Other·November 30, 2018

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 Department of Public Health during an investigation of one facility reported incident during an annual recertification visit conducted on 11/4/18. Facility reported incident number: 610670 Representing the Department of Public Health: Evaluator ID No: 38942, RN, HFEN Evaluator ID No: 33670, RN, HFEN Total Resident Population: 43 Total Resident Sample: 16 Highest Scope and Severity: G No deficiencies were issued for facility reported incident 610670.

F640 SS=E Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 11/03/2018 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. 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: 7FRU11 Facility ID: CA950000260 If continuation sheet 1 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 2 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 review, the facility failed to transmit the Minimum Data Set (MDS), a standardized resident assessment and care screening tool, into the CMS (Centers for Medicare and Medicaid Services) system for six of 16 sampled residents (Residents 1, 2, 4, 5, 6, and 7) within 14 days of the completion date. This deficient practice had the potential for the facility not to identify or monitor each resident's decline and progress over time. Findings: On 11/3/18, at 1:30 p.m., in an interview and concurrent record review of the MDS assessments for Resident s 1, 2, 4, 5, 6, and 7 the MDS Nurse Coordinator stated, the MDS assessment were completed for the residents but were not accurately transmitted into the CMS-MDS system. 1. A review of the Profile Face Sheet indicated, Resident 1 was admitted to the facility on 6/8/16, with diagnosis that included, malnutrition (poor food intake) and dementia (a brain disorder that results in memory loss and altered thought process). A review of the MDS Submission Report indicated, Resident 1's MDS assessment was not transmitted to the CMS-MDS system by the target date of 7/26/18. 2. A review of the Detailed Summary indicated Resident 2 was admitted to the facility on 5/28/16, with diagnoses that included age related physical debility (frailty) and atrial fibrillation (irregular heart rate). A review of the MDS Submission Report indicated Resident 2's assessment was not transmitted to the CMS-MDS system by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 3 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 target date of 8/10/18. 3. A review of the Detailed Summary indicated Resident 4 was admitted to the facility on 1/16/16 and was readmitted on 3/15/18, with diagnoses that included, urinary tract infection, muscle weakness and spinal stenosis (narrowing of the back bone or spine that puts pressure on the nerves and spinal cord and can cause pain). A review of the MDS Submission Report indicated Resident 4's assessment was not transmitted to the CMS-MDS system by the target date of 9/14/18. 4. A review of the Detailed Summary indicated Resident 5 was admitted to the facility on 3/9/10 and was readmitted to the facility on 6/6/12, with diagnosis that included dementia. A review of the MDS Submission Report indicated Resident 5's MDS assessment was not transmitted to the CMS-MDS system by the target date of 7/17/18. 5. A review of the Detailed Summary indicated Resident 6 was admitted to the facility on 11/14/11 and was readmitted on 6/1/15, with diagnosis that included dementia. A review of the MDS Submission Report indicated Resident 6's MDS assessment was not transmitted to the CMS-MDS system by the target date of 9/21/18. 6. A review of the Detailed Summary indicated Resident 7 was admitted to the facility on 7/1/17, with diagnosis that included Parkinson's disease (a brain disorder that results in slow, poor coordination, balance, trembling and stiffness arms, legs and torso). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 4 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 of the MDS Submission Report indicated Resident 7's MDS assessment was not transmitted to the CMS-MDS system by the target date of 9/21/18. On 11/4/18, at 8:59 a.m., during an interview the Medical Record Director (MRD) stated, the MDS assessment did not accurately transmit to the CMS-MDS system on the target date due to the "glitz" in the facility's computer programing. The MRD explained she did not inform the MDS nurse coordinator or the MDS central office regarding the failure to transmit the MDS assessment of the residents to the CMS-MDS system.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 11/03/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation and record review, the facility failed to ensure that wound care treatment was provided according to the professional standards of care for one of two sampled residents (Resident 28) with pressure ulcers (localized injury to the skin and/or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 5 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 underlying tissue usually over a bony prominence, as a result of pressure) in total of 16 sampled residents. This deficient practice had the potential to result in wound infection. Findings: A review of Resident 28's Detailed Summary indicated that Resident 28 was originally admitted to the facility on 3/15/18 and was readmitted on 9/25/18. A review of