Arcadia Health Care Center

F-F550)

Findings:

a. During a review of Resident 279's Admission Record (AR) the AR indicated Resident 279 was admitted to

the facility on [DATE REDACTED] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood).

During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed.

During a review of Resident 279's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 279 had a history of falling. The care plan indicated Resident 279 required 1 person assistance from staff for assistance to transfer from the bed.

During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions.

During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom.

During an observation on 7/24/2024 at 8:33 AM, Resident 279 was walking alone in her room. There were no staff in Resident 279's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 7/24/2024 at 8:57 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 279 required one person transfer (staff person is present to give assistance) when walking to the Level of Harm - Minimal harm or bathroom. potential for actual harm

During an interview on 7/24/2024 at 9:10 AM with Resident 279, Resident 279 stated the facility staff did not Residents Affected - Some inform Resident 279 to call for help/assistance with walking, before getting out of the bed. Resident 279 stated facility staff knew Resident 279 would get out of bed on her own and staff did not have a problem with it.

b. During a review of Resident 55's AR, the AR indicated Resident 44 was admitted to the facility on [DATE REDACTED] with diagnoses including wedge compression fracture of second lumbar vertebra (broken bone of the backbone), malignant neoplasm of the stomach (cancer of the stomach) and hypertension (high blood pressure).

During a review of Resident 55's MDS dated [DATE REDACTED], the MDS indicated Resident 55 had moderately impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 55 required partial/moderate (helper does less than half the effort) from staff for toileting and bathing.

During a review of Resident 55's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 55 had a history of falling. The care plan indicated Resident 55 was at high risk of falling. The care plan indicated facility staff needed to place Resident 55's bed in the lowest position. The care plan indicated to place floor mats on both sides of Resident 55's bed.

During a review of Resident 55's Assessment Outcome, dated 7/20/2024, the Assessment Outcome indicated Resident 55 was at a high risk of falling.

During a concurrent observation and interview on 7/24/2024 at 12:36 PM, with LVN 2 in Resident 55's room, Resident 55's bed was in a raised position. There were no floor mats on either side of Resident 55's bed. LVN 2 lowered the bed to its lowest position.

During an interview on 7/25/2024 at 10:00 AM with the Director of Nursing (DON), the DON stated the purpose of Resident 55's floor mats were to minimize injuries if Resident 55 fell .

During a review of the facility's P&P titled, Falls - Clinical Protocol, revised March 2018, the P&P indicated, Based on the preceding assessment. the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729 potential for actual harm Based interview and record review, the facility failed to monitor fluid restriction on 7/2/2024, 7/4/2024, Residents Affected - Some 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 for one of one sampled resident (Resident 49) in accordance with the physician's orders.

These failures had the potential to lead to fluid overload (too much fluid volume in the body) and overall decline in health.

Findings:

During a review of Resident 49's Admission Record (AR), the AR indicated Resident 49 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs), end stage renal disease (a condition in which a person's kidney's stop functioning on a permanent basis) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working).

During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/30/2024, the MDS indicated Resident 49 had severe impairment with cognitive skills (ability to make decisions, reason). The MDS indicated Resident 49 was dependent (helper does all of the effort) on staff for toileting and eating.

During a review of Resident 49's Order Summary Report, (OSR) dated with active orders as of 7/24/2024,

the OSR indicated fluid restriction 1000 milliliters (ml-unit of volume) per 24 hours. Dietary total limit, 600 ml: Breakfast, 240 ml Lunch - 120 ml Dinner - 240 ml Nursing total limit 400 ml: Day shift 180 ml Evening shift - 180 ml Night shift - 40 ml every shift.

During a concurrent interview and record review on 7/24/2024 at 11:44 AM with Licensed Vocational Nurse 4 (LVN 4), Resident 49's Intake and Output Form (I&O) was reviewed. The I&O did not indicate any record of Resident 49's intake or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024. LVN 4 stated Resident 49 had an active order for fluid restriction and all intakes and outputs should be recorded on the I&O form by the nursing staff. LVN 4 stated Resident 49 had a fluid restriction because Resident 49 required dialysis and if the fluid restriction was not followed it would lead to fluid overload for Resident 49.

