cigarette and lighter) to be stored by resident per his preference and to respect resident's wishes and right. During a concurrent record review and telephone interview with DON on 3/27/20 at 4:10 p.m., she stated Resident 1's care plan interventions addressing Resident 1's smoking, non-compliance to smoking schedule and the risk for injury did not and should have included Resident 1's needs to be supervised during smoking, as indicated on the smoking assessment. DON stated the care plan should have been revised when the MDS was completed on 7/19/19. DON stated this was important to ensure that the staff will know how to take of the resident. A review of the facility's policy and procedure, titled "Residents Smoking Policy," revised on 7/2017, indicated the any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. A review of the facility's policy and procedure, titled "Comprehensive Person-Centered Care Plans," revised 12/2016, indicated the Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/26/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1), who was assessed as a high risk for falls. Resident 1, who was moderately impaired to make decisions and required supervision during smoking, was left unattended while smoking outside at the facility's patio area. This deficient practice resulted in Resident 1 sustaining a fall on 9/20/19 at 1:30 a.m., causing severe pain on the resident's right leg and hip. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on the same day, where Resident 1 was identified to have sustained a right hip intertrochanteric fracture (a break in the bony protrusions of the thighbone) and had undergone an open reduction and internal fixation (surgical implementation of implants to repair severely broken bone). Findings: A review of Resident 1's Admission Record indicated the facility readmitted the resident on 11/6/17. Resident 1's diagnoses included displaced fracture of greater tuberosity of left humerus (break in the long bone of the upper arm), displaced intertrochanteric fracture of the left femur (break in the thigh bone), fall from non-moving wheelchair, history of falling, generalized muscle weakness, Alzheimer's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disease (a slowly progressive disease of the brain characterized by symptoms like impairment of memory and disturbances in reasoning, planning, language, and perception), and chronic obstructive pulmonary disease (lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult). A review of Resident 1's care plan for Resident at Risk for Injury Due to Parkinson's Disease/Alzheimer's, initiated 7/24/18, indicated Resident 1 is a smoker and noncompliant on the smoking schedule. Staff interventions were to explain to resident the risk of non-complying on scheduled smoking time, smoking hazards, facility's policy on smoking including locations, times, safety concerns, and notify Charge Nurse immediately if suspected resident has violated facility smoking policy. A review of Resident 1's care plan for Falls Related to Gait/Balance Problems, Seizure Disorder, and history of falls with fracture," initiated on 4/9/19, indicated for staff to anticipate and meet the resident's needs to minimize the potential for falls and educate the resident about safety reminders. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/9/19, indicated Resident 1 had moderate impairment in cognition (ability to think and process information). The MDS indicated Resident 1 required supervision (oversight, encouragement or cueing) for bed mobility, transferring, walking, and locomotion (how resident moves between locations). A review of Resident 1's Smoking Assessment, dated 7/9/19, indicated the resident's diagnoses included Parkinson's disease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (degenerative disorder affecting the motor system with symptoms that included shaking, rigidity, slowness of movement and difficulty with walking and gait) and epilepsy (brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, and uncontrolled movements of the body). The assessment indicated Resident 1 was not able to store smoking and lighting materials to prevent access by other residents. Resident 1 cannot light own cigarette. Resident 1 was determined as not cognitively alert and does not exhibit independent judgment to maintain own smoking and/or lighting materials. The assessment indicated Resident 1 required supervision while smoking/and or using lighting materials. A review of GACH 1's History and Physical, dated 9/20/19, indicated the resident was walking to the patio outside to smoke when he subsequently slipped, fell and landed on his right hip. Resident 1 was transferred to GACH 1's emergency unit for further medical condition. X-ray (photographic or digital image of the internal composition of something, especially a part of the body) showed right hip intertrochanteric fracture. A review of Resident 1's Situation-BackgroundAssessment-Request/Change of Condition (SBAR /COC, communication tool used in healthcare), dated 9/20/19, indicated at 1:30 a.m., the Charge Nurse (unidentified) was notified by Resident 2's visitor of a noise from the parking lot and a resident lying on the ground at the facility patio area. The assessment indicated the Charge Nurse found Resident 1 lying on his left side on the ground at the facility patio area. The Charge Nurse assessed Resident 1's range of motion (ROM) on the left lower extremities and bilateral upper extremities and found no impairment. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment indicated the Charge Nurse was not able to assess Resident 1's right lower extremity due to Resident 1 did not allow the Charge Nurse to touch the right leg due to severe pain. The Charge Nurse called emergency 911 (emergency phone number) at 1:40 a.m. and Resident 1 was transferred to GACH 1 via paramedics on 9/20/19 at 1:55 a.m. for further evaluation and treatment. A review of Resident 1's progress notes, dated 9/20/19, indicated Resident 1's fall was unwitnessed. A review of the GACH 1's Operative Report, dated 9/21/29, indicated Resident 1's preoperative and postoperative diagnosis was right intertrochanteric fracture. Resident 1 had undergone an open reduction and internal fixation. A review of the Significant Change in Status Assessment MDS, dated 10/8/19, indicated a decline in Resident 1's level of assistance required for activities of daily living (ADL). Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transferring, walking, locomotion, dressing, eating, toilet use, personal hygiene and total dependence on the staff for bathing. During a telephone interview on 3/27/20 at 3:43 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 needs assistance with activities of daily living (ADL), but since Resident 1 refuses to be assisted, staff only provides supervision. CNA 1 stated Resident 1 was at risk for fall due to his balance was not good. CNA 1 added Resident 1 frequently goes outside the patio area to smoke and does not like to follow the smoking schedule. CNA 1 stated smoking schedule was at 9 a.m., 6 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8 p.m. and the rest, she does not remember, but it was twice every shift. CNA 1 stated Resident 1 kept his cigarette and lighter in his room in a locked bedside drawer. Resident 1 lights his cigarette with his lighter. CNA 1 stated she had observed Resident 1 holding the cigarette with minimal hand shaking due to Parkinson's disease. CNA 1 stated on 9/19/19, Resident 1 woke up at 9:45 p.m. and requested to go outside the facility patio area to smoke. CNA 1 stated she told Resident 1 not to do so, but Resident 1 did not listen and wheeled himself outside the facility patio area. CNA 1 stated she went out to check on Resident 1 after he wheeled himself outside and encouraged him to go back inside the facility because he was at risk for fall. CNA 1 stated she went back inside the facility to take care of other residents when Resident 1 declined to go inside the facility. CNA 1 stated she went back out at the patio area at 10:30 p.m. and observed Resident 1 smoking while sitting on his wheelchair. CNA 1 stated she went out two more times at 11:30 p.m. and 12:30 a.m. and observed Resident 1 was still smoking while sitting on the wheelchair. CNA 1 stated she was taking care of another resident inside the resident's room prior to going out to check on Resident 1 at 1:30 a.m. CNA 1 stated when she went back out at 1:30 a.m., she found the resident lying on the ground at the facility patio area with three (3) other staff. CNA 1 stated Resident 1 was still holding his cigarette while lying on the ground. CNA 1 stated Resident 1 said he lost his balance when he got up to check the time. Resident 1 complained of leg pain and the Charge Nurse called the paramedics. During a concurrent review of Resident 1's Smoking Assessment, dated 7/9/19 and telephone interview with Director of Nursing (DON), on 3/27/20 at 4:02 p.m., she stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment indicated Resident 1 was not cognitively alert, oriented and does not exhibit independent judgment to maintain own smoking and/or lighting materials and requires supervision while smoking and/or using lighting materials. The DON stated due to Resident 1's risk factors, Resident 1 need to be supervised while smoking by the CNA assigned to him. The DON stated Resident 1 was unsupervised outside at the facility patio when the resident fell on 9/20/19. The DON stated it was Resident 2's visitor who saw Resident 1 outside lying on the ground and notified staff. The DON stated according to Resident 1, he stood up and walked to look at the clock to check the time and fell. The DON stated Resident 1 needed to be supervised all the time while smoking. During a telephone interview, on 3/27/20 at 4:07 p.m., the DON stated during smoking schedule (9 a.m., 11 a.m., 1 p.m., 3 p.m., 6 p.m., and 8 p.m.), one activity staff and one CNA take turn to supervise the residents who smoke in the designated smoking area. The DON stated Resident 1 slept mostly during the day and smoked when he was awake at night. The DON stated Resident 1 was non-compliant to smoking schedule and would wheel himself to the patio. The DON stated staff would sometimes find Resident 1 sitting or smoking in the patio by himself. The DON stated Resident 1 was allowed to keep smoking paraphernalia (cigarette and lighter) locked in a bedside drawer inside the resident's room to respect Resident 1's preference and right. During a concurrent review of Resident 1's care plan and telephone interview with the DON on 3/27/20 at 4:10 p.m., she stated Resident 1's care plan intervention indicated for staff to notify the Charge Nurse immediately if resident has violated facility's smoking policy including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE locations, times, safety concerns. During a telephone interview on 3/27/20 at 5:30 p.m., Resident 1 stated he was outside sitting at the patio area early morning on 9/20/19 but was not smoking. Resident 1 stated he got up from his wheelchair to look at the clock and fell. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 3/31/20 at 7:30 a.m., she stated on 9/20/19, Resident 2's visitor knocked on the facility's locked door and informed her of the noise she heard from the parking lot. LVN 1 stated Resident 2's visitor also reported someone was lying on the ground at the facility patio area. LVN 1 stated she called another staff to go with her to check the patio area and they found Resident 1 alone outside lying on the ground. LVN 1 stated Resident 1 said he got up, but lost his balance and fell when he peeked through the dining room sliding door to check the time. LVN 1 stated due to Resident 1's complain of left leg and left hip pain, paramedic was called and transferred resident to GACH for further evaluation and treatment. A review of the facility's policy and procedure, titled "Residents Smoking Policy," revised on 7/2017, indicated the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). The policy indicated any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. The policy indicated the facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055259 (X3) DATE SURVEY COMPLETED 10/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MONROVIA POST ACUTE 1220 Huntington Dr Duarte, CA 91010 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE levels of support and supervision. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFDC11 Facility ID: CA950000073 If continuation sheet 12 of 12