Resident 28's History and Physical (H&P) dated 9/25/18, indicated that Resident 28 had intact skin. The H&P also indicated that Resident 28 had diagnoses that included dementia (general term for loss of memory and other mental abilities severe enough to interfere with daily life), Alzheimer's disease (progressive memory loss), congestive heart failure (inability of the heart to pump out enough blood supply to the body) and scoliosis (sideways curvature of the spine). A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 10/9/18, indicated that Resident 28 had moderate cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance with two-person assist from staff for transferring and extensive assistance with oneperson assist from staff for bed mobility, toilet use, personal hygiene and dressing. The MDS also indicated that Resident 28 did not have pressure ulcer and had urinary/bowel incontinence. During wound care observation on 11/3/18, at 9:39 a.m., the Treatment Nurse/Registered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 6 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 Nurse 1 (RN 1) was observed to clean the wound by dabbing the 2 x 2 gauze on the wound 3 to 4 times using the same side of the gauze while cleansing the wound. RN 1 was also observed dabbing the 2 x 2 gauze on the periwound bed using the same side of the gauze 4 to 5 times to clean the area. A review of the guidelines from woundcareadvisor.com indicated that for a resident with an open wound, the nurse should gently clean the wound in a full or half circle, beginning in the center and working toward the outside.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 11/03/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that soiled briefs are changed timely for one of 16 sampled residents (Resident 10). This deficient practice had the potential to contribute to skin breakdown, pain and stinging on Resident 10's buttocks. Findings: A review of Resident 10's Detailed Summary indicated that Resident 10 was initially admitted on 5/18/16 and was re-admitted on 10/23/18. A review of Resident 10's record titled "History FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 7 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 and Physical" dated 10/27/18 indicated that Resident 10 had diagnoses that included left lower extremity lymphedema (condition in which extra lymph fluid [colorless fluid containing white blood cells] builds up in tissues and causes swelling) and chronic left lower extremity ulcer (an open sore). A review of the Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 10/30/18, indicated that Resident 10 had severe cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance with one-person assist from staff for bed mobility, transfer, toilet use, personal hygiene and dressing. The MDS also indicated that Resident 10 had bowel incontinence and had suprapubic catheter (tube surgically inserted into the bladder to drain the urine). During observation and concurrent interview on 11/1/18, at 7:19 p.m., Certified Nurse Assistant 1 (CNA 1) was observed putting Resident 10 to bed (from the rest room) with soiled briefs. CNA 1 stated that she assisted Resident 10 to use the restroom, but did not remove her soiled briefs. CNA 1 stated that she was planning to change Resident 10's briefs in bed (because it was easier to change in bed than the restroom), but forgot. CNA 1 was observed changing Resident 10's briefs, together with CNA 2, from 7:25 p.m. to 7:51 p.m. Resident 10's bowel movement (BM) was observed to be dry, green and appeared stuck to Resident 10's buttocks. CNA 1 stated, that is how Resident 10's BM usually looks like. CNA 1 stated that she uses paper towels to clean Resident 10's BM because it is softer than the wash cloth. Observed CNA 1 using a paper towel five times but was unable to thoroughly clean Resident 10. CNA 1 left and went to get a wash cloth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 8 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 and a basin of water to clean Resident 10. Resident 10 was observed with redness on the inner left and right buttocks. Resident 10 stated she felt pain and stinging sensation in her buttocks area. During an interview with the Director of Nurses (DON) on 11/2/18, at 8:49 p.m., the DON stated that the possible causes of redness of the buttocks are bowel/bladder incontinence, not changing briefs in a timely manner, not cleaning thoroughly, and stated that nursing played a huge part in that. The DON stated that it was important to change residents timely and clean thoroughly because the possible consequences are pressure ulcer, pain, and stinging in the area affected. A review of the record titled Care Plan, under "Continence" dated 11/2/18, indicated that Resident 10 had absence or decreased perception of the need to move bowels and that the facility will assist Resident 10 to the toilet and will provide hygiene after bowel movement. A review of the record titled Care Plan, under "Pressure Ulcer" dated 10/24/18, did not indicate that the facility will keep the Resident 10 clean and dry. A review of the facility's policy titled, "Skin Protocol," revised and updated on 6/11/18, indicated that the facility will provide appropriate interventions for resident with impaired skin integrity.