During a concurrent interview and record review on 7/25/2024 at 4:36 AM with the Director of Nursing (DON), Resident 49's I&O was reviewed. The DON stated there was no documentation for input or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 and there had been no documentation from the nightshift for any dates from 7/1/2024 to 7/23/2024. The DON stated the facility could not prove the fluid restriction was being followed because of the missing documentation and if the restriction was not followed it would result to shortness of breath, edema (water retention) and overall decline

in health for Resident 49.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 During a review of the facility's Policy and Procedure (P&P) titled, Intake and Output dated 6/2019, the P&P indicated intake and output shall be documented when indicated by resident's condition and/or treatment. Level of Harm - Minimal harm or The P&P further indicated nursing staff shall be responsible for documenting the intake and output each shift potential for actual harm and record in the medical record.

Residents Affected - Some

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Level of Harm - Minimal harm or potential for actual harm 36288

Residents Affected - Few Based on observation, interviews, and record review, the facility failed to follow the food preferences of one of four sampled residents (Resident 27) during lunch tray line (system of food preparation in which meal trays are moved along an assembly line).

This failure had the potential to cause inadequate nutrition related to decreased appetite, refused meal, or meal replacement with less healthier options.

Findings:

During a review of Resident 27's Admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 27 on 4/6/2022 with diagnoses including dementia (impairment of brain functions that interfere with daily life), type 2 diabetes mellitus (long-term condition of uncontrolled blood sugar), vitamin B12 deficiency anemia (lower than normal amounts of vitamin B12 in the blood that leads to reduced healthy red blood cells), iron deficiency anemia (too little iron in the body causing reduced healthy red blood cells), ascorbic acid deficiency (vitamin C deficiency), and vitamin D deficiency.

During a review of Resident 27's History and Physical Examination (H&P 1) dated 11/16/2023, H&P 1 indicated Resident 27 did not have the capacity to understand and make decisions.

During a review of Resident 27's Diet Review/Food & Beverage Preference List (DR 1) dated 2/16/2024, DR 1 indicated Resident 27's food preference was No Fish.

During a review of Resident 27's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 5/14/2024, MDS 1 indicated Resident 27 had severe impairment in cognition (ability to acquire, process and, recall information). MDS 1 indicated Resident 27 was dependent with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and mobility. MDS 1 indicated Resident 27 required substantial/maximal assistance with eating.

During a review of the facility's lunch menu for 7/24/2024, the following items were prepared for the residents: Fish Italiano, Scalloped Potatoes, Italian Herb Vegetables, Red & [NAME] Salad, and Peach Crisp.

During a concurrent tray line observation and interview on 7/24/2024 at 12:27 PM, Resident 27's meal tray was observed. Resident 27's meal tray card indicated No Fish under Dislikes. With prompting to verify Resident 27's prepared meal tray, [NAME] 1 stated she should have served Resident 27 chicken (instead of fish) because Resident 27 disliked fish. [NAME] 1 immediately prepared another meal plate with chicken for Resident 27.

During an interview on 7/25/2024 at 3:25 PM, Dietary Services Supervisor (DSS) stated it was important to

review the meal tray card during tray line to ensure the residents' food preferences were followed and adequate nutrition was delivered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 During a review of the facility's Policy and Procedure (P&P 4), titled Food Preferences, dated 2018, P&P 4 indicated resident's food preferences must be adhered to within reason, and substitutes for all foods disliked Level of Harm - Minimal harm or must be given from the appropriate food group. potential for actual harm

During a review of the facility's Policy and Procedure (P&P 5), titled Food Substitutions During Tray Line: An Residents Affected - Few Alternate for a Food Item Resident Does Not Like That is Recorded on the Tray Card, P&P 5 indicated the cook must provide a food substitute at each meal for a food item that a resident might dislike which has been noted on their tray card.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 36288

Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement its facility's Policies and Procedures (P&Ps) on dishwashing and standard precautions for one of one dishwasher (DW 1) observed in

the facility's kitchen.

This failure had the potential to for foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents related to food contamination.

Findings:

During an observation of DW 1's dishwashing and sanitizing practices on 7/25/2024 at 3:25 PM with the Dietary Services Supervisor (DSS), DW 1 washed and rinsed the dirty pans and trays in the sink, then touched the metal trays that were sanitized in the dishwasher.