F684 SS=D Quality of Care CFR(s): 483.25 FORM CMS-2567(02-99) Previous Versions Obsolete

F684 Event ID: 7FRU11 11/03/2018 Facility ID: CA950000260 If continuation sheet 9 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accurately assess redness on two out of two sampled residents (Resident 10 and 28) with pressure ulcer injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure) in a total sample of 16. There were no measurements taken to evaluate whether the redness had improved or deteriorated. Findings: 1. A review of Resident 10's Detailed Summary indicated that Resident 10 was initially admitted on 5/18/16 and was re-admitted on 10/23/18. A review of Resident 10's History and Physical (H&P) dated 10/27/18, indicated that Resident 10 had diagnoses that included left lower extremity lymphedema (condition in which extra lymph fluid [colorless fluid containing white blood cells] builds up in tissues and causes swelling) and chronic left lower extremity ulcer (an open sore). A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 10/30/18, indicated that Resident 10 had severe cognitive impairment (the mental action or process of acquiring knowledge and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 10 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 understanding through thought, experience, and the senses) and required extensive assistance with one-person assist from staff for bed mobility, transfer, toilet use, personal hygiene and dressing. The MDS also indicated that Resident 10 had bowel incontinence and had suprapubic catheter (tube surgically inserted into the bladder to drain the urine). A review of Resident 10 record titled "Skin Evaluation Form" dated 10/23/18, indicated redness to inner buttocks but the documentation did not include measurement or description. A review of the Physician's order indicated an order to apply Aloe Vesta cream (skin protectant) to inner buttocks three times a day for two weeks, with a start date of 10/24/18. A review of the Care Plan dated 10/24/18 indicated to assess area every shift for any open areas or skin breakdown. During an observation on 11/1/18, at 7:19 p.m. with Certified Nursing Assistant 1 (CNA 1) and CNA 2, Resident 10 was noted to have redness to the right and left inner buttocks. During an interview and concurrent record review in the computer on 11/3/18, at 3:32 p.m., Registered Nurse 1 (RN 1), who was also the treatment nurse, stated that there were no documented evidence that there was redness on the buttocks area. RN 1 stated, that he was not aware that Resident 10 had redness on the buttocks area. 2. A review of Resident 28's Detailed Summary indicated that Resident 28 was originally admitted to the facility on 3/15/18 and was readmitted on 9/25/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 11 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 of Resident 28's H&P dated 9/25/18, indicated that Resident 28 had intact skin. The H&P also indicated that Resident 28 had diagnoses that included dementia (general term for loss of memory and other mental abilities severe enough to interfere with daily life), Alzheimer's disease (progressive memory loss), congestive heart failure (inability of the heart to pump out enough blood supply to the body), and scoliosis (sideways curvature of the spine). A review of the MDS dated 10/9/18, indicated that Resident 28 had moderate cognitive impairment and required extensive assistance with two-person assist from staff for transferring and extensive assistance with one-person assist from staff for bed mobility, toilet use, personal hygiene and dressing. The MDS also indicated that Resident 28 did not have pressure ulcer and had urinary/bowel incontinence. During wound care observation on 11/3/18, at 9:39 a.m., the Treatment Nurse/Registered Nurse 1 (RN 1) measured the wound at 1.2 centimeters (cm) length x 0.8 cm wide; and 0.2 cm in depth, was red and tender to touch, had 100% slough. RN 1 did not measure the redness around the periwound area (tissue surrounding the wound itself) until asked. During an interview on 11/4/18, at 10:15 a.m., RN 2 stated, that it was not the practice of this facility to measure redness. RN 2 could not verbalize how the facility would evaluate if the redness was improving or deteriorating. During an interview on 11/4/18, at 11:26 a.m., the Director of Nurses (DON) stated, that the best practice, would be for them to measure the redness to see if it was improving or deteriorating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 12 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 During an interview on 11/4/18, at 2:32 p.m., the Administrator stated that she monitors the pressure sore but it was not a practice of the facility to measure redness. The Administrator was unable to verbalize how the facility would evaluate if the redness was improving or deteriorating. A review of the facility's policy titled "Skin Protocol," revised and updated on 6/11/18, indicated that "whether a resident is admitted with a pressure ulcer or other altered skin condition, or if one develops or deteriorates during residency, and regardless of the causes (s), documentation in the health record is required at the time of discovery. The documentation shall include but will not be limited to the following: Skin report form: Date that the pressure ulcer or skin breakdown was first noted, location, measurement, etc. and the response to treatment.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 11/03/2018 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 13 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 28), who developed a pressure ulcer/sore (localized injury to the skin and / or underlying tissue as a result of pressure or pressure in combination with shear [skin layers are laterally shifted in relation to each other] and/or friction [rubbing]) at the facility by: 1. Failure to implement Resident 28's plan of care to reposition every two hours or as needed and offload (remove) pressure from the coccyx (tailbone). 