During an interview on 7/25/2024 at 3:26 PM, DSS stated DW 1 was not supposed to touch or move the sanitized metal trays while washing the dirty pans and trays. DSS stated another staff member, Dietary Aide 2 (DA 2), was assigned to put away the sanitized metal pans and trays to prevent cross-contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) of items that come in contact with food.

During a review of the facility's Policy and Procedure (P&P 3), titled, Dish Washing, dated 2018, P&P 3 indicated all dishes must be properly sanitized through the dishwasher.

In addition, during a review of the facility's Policy and Procedure (P&P 1), titled Standard Precautions, Enhanced Barrier Precautions and Transmission-Based Precautions, dated 6/25/2024, P&P 1 indicated the facility must provide guidelines for infection control practices to reduce the potential for transmission of pathogens. P&P 1 indicated when handling dishes, all tableware must be treated as contaminated and must be sanitized according to facility protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36288 potential for actual harm Based on interview and record review, the facility failed to ensure the Responsible Party (RP 85), who signed Residents Affected - Few the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) for one of three sampled residents (Resident 85) understood the BAA prior to signing.

This failure had a potential to result in a decline in Resident 85's physical and/or psychosocial condition due to possible hardships related to arbitration proceedings.

Findings:

During a review of Resident 85's Admission Record (AR 1), AR 1 indicated the facility originally admitted Resident 85 on 6/27/2022 and readmitted on [DATE REDACTED] with diagnoses including dementia (impairment of brain functions that interfere with daily life), adult failure to thrive (worsening of physical frailty frequently accompanied by cognitive [ability to acquire, process, and recall information] impairment and/or functional disability in older adults), and polyarthritis (joint disease affecting multiple joints). AR 1 indicated Responsible Party 85 (RP 85) was Resident 85's representative.

During a review of Resident 85's Initial History and Physical (H&P), dated 2/10/2024, the H&P indicated Resident 85 had increased confusion and did not have the capacity to understand and make decisions.

During a review of Resident 85's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 6/26/2024, the MDS indicated Resident 85 was dependent with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and mobility. The MDS indicated Resident 85 required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 85's undated Resident - Facility Arbitration Agreement (RFAA 1), the RFAA 1 indicated RP 85 signed RFAA 1 electronically on 7/6/2022.

During a telephone interview on 7/25/2024 at 11:55 AM, RP 85 stated Admissions Coordinator (AC) sent RP 85 an electronic mail (e-mail) regarding signing the RFAA form upon Resident 85's admission to the facility. RP 85 stated RP 85 did not know what RFAA 1 was intended for. RP 85 stated no staff member explained

the purpose and the terms of the RFAA 1.

During an interview on 7/25/2024 at 12:55 PM, AC stated AC was responsible for offering RFAA to the resident (in general) and/or RP upon the resident's admission to the facility. AC stated AC has not met RP 85

in person and communicated with RP 85 via telephone. AC stated she recalled sending RP 85 an e-mail with

the RFAA 1 and instructed RP 85 to call her for any questions. AC stated RP 85 did not call her to ask for any questions regarding RFAA 1. AC stated the space on the electronic RFAA form indicated the signature was optional. AC was unable to explain the details of the RFAA form, including the selection process of the neutral arbitrator or arbitration venue.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 During a review of the facility's Policy and Procedure (P&P 2), titled Admission Criteria, dated 3/2023, P&P 2 indicated residents must not be required to sign the arbitration agreement as a condition of admission to the Level of Harm - Minimal harm or facility. P&P 2 indicated resident has the right to refuse to enter into the arbitration agreement and has the potential for actual harm right to rescind it within 30 days if they signed the arbitration agreement on admission.

Residents Affected - Few

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36288 potential for actual harm Based on observation, interview, and record review, the facility failed to implement interventions to prevent Residents Affected - Some and control the spread of infections in the facility in accordance with the facility's policies and procedures and national health guidelines.

A. One of one Certified Nursing Assistant (CNA 1) did not don (wear) the required protective personal equipment (PPE, equipment worn to minimize exposure to a variety of hazards) prior to entering the room of one of one sampled resident (Resident 55), who was on contact isolation precautions (type of transmission-based precaution requiring the use of gown and gloves to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment).

B. One of one Licensed Vocational Nurse (LVN 2) attempted to use the toilet paper in the shared bathroom when administering eye drops to Resident 13.