2. Failure to include in the plan of care Resident 28's preference to sit most of the day in the wheelchair and interventions to ensure offloading, repositioning and toileting. 3. Failure to refer Resident 28 to physical therapy for recommendations about posture and devices to address proper body alignment while in a wheelchair. As a result, Resident 28, who was re-admitted without pressure sores on 9/25/18, developed on 10/21/18 a Stage II (partial thickness skin loss involving epidermis, dermis, or both [top layers of the skin]) pressure sore to the coccyx. By 11/3/18, the pressure sore deteriorated to a Stage III (full-thickness skin and tissue loss with fatty tissue visible, slough and/or eschar [dead tissue] may be visible) and caused Resident 28 pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 14 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 Findings: On 11/1/18, Resident 28 was observed at 6:25 p.m., sitting in a wheelchair with pressure relieving cushion. On 11/2/18, at 5:01 p.m., 5:55 p.m., and at 7:10 p.m., Resident 28 was observed sitting in her wheelchair. A review of the Admission Record indicated Resident 28 was initially admitted to the facility on 3/15/18 and re-admitted on 9/25/18, with diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life), Alzheimer's disease (progressive memory loss), and scoliosis (sideways curvature of the spine). The "History and Physical (H & P)," dated 9/25/18, indicated Resident 28 had intact skin. A review of the Minimum Data Set (MDS standardized assessment and care-planning tool) dated 10/9/18, indicated Resident 28 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding), required extensive assistance (staff provided weight bearing support) with two-person assist for transferring and oneperson assist for bed mobility, toilet use, personal hygiene, and dressing. The MDS indicated Resident 28 did not have pressure sore and was incontinent (unable to control) of bowel and bladder functions. A review of the plan of care developed on 10/12/18 for Resident 28's risk for developing a pressure sore due to decreased functional mobility related to osteoarthritis, muscle weakness, and scoliosis had a goal for Resident 28 not to have open skin areas caused by pressure or friction for the next 90 days. The interventions included repositioning Resident 28 every two hours or as needed and to offload the pressure areas of concern, if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 15 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 applicable. The plan of care was updated/revised indicating on 10/21/18; Resident 28 developed a coccyx Stage II pressure sore. The revised goal was for the pressure sore to resolve within 30 days. The revised interventions included repositioning Resident 28 every two hours and as needed. The plan of care, updated on 11/1/18, indicated Resident 28 had MASD (Moisture Associated Skin Damage), on both buttocks and the periarea (the area below the pelvis and between the thighs). The interventions included to check and change Resident 28's briefs every two to three hours or as needed, keep area clean and dry, and assist with toileting as needed. On 11/3/18, at 9:39 a.m., during a treatment observation of Resident 28's coccyx pressure sore and a concurrent interview, Registered Nurse 1 (RN 1) stated Resident 28's pressure sore was a Stage II but was now a Stage III. RN 1 stated Resident 28 did not like to be in bed and sat in her wheelchair for long hours. RN 1 stated Resident 28 was incontinent and often needed to be changed. On 11/3/18, at 9:55 p.m., 11:58 a.m., 4:45 p.m., and at 5:48 p.m., Resident 28 was observed sitting in her wheelchair. On 11/3/18, at 3:28 p.m. during a review the Skin Evaluation forms and an interview, RN 1 stated he called Resident 28's physician and received a new treatment order for the Stage III pressure sore. RN 1 stated RN 2 performed the wound care on 11/2/18, but RN 2 did not document a change of the pressure sore status. A review of the Skin Evaluation forms indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 16 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 Resident 28 had a coccyx pressure sore assessed as follows: - On 10/21/18, Stage II, measuring 0.3 centimeters (cm) in length by 0.3 cm in width by 0.1 cm in depth, described as a shallow open ulcer (sore) with red/pink color with no drainage. - On 10/22/18, Stage II, measuring 0.5 cm in length by 1 cm in width with no depth and 100 % dermis. - On 10/29/18, Stage II, measuring 0.5 cm in length by 0.8 cm in width with no depth and 100 % dermis. - On 11/3/18, Stage III, measuring 1 cm by 0.8 cm by 0.2 cm with 100 % slough, moderate yellow drainage, redness on surrounding area measuring 5 cm by 4 cm, slightly tender to touch. On 11/4/18, at 10:01 a.m. and at 11:48 a.m., Resident 28 was observed sitting in her wheelchair. During an interview on 11/4/18, at 10:15 a.m., RN 2 stated when she performed the wound care on 11/2/18, the pressure sore was slightly pink. RN 2 stated Resident 28 was sitting long periods in the wheelchair. RN 2 stated that Certified Nursing Assistants (CNAs) should reposition Resident 28 while on the wheelchair and make her stand a little to relieve the pressure. RN 2 stated she did not instruct the CNAs to reposition Resident 28 while in the wheelchair. During a concurrent record review, RN 2 confirmed the plan of care for pressure sore did not include Resident 28's preference to sit most of the day in the wheelchair and interventions to reposition Resident 28 while in the wheelchair. On 11/4/18, at 11:26 a.m., during an interview, the Director of Nursing (DON) stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 17 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 28 had scoliosis which could have contributed to Resident 28's development of the coccyx pressure sore. The DON stated there was no referral for physical therapy ([PT] a healthcare specialty that evaluate, assess, and provide treatment to individuals with limitations in functional mobility) for evaluation and recommendations about Resident 28's proper body alignment while sitting in a wheelchair to prevent pressure on the coccyx area. The DON stated Resident 28 was often observed crying. During an observation on 11/4/18, at 1:54 p.m., Resident 28 was observed sitting at the edge of the bed, moaning and crying. During a concurrent interview, in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 28 stated she was in a lot of pain pointing towards the coccyx area. LVN 1 asked the intensity of pain using the scale of 0-10 (0, being no pain and 10, being the worst pain), Resident 28 replied, "It's between 7 or 8." A review of the Medication Administration Record (MAR) for the months of October and November 2018, indicated between 10/2/18 to 11/3/18, Resident 28 complained of lower back pain everyday with intensity ranging from 2 to 9 out of 10 on the pain scale, that was relieved with Tylenol Extra Strength 500 milligrams (mg) tablet (pain medication) or Norco 5-325 mg tablets (a controlled pain medication containing opioid). During an interview on 11/4/18, at 2:12 p.m., CNA 1 stated she routinely took care of Resident 28 during the day shift (7 a.m. to 3 p.m.). CNA 1 stated every morning, at around 9:30 a.m., she assisted Resident 28 to sit in the wheelchair to attend activities. CNA 1 stated after lunch, at approximately 1:15 p.m., she would take Resident 28 back to bed. CNA 1 stated she was aware Resident 28 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 18 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 pressure sore to the coccyx area and was incontinent of bladder and bowel. CNA 1 stated she did not attend to Resident 28 while in the dining room between 9:30 a.m. to 1:15 p.m. because of other assignments she needed to do. During a telephone interview on 11/4/18, at 2:15 p.m., the Director of Rehabilitation Services (DRS) stated the facility did not refer Resident 28 to the Rehabilitation Department for evaluation. The DRS stated that a specific type of cushion (pommel cushion) could be used on the wheelchair to prevent Resident 28 from sliding (cause friction/shear) and relieve pressure on the coccyx by maintaining proper body alignment and make the resident more comfortable while on the wheelchair. A review of the facility's undated policy and procedure, titled, "Prevention of Pressure Ulcer Injury," for residents with pressure ulcer injury, the facility will identify and treat the underlying cause of the pressure injury and consider possible risk and complications. The interventions included, identifying responsible discipline for each approach and the monitoring and observation of the underlying condition. According to Medical-Surgical Nursing, Ninth Edition, 2013, pages 186-187, "Prevention remains the best treatment for pressure sores. Reposition the patient frequently to prevent pressure sore at least every two hours and every hour when in a chair. Never position the patient directly on the pressure sore." According to National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and Treatment of Pressure Ulcer: A Quick Reference Guide, "If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 19 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 three times a day in periods of 60 minutes or less." Moisture Associated Skin Damage (MASD) is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. It is proposed that for MASD to occur, another complicating factor is required in addition to mere moisture exposure. Possibilities include mechanical factors (friction), chemical factors (irritants contained in the moisture source), or microbial factors (microorganisms). https://www.woundsource.com/print/patientcon dition/moisture-associated-skin-damage-masd

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 11/03/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 20 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to: a. Implement a sufficient detailed record of receipt of controlled medications for (medications that have a potential for abuse or lead to physical or psychological dependence) to ensure accurate reconciliation between the Director of Nursing (DON) and the licensed staff for three of three bubble packs (a method of protecting individual doses of medications within a transparent cavity or cell made from a dome-shaped plastic barrier) of controlled medications stored in the Director of Nursing (DON) office. There was no documentation when and with whom the DON reconciled or verified that the controlled medication count. This deficient had the potential to result in misuse or being unable to detect loss of controlled medications easily. b. Ensure medications were administered only by licensed staff to one of 16 sample residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 21 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 (Resident 10). This deficient practice had the potential to result in the wrong medication being administered. Findings: a. On 11/2/18 at 8:39 p.m. in an interview the DON explained the facility's practice of storing and the destruction controlled medications were as follows: 1. The controlled medications are given to the DON by the licensed nurse. The DON nor the licensed nurse documents if the controlled medication count was accurate. 