These failures had the potential to result in an increased spread of infection in the facility.

Findings:

a. During a review of Resident 55's Admission Record (AR 1), AR 1 indicated the facility admitted Resident 55 on 4/6/2024 with diagnoses including enterocolitis (inflammation of intestines) due to Clostridium difficile (C. difficile, bacterium that causes infection of the large intestine and spreads easily in hospitals and nursing homes from the caregivers' hands to the other patients/residents they provide care for and through spores that can live for months on common surfaces) and dementia (impairment of brain functions that interfere with daily life).

During a review of Resident 55's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 4/8/2024, MDS 1 indicated Resident 55 had moderate impairment in cognition (ability to acquire, process, and recall information). MDS 1 indicated Resident 55 required partial/moderate assistance with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and mobility. MDS 1 indicated Resident 55 required supervision or touching assistance with eating, oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 55's History and Physical Examination (H&P 1), dated 4/9/2024, H&P 1 indicated Resident 55 had the capacity to understand and make decisions.

During a review of Resident 55's Order Summary Report (OSR 1) for 7/2024, OSR 1 indicated Resident 55 was on fortified diet, mechanical soft texture, regular liquid consistency, 6 small meals per day as ordered by

the physician on 7/20/2024.

During a review of Resident 55's Care Plan (CP 1), titled MRSA-VRE-ORSA-ESBL-C.DIFFICILE, dated 7/20/2024, CP 1 indicated Resident 55 was placed on contact isolation (alone in the room) due to C. difficile.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 7/24/2024 at 12:56 PM with Dietary Services Supervisor (DSS), Certified Nursing Assistant 1 (CNA 1) entered Resident 55's room to deliver the lunch tray without the Level of Harm - Minimal harm or required PPE. A Contact Isolation signage was posted on the wall, and an isolation cart with PPE was placed potential for actual harm by Resident 55's room entrance. CNA 1 stated she did not wear the required PPE as posted because CNA 1 was only delivering a meal tray and not providing resident care. Residents Affected - Some

During an interview on 7/25/2024 at 5:50 PM, the Director of Nursing (DON) stated to prevent transmission of infection, all staff must wear the required PPE (gown and gloves) prior to entering an isolation room.

During a review of the facility's Policy and Procedure (P&P 1), titled Standard Precautions, Enhanced Barrier Precautions and Transmission-Based Precautions, dated 6/25/2024, P&P 1 indicated contact precautions required the use of gown and gloves for all contact with body fluids and with environmental surfaces in the resident's room.

During a review of the Centers for Disease Control and Prevention (CDC) guidelines, titled Transmission-Based Precautions, dated 4/3/2024, the CDC guidelines indicated donning PPE, including gown and gloves, must be done upon room entry, and properly discarding PPE must be done before exiting

the resident room to contain pathogens.

[Source: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html]

42307

b. During a review of Resident 13's Admission Record (AR), the AR indicated, Resident 13 was admitted to

the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and other chronic pancreatitis (a long-standing inflammation of the pancreas).

During a review of Resident 13's History and Physical Examination (H&P), dated 9/23/23, the H&P indicated Resident 13 could not make medical decisions.

During a review of Resident 13's Minimum Data Set (MDS, an assessment and screening tool), dated 6/1/2024, the MDS indicated Resident cognitive (ability to think and process information) status was severely impaired.

During a review of Resident 13's Order Summary Report (OSR), dated as of 7/25/2024, the OSR indicated

an order dated 9/18/2023 for licensed staff to administer to Resident 13, Restasis Ophthalmic Emulsion 0. 05% [Clyclosporine (Ophth], a medication for treatment of dry eye disease), instill one (1) drop in both eyes every twelve (12) hours for dry eyes.

During a concurrent medication administration observation and interview on 7/23/2024 at 9:29 a.m. with LVN 2 and LVN 7, LVN 2 went inside the restroom of Resident 13 to get toilet paper from inside the restroom to use for eye drop administration of Resident 13. LVN 2 stated, LVN 2 should not use the toilet paper from the restroom because the toilet paper could be contaminated.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 7/24/2024 at 8:13 a.m. with the Infection Preventionist (IP), the IP stated, licensed staff should not use toilet paper from the restroom to use for eye drop administration for infection control. The Level of Harm - Minimal harm or IP stated the restroom was a shared restroom and the toilet paper in the restroom could have been touched potential for actual harm by multiple people and could have been contaminated.