2. The DON documents the controlled medications name, the name of the resident and into the Controlled Medication log. 3. the pharmacist and DON confirms the count of the controlled medication in the log and the count of the controlled medication in the bottle or bubble pack and destroys the medications in the incinerator (a waste disposal using combustion). In a concurrent the DON stated, when the controlled medications were given to her by the licensed nurses, the licensed nurse does not sign the Controlled Medication Log or the Controlled Medication count sheet. The DON stated, there was no documentation which licensed nurse counted the controlled medication with her or when the reconciliation was done. On 11/2/18, at 8:45 p.m., during an observation the following controlled medications in a bubble pack with a Controlled Medication Sheet wrapped around the bubble pack were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 22 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 observed in the DON's office which were in a locked drawer: 1. 22 tablets of Acetaminophen #3 (300 milligrams (gm) acetaminophen with 30 mg of codeine (a pain medication) 2. 22 tablets of Lorazepam (medication use to treat anxiety) 3. 30 tablets of Zolpidem (a sleeping pill) In a concurrent interview, the DON explained, the controlled medications listed above was given to her by the licensed staff but she was not sure from whom and when the controlled medications were given to her because there was no signature or date when she received the controlled medication. The DON also stated, it will be difficult to know track if there was any missing controlled medications. b. A review of Resident 10's Detailed Summary indicated that Resident 10 was initially admitted on 5/18/16 and was re-admitted on 10/23/18. A review of Resident 10's History and Physical dated 10/27/18, indicated that Resident 10 had diagnoses that included left lower extremity lymphedema (condition in which extra lymph fluid [colorless fluid containing white blood cells] builds up in tissues and causes swelling) and chronic left lower extremity ulcer (an open sore). A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 10/30/18 indicated that Resident 10 had severe cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance with one-person assist from staff for bed mobility, transfer, toilet use, personal hygiene and dressing. The MDS also indicated that Resident 10 had bowel incontinence and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 23 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 had suprapubic catheter (tube surgically inserted into the bladder to drain the urine). During observation and concurrent interview on 11/1/18, at 7:49 p.m., Resident 10 was observed with redness on the inner left and right buttocks. Certified Nurse Assistant 1 (CNA 1) was observed putting a cream on Resident 10's buttocks. CNA 1 stated that she applied Calazinc (helps prevent skin irritation associated with wet, cracked skin) body shield to Resident 10's buttocks area. During an interview on 11/3/18, at 5:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that the CNA informed him of the redness and that he checked the chart and saw it was already noted (not new) on 10/23/18, and had an order for Aloe Vesta (skin protectant) three times a day for two weeks. LVN 1 stated that CNA 1 should not have applied Calazinc because there was no order for it. LVN 1 stated that the Aloe Vesta was due to be administered at 5 p.m., but he did not administer it until after the CNA 1 told him about the redness (CNA 1 completed Resident 10's care at 7:51 p.m.). During an interview on 11/3/18, at 3:30 p.m., Registered Nurse 1 (RN 1) stated that Calazinc requires a physician's order and only licensed staff are supposed to administer the Calazinc lotion. A review of the undated policy and procedure titled, "Medication Management," indicated that "Residents receive medications only if ordered by the prescriber."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 11/03/2018 Facility ID: CA950000260 If continuation sheet 24 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 25 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 46) did not receive psychotropic (medications that affect mood and behavior) unnecessarily. Resident 46 received the following psychotropic medications without adequate indication for use. In addition, duplicate medications were used to treat depression. a. Sertaline (medications that affects mood and behavior) for depression manifested by (feeling of severe sadness and hopelessness) manifested by aggressive startle response to staff. b. Trazadone for depression manifested by insomnia (difficulty sleeping or remaining asleep). This deficient practice put the resident at risk for adverse drug reaction (untowards effects of medication). Findings: A review of the Detailed Summary indicated Resident 46 was admitted to the facility on 12/5/14 and readmitted on 9/27/18, with diagnoses that included, anxiety disorder (a mental disorder manifested by having fear of the unknown), depression, and dementia (a brain disorder that results in memory loss and impaired cognition [ability to think and reason]). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 26 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 of the Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated 10/24/18, indicated Resident 46 had severe memory and cognitive impairment and required extensive assistance (resident involved with the activity) from one person for bed mobility, transfers, personal hygiene, eating, and dressing. A review of Resident 46's physician's order, dated 9/27/18, indicated Resident 46 was to receive the following medications: a. Sertaline 25 milligrams (mg) tablet given by mouth at bedtime manifested by aggressive startle response to staff. b. Trazadone 50 mg tablet given by mouth for depression manifested by insomnia. A review of Resident 46's medical record had no documented evidence that indicated the duplicate use of the Sertaline and Trazadone for treatment of depression was necessary. On 11/4/18, at 8:10 a.m., in an interview the Director of Nurses (DON) stated, Resident 46 had dementia and did not trust others, so when the staff entered his room Resident 46 got startled. The DON explained, the indication for the use of Trazadone and Sertaline should had been more specific because, "startled," behavior was not specific behavior manifestation for depression.