Residents Affected - Some During a review of the facility's P&P titled, Surveillance for Infections, revised September 2023, the P&P indicated, the facility employs an infection control surveillance program to help prevent to the extent possible

the development and transmission of disease and infection.

During a review of the facility's P&P titled, Instillation of Eye Drops, revised January 2024, the P&P indicated,

the purpose of the procedure was to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. The P&P indicated, one of the steps in the procedure was to gently dry the eyelid with cotton ball if dripping occurs.

During a review of the facility's P&P titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 6/25/24, the P&P indicated, the purpose of the P&P was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens (any organism that causes disease).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 555729

F-F689)

Findings:

a. During a review of Resident 120's AR, the AR indicated Resident 120 was admitted to the facility 6/28/2024 with diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on

the spinal cord and nerve roots), muscle weakness, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).

During a review of Resident 120's care plan titled Bladder and Bowel Retraining, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 use of the bathroom as needed.

During a review of Resident 120's care plan titled ADL and Functional Mobility, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 with Activities of Daily Living (ADLs, activities related to personal care) as needed.

During a review of Resident 120's H&P dated 6/29/2024, the H&P indicated, Resident 120 had the capacity to make medical decisions.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 During a review of Resident 120's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated Resident 120 had no impairment in cognitive skills (the ability to Level of Harm - Minimal harm or make daily decisions). The MDS indicated Resident 120 was dependent on staff for toileting, dressing, and potential for actual harm bathing.

Residents Affected - Some During a review of Resident 279's Admission Record (AR) the AR indicated Resident 279 was admitted to

the facility on [DATE REDACTED] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood).

During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed.

During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom.

During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions.

During an interview on 7/23/2024 at 2:56 PM with the Director of Nursing (DON), the DON stated call lights should be answered by facility staff immediately but no longer than five minutes. The DON stated residents (in general) could feel frustrated because the residents (in general) were not able to care for themselves. The DON stated residents (in general) would feel worthless if they have to wait too long for their call lights to be answered by staff.

During an interview on 7/24/2024 at 3:11 PM with Resident 120, Resident 120 stated sometimes Resident 120 waited up to 2 hours for facility staff to answer the call light during the night. Resident 120 stated during

these incidents, Resident 120 needed assistance with changing Resident 120's adult brief or assistance with moving Resident 120's legs because Resident 120's legs felt numb. Resident 120 stated Resident 120's legs would go numb because Resident 120 could not move Resident 120's legs due to a spinal cord injury (damage to any part of the spinal cord). Resident 120 stated when Resident 120's legs felt numb, Resident 120 needed help from staff to move the legs. Resident 120 stated moving his legs helped the numbness to go away. Resident 120 stated Resident 120 felt frustrated when Resident 120 waited a long time to get assistance from the facility staff.

b. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes mellitus (elevated blood sugar levels), Residents Affected - Some dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure).

During a review of Resident 15's MDS, dated [DATE REDACTED], the MDS indicated Resident 15 had severely impaired cognitive skills (the ability to make daily decisions). The MDS indicated Resident 15 was dependent (helper does all the effort) on staff for bathing, dressing, and toileting.

During a dining observation on 7/22/2024 at 12:56 PM, Resident 15 was sitting at a round table with four other residents (not identified). Speech Therapist 1 (ST 1) was standing at Resident 15's left side. ST 1 was feeding Resident 15 with lunch.

During an interview on 7/22/2024 at 1:05 pm with ST 1, ST 1 stated ST 1 needed to sit next to Resident 15 to be at eye level with the resident while feeding.

During an interview on 7/23/24 at 2:53 PM with the DON, the DON stated facility staff needed to sit down when feeding residents (in general) so the facility staff would be at eye level with the residents. The DON stated standing while feeding a resident would degrade (treat someone with contempt or disrespect) the resident.

During a concurrent observation and interview on 7/24/2024 at 1:11 PM with Activity Assistant 1 (AA 1) , AA 1 was feeding Resident 13 with lunch. AA 1 was standing next to Resident 13. AA 1 stated AA 1 needed to sit down next to Resident 13 when feeding Resident 13.

During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example .promptly responding to a resident's request for toileting assistance . The P&P indicated, Staff are expected to knock and request permission before entering residents' rooms.

During a review of the facility's P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, Answer the resident call system immediately.

During a review of the facility's P&P titled, Assisting the Resident During Meals, revised December 20I3, the P&P indicated, Staff must be seating when feeding residents.

42307

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 c. During a review of Resident 13's AR the AR indicated Resident 13 was admitted to the facility on [DATE REDACTED] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable Level of Harm - Minimal harm or movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive potential for actual harm pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and Residents Affected - Some produce extra mucus, which makes it difficult to breathe).

During a review of Resident 13's H&P, dated 9/23/2023, the H&P indicated, Resident 13 could not make decisions.

During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 had severely impaired cognitive skills. The MDS indicated Resident 13 was dependent on staff for toileting, dressing, and bathing.

During a review of Resident 75's AR, the AR indicated, Resident 75 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including end stage renal disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure).

During a review of Resident 75's H&P, dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions.

During a review of Resident 75's MDS, dated [DATE REDACTED], the MDS indicated Resident 75 had intact cognition.

During a review of Resident 86's AR, the AR indicated, Resident 86 was admitted to the facility on [DATE REDACTED] with diagnoses including other specified diseases of liver, kidney failure and adult failure to thrive (a decline

in older adults that manifests as a downward spiral of health and ability).

During a review of Resident 86's MDS, dated [DATE REDACTED], the MDS indicated Resident 86 had severely impaired cognitive skills.

During a review of Resident 86's H&P, dated 6/6/2024, the H&P indicated, Resident 86 did not have the capacity to understand and make decisions.

During an observation on 7/23/2024 at 8:59 a.m. Resident 86 was in the room in bed and had a female visitor (unnamed). Resident 13 (Resident 86's roommate) was also in the room. Resident 13 was sitting up in

a wheelchair at Resident 13's bedside. LVN 2 and LVN 7 were observed entering and exiting Resident 86 and Resident 13's room twice without knocking. LVN 2 then opened the restroom without knocking and Resident 75 was inside using the restroom. LVN 2 and LVN 7 stated, staff needed to knock the door to maintain the resident's dignity.

During an interview on 7/24/2024 at 12:30 p.m. with the Director of Nursing, the DON stated, the facility's policy was for staff to knock before entering, introduce themselves and state their purpose. The DON stated,

it was important for staff to knock the door, to show respect to the residents, to maintain dignity and for those residents with impaired vision to identify who the staff was.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, Resident 75 got startled when LVN 2 opened the door to the restroom where Resident 75 was using without LVN 2 knocking first. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Resident Rights, revised December 2019, the P&P indicated, employees should treat all residents with kindness, respect, and dignity. The P&P indicated, a list of Residents Affected - Some resident's rights including right to a dignified existence and be treated with respect, kindness, and dignity.

During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, one of the many policy interpretation and implementation included residents are treated with dignity and respect at all times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Some Based on interview and record review, the facility failed to ensure the resident's representative was provided education regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as

a living will or durable power of attorney [legal document that allows someone to act on your behalf in certain situations] for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the information was complete and accurate for two of eight sampled residents (Residents 4 and19).

These deficient practices had the potential for the residents to receive life-sustaining care and/or treatment against their will.

Findings :

a.During a review of Resident 4's Admission Record, (AR) dated 7/24/2024, the AR indicated Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition

in which a high level of sugar is present in the bloodstream), and heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs).

During a review Resident 4's History and Physical (H&P) dated 5/9/2024, the H&P indicated Resident 4 did not have the capacity to understand or make decisions.

During a review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/14/2024, the MDS indicated Resident 4 required maximal assistance (helper does more than half of the effort) for toileting and personal hygiene.

During a concurrent interview and record review on 7/24/2024 at 12:18 PM with Admissions Coordinator (AC), Resident 4's Advance Directive Acknowledgement (ADA) dated 5/8/2024 was reviewed. The ADA indicated the purpose of the form was to acknowledge that the resident or resident representative had been informed of their rights and of all rules and regulations regarding decisions concerning their medical care.