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F812 Event ID: 7FRU11 01/10/2019 Facility ID: CA950000260 If continuation sheet 27 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: The facility failed to ensure the juice stored in the kitchen refrigerator was labeled with the type of juice and ensure that the juice was prepared for the resident and not for the staff. This deficient practice had the potential to result in food contamination and lead to food borne illness. Findings: On 11/1/18, at 6:30 p.m., during an initial kitchen observation and concurrent interview, in the walk-in refrigerator was a plastic bottle that contained yellow juice labeled "juice," and just a first name on it. The Wait Staff, stated, the juice was prepared by another wait staff for a resident. The Wait Staff did not know what was in the plastic bottle. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 28 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 On 11/1/18, at 6:40 p.m. the Wait Staff returned with a package of "Crystal Light" and stated a staff prepared the juice for the resident. However, the Director of Culinary and the Hospitality Director stated they did not know for whom the "Crystal Light" juice was prepared for, which could be a staff or a resident. On 11/1/18, at 6:47 p.m., in an interview the Hospitality Director stated, the staff should properly label the juices in the refrigerators, and the staff should not leave any food items that belonged to the residents or the staff in the walk-in refrigerator to prevent food contamination.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 11/03/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 29 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 30 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to: a. Ensure that the oxygen tubing for Resident 40 was not touching the floor. This deficient practice had the potential to result in infection to Resident 40. b. Maintain a temperature log for the washing machine and dryer. c. Ensure Resident 46 was included in the surveillance form used to tract residents with infection at the facility for the month of September 2018. These deficient practices had the potential to result in infection and cross-contamination. Findings: a. A review of the Detailed Summary indicated that Resident 40 was initially admitted on 12/27/16 and was re-admitted on 10/1/18, with diagnoses that included pneumonia (is an infection that inflames the air sacs in one or both lungs, the air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing), weakness, and chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of the Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated 10/18/18, indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 31 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 Resident 40 had intact cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), had an order for oxygen therapy and was on hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible). During an observation and concurrent interview, on 11/1/18, at 6:46 p.m., Resident 40 was observed with her oxygen tubing touching the floor. Registered Nurse 3 (RN 3) stated that the tubing should not have been on the floor due to infection control issues. A review of the policy and procedure title "Infection Control" dated 12/1/17, indicated that the facility will provide a safe and sanitary environment as well as help prevent the development and transmission of disease and infection. b. During an observation in the laundry room on 11/3/18, at 7:52 a.m., with Housekeeper 1 (HK 1) and the Director of Environmental Services (DES), the washing machine temperature was noted to be at 80 degrees Fahrenheit (degrees). At 7:56 a.m., the water temperature was 85 degrees. During the same observation, a poster on the wall indicated that the washer water temperature should be 140 degrees. During a concurrent interview, the DES stated that the facility does not check the temperature of the washer to make sure it reaches that temperature (140 degrees). The DES further stated that there is no water temperature log for the washing machine. The DES stated he is not sure if the temperature gauge was working. The DES stated that it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 32 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 should have been addressed because there is a potential for infection or to not kill the bacteria enough. During an observation and concurrent interview on 11/3/18, at 8:01 a.m., Housekeeper 2 (HK 2) was observed doing laundry on another smaller household washing machine. HK 2 stated that they use both washing machines to do laundry for resident's personal clothes and that the only difference was one had a large capacity and the other one had a small capacity. HK 2 stated that they do not do temperature check on both washing machines. During an interview on 11/3/18, at 11 a.m., the Director of Building and Grounds (DBG) stated they are only using the washing machine for personal clothes and that the temperature should be between 110-120 degrees. The DBG stated that there is no temperature log for the washer and that they will call the laundry machine manufacturer to make sure that there is a way for the facility to check the temperature settings. The DBG checked the water temperature of the washing machine and it was 120 degrees. It was the thermometer of the washing machine which was inaccurate. During an interview on 11/3/18, at 10:49 a.m., the Administrator stated that she was not aware that there was an issue with the temperature of the washer because it was not reported to her. The Administrator stated that checking the temperature was important to prevent infections. A review of the policy and procedure titled "Handling Laundry" updated on 1/7/2004, under the procedure "Washing of Clothes" indicated that one of the factors that contribute to a clean product was the temperature of the water. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 33 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 During an observation in the laundry room with DES and HK 1 on 11/3/18, at 7:52 a.m., a poster on the wall indicated "Dryer Temperature Cycle Chart and Cycle 13 - 190 degrees; Cycle 14- 160 degrees; Cycle 15- 140 degrees. During a concurrent interview, the DES stated that the dryer had no indication of temperature setting, only Cycle setting. The DES stated that they trust the manufacturer that, if they put the setting on that particular cycle, it will be that temperature. During an interview on 11/3/18, at 11 a.m.,, the interim Director of Building and Grounds (DBG) stated they will call the dryer machine manufacturer to make sure that there is a way for the facility to check the temperature settings. A review of the job description indicated that the DBG performs administrative and supervisory oversight, directing the housekeeping, laundry, maintenance, among others. During an interview on 11/3/18, at 11:49 a.m., the Administrator stated that she was not aware that there was an issue with the temperature of the dryer because it was not reported to her. The Administrator stated that checking the temperature was important to prevent infection. The Administrator stated that the facility advertised for the position of Director for Building and Grounds since August but had not filled the position yet. A review of the policy and procedure titled, "Handling Laundry," updated on 1/7/2004, under the procedure "Washing of Clothes," indicated that one of the factors that contribute to a clean product was the drying temperature.c. A review of the Detailed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 34 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 Summary indicated Resident 46 was admitted to the facility on 12/5/14 and readmitted on 9/27/18, with diagnoses that included, anxiety disorder (a mental disorder manifested by having fear of the unknown), depression and dementia (a brain disorder that results in memory loss and impaired cognition (ability to think and reason). A review of the MDS dated 10/24/18, indicated Resident 46 had severe memory and cognitive impairment that required extensive assistance (resident involved with the activity) from one person on bed mobility, transfers, personal hygiene, eating and dressing. A review of the Electronic Nursing Progress Notes, dated 9/27/18, indicated, Resident 46 was placed on contact precaution (infections, diseases, or germs that are spread by touching the patient or items in the room) due to the diagnoses of MRSA infection (MRSA (Methicillin-resistant Staphylococcus aureus is a bacteria that causes infections in different parts of the body, which is resistant to many antibiotics) of the nares (nostrils) that was treated with Mupirocin ointment 2% (medication use to treat infection). On 11/3/18, at 7:51 p.m., during a review of the surveillance form used by the facility to identify and tract residents with infection and concurrent interview, Resident 46's name was not listed for the month of September 2018. The Director of Nursing (DON) stated, Resident 46 was missed and was not placed in the surveillance form. The DON also explained, all residents with infection should be listed in the surveillance form to appropriately identify and tract the types of infections present in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 35 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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

F881 Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/03/2018 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record record, the facility failed to adequately implement the facility's Antibiotic Stewardship Program (a program that set guidelines to ensure appropriate use of antibiotics) for two of four sampled residents (Resident 8 and 46) who were prescribed with antibiotics (medications used to treat infection) in a total of 16 sampled residents. 1. For Resident 46, received Augmentin (antibiotics) to treat pneumonia (a severe infection of the lungs) without a sputum culture and sensitivity laboratory test (culture, a test to identify the presence of disease causing organism in the sputum) and (sensitivity, a test to determine the appropriate antibiotic to treat the infection) to indicated if Augmentin was appropriate antibiotic to treat the infection. 2. For Resident 8, received Bactrim (antibiotics) to treat Urinary Tract Infection (infection of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 36 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 renters, urethra and the bladder) without culture and sensitivity test to indicate if Bactrim was the appropriate antibiotic to treat the infection. This deficient practice had the potential to result in the development of DROP (Multi-Drug Resistant Organisms) which could lead to a wide spread infection that is difficult to treat. Findings: 1. A review of the Detail Summary indicated Resident 46 was admitted to the facility with diagnoses that included pneumonia. A review of the Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated 10/24/18, indicated Resident 46 had severe memory and cognitive impairment (ability to think and reason) and required extensive assistance (resident involved with the activity) from one person with bed mobility, transfers, personal hygiene, eating and dressing. A review of the physician order, dated 10/17/18, indicated Resident 46 was to receive Augmentin 500 milligrams (mg) tablet, every 12 hours for ten days due to unspecified organism. On 11/2/18, at 7:27 p.m., in a concurrent record review and interview, the Director of Nursing (DON) stated, there was no documentation that a sputum culture and sensitivity was collected to determine the type of lung infection and to determine if Augmentin was the appropriate antibiotic to use for Resident 46. 2. A review of the Detailed Summary indicated Resident 8 was admitted to the facility on 6/23/18, with diagnoses that included anxiety FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 37 of 38 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: _______________ 555503 (X3) DATE SURVEY COMPLETED 11/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROYAL OAKS MANOR - BRADBURY OAKS 1763 Royal Oaks 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 (severe fear of the unknown). A review of the MDS, dated 6/30/18, indicated Resident 8 had moderate memory and cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), required extensive assistance with one-person assistance with bed mobility, transfers, toilet use and personal hygiene. A review of the physician order, dated 10/27/18, indicated Resident 8 was to receive Bactrim DS (double strength) 800 mg-160 mg tablet by mouth twice a day for UTI from 10/27/18 to 11/3/18. On 11/2/18, at 7:35 p.m., during a record review and concurrent interview the DON stated, Resident 8's urine culture and sensitivity test was collected on 10/27/18, but the result was not followed up to indicate if Bactrim was the appropriate antibiotics to treat the UTI. The DON explained, the licensed staff did not appropriately implement the Antibiotic Stewardship Program to ensure adequate use of antibiotics. According to the facility policy and procedure, dated 10/12/16, titled, "Antibiotic Stewardship Program," the facility will optimize the treatment of infections and antibiotic use by identifying the residents who do not meet the criteria for antibiotic use once laboratory results are available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7FRU11 Facility ID: CA950000260 If continuation sheet 38 of 38