The AC stated the ADA should be signed upon admission within three days. The AC stated the AC could not determine whether Resident 4's Representative understood the written materials provided or Resident 4's right's regarding decisions for their medical care based on the absence of check marks indicating the above.

During a review of the facility's Policy and Procedure (P&P) titled, Advance Directive, dated 12/2016, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The P&P further indicated if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives and nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

44027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 b.During a review of Resident 19's Admission Record (AR), the AR indicated Resident 19 was admitted to

the facility on [DATE REDACTED] with diagnoses including malignant neoplasm of bronchus or lung (lung cancer), Level of Harm - Minimal harm or muscle weakness, and chronic obstructive pulmonary disease (COPD, a group of diseases that cause potential for actual harm airflow blockage and breathing-related problems). The AR did not indicate who was Resident 19's Responsible Party. Residents Affected - Some

During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/1/2024, the MDS indicated Resident 19 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing.

During a review of Resident 19's History and Physical (H&P), dated 6/28/2024, the H&P indicated Resident 19 did not have the mental capacity to understand and make medical decisions.

During a concurrent interview and record review on 7/24/2024 at 11:54 AM with RN 1, Resident 19's POLST, dated 6/24/2024, and Resident 19's Advanced Directive Acknowledgement, dated 6/24/2024, were reviewed. RN 1 and RN 3 signed the documents indicating RN 1 and RN 3 were Resident 19's representative and legally recognized decisionmaker. RN 1 stated RN 1 and RN 3 were instructed to sign Resident 19's documents. RN 1 stated Resident 19 did not have a responsible party to represent Resident 19. RN 1 stated RN 1 did not know if the facility had a Bioethics Committee to make decisions for residents (in general) who were not capable to make decisions and did not have representatives.

During an interview on 7/24/2024 at 12:00 PM with the facility's Administrator (ADM), the ADM stated if a resident was admitted to the facility and did not have a representative, but was self-responsible, the resident could sign their own admission documents (including POLST and AD Acknowledgment). The ADM stated if

the resident did not have a representative and did not have the capacity to make their own decisions, the facility would refer to the facility's Bioethics Committee. The ADM stated the Bioethics Committee would consist of different staff members representing different areas affecting the resident care. The ADM stated nurses alone ( RN1 and RN 3) were not capable to make decisions for the unrepresented resident (in general).

During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P indicated, Upon admission, the resident will be provided with written information concerning

the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.

During a review of the facility's policy and P&P titled, Bioethics, dated November 2021, the P&P indicated, It is the policy of this facility to uphold the rights of residents to participate in medical de cisions. Sometimes situations arise wherein the decisions may be too complex for the surrogate decision-maker, or there is no surrogate. The P&P indicated, The Bioethics Committee is comprised of at least one physician, facility administrator, and a representative from nursing, social service, activities, dietary, rehabilitation, [NAME] ness office, and other departments as indicated. Furthermore, any facility staff member who has knowledge of the resident may be invited to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48729

Residents Affected - Few Based on interview and record review, the facility staff failed to notify the physician of one of one sampled resident's (Resident 14) blood sugar value of 420 milligram/deciliter (mg/dL - unit of measurement) on 7/1/2024 as indicated in Resident 14's Medication Administration Record (MAR).

This failure had the potential for Resident 14 to experience undesired effects of high blood sugar.

Findings:

During a review of Resident 14's Admission Record, the AR indicated Resident 14 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat or lipids in the blood).

During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.

During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/23/2024, the MDS indicated Resident 14 was dependent (helper does all of the effort to complete the activity) on staff for toilet use and personal hygiene.

During a concurrent telephone interview and record review on 7/25/2024 at 1:08 pm with Licensed Vocational Nurse 3 (LVN 3), Resident 14's MAR dated with active orders as of 7/25/2024 was reviewed. The MAR indicated Resident 14's blood sugar level was 420 mg/dL on 7/1/2024 at 4:30 pm. The MAR indicated for licensed staff to call the Medical Doctor (MD) for blood sugar level above 400 mg/dL. LVN 3 stated LVN 3 could not remember if the MD was notified but since it was not documented then it was not done. LVN 3 stated Resident 14's MD should have been notified of the elevated blood sugar according to the physician's order.

During a concurrent interview and record review on 7/25/204 at 4:36 PM with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017 was reviewed. The P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): i. specific instruction to notify the Physician of changes in the resident's condition. The DON stated if it wasn't documented then it was not done, and the doctor should have been notified per physician's order. The DON stated it was important for the MD to be notified so that the MD can determine if Resident 14's insulin needed to be adjusted and determine the type of care needed for Resident 14.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Level of Harm - Minimal harm or 36288 potential for actual harm Based on interviews and record review, the facility failed to notify the responsible party of two of three Residents Affected - Some sampled residents (Residents 178 & 179) in writing regarding the Medicare Advance Beneficiary Notice (ABN, written notice that informs Medicare beneficiaries of certain items or services that Medicare may not pay for prior to receiving the items or services).

This failure had the potential to negatively affect Residents 178 and 179's physical and psychosocial well-being due to responsible party's lack of information, including the resident's right to appeal.

Findings:

a. During a review of Resident 178's Admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 178 on 2/5/2024 with diagnoses including intracerebral hemorrhage (life-threatening bleeding inside the brain), hemiplegia and hemiparesis (paralysis or weakness on one side of the body), atelectasis (lung collapse), and chronic (long-standing) kidney disease. AR 1 indicated Responsible Party 178 (RP 178) was Resident 178's representative.

During a review of Resident 178's History and Physical Examination (H&P 1), dated 2/6/2024, H&P 1 indicated Resident 178 did not have the capacity to understand and make decisions.

During a review of Resident 178's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 5/9/2024, MDS 1 indicated Resident 178 had moderate impairment in cognition (ability to acquire, process, and recall information).

During a review of Resident 178's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN 1, Form CMS-10055), dated 5/6/2024, ABN 1 indicated Resident 178's health coverage for skilled services would end on 5/8/2024. ABN 1 indicated beginning 5/9/2024, Resident 178 would have to pay out of pocket for this care if no other insurance would cover these costs. ABN 1 indicated the facility staff notified RP 178 by telephone on 5/6/2024 at 1 PM regarding ABN 1.

During a concurrent interview and record review on 7/25/2024 at 10:48 AM with the Business Office Manager (BOM), Resident 178's ABN 1 was reviewed. The BOM stated she did not provide a written copy of ABN 1 to RP 178.

b. During a review of Resident 179's Admission Record (AR 2), AR 2 indicated the facility initially admitted Resident 179 on 3/3/2024 wit diagnoses including type 2 diabetes mellitus (long-term condition of uncontrolled blood sugar), end-stage renal disease (kidney failure) with renal dialysis (treatment to remove extra fluid and waste products from the blood when kidneys were no longer able to function properly) dependency, heart failure, and dementia (impairment of brain functions that interfere with daily life). AR 2 indicated Responsible Party 179 (RP 179) was Resident 179's representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 During a review of Resident 179's ABN (ABN 2), dated 4/29/2024, ABN 2 indicated Resident 179's health coverage for skilled services would end on 5/1/2024. ABN 2 indicated beginning 5/2/2024, Resident 179 Level of Harm - Minimal harm or would have to pay out of pocket for this care if no other insurance would cover these costs. ABN 2 indicated potential for actual harm the facility staff notified RP 179 by telephone on 4/29/2024 at 10:15 AM regarding ABN 2.

Residents Affected - Some During a review of Resident 179's Minimum Data Set (MDS 2), dated 5/2/2024, MDS 2 indicated Resident 179 had severe impairment in cognition. MDS 2 indicated Resident 179 required substantial/maximal assistance with toileting hygiene, showering/bathing self and required partial/moderate assistance with upper and lower body dressing, putting on/taking off footwear, and mobility.

During a telephone interview on 7/25/2024 at 10:24 AM, RP 179 stated she could not recall being informed about or receiving a written copy of Resident 179's ABN 2.

During a concurrent interview and record review on 7/25/2024 at 10:48 AM with BOM, Resident 179's ABN 2 was reviewed. The BOM stated she did not provide a written copy of ABN 2 to RP 179.

During an interview on 7/25/2024 at 3:15 PM, Business Office Assistant (BOA) stated not providing ABN in writing per facility policy would lead to missed information relayed to the resident or responsible party (in general).

During a review of the facility's policy and procedure (P&P 6), titled Medicare Advance Beneficiary Notice, dated 4/2021, P&P 6 indicated the following:

1. If the Admissions/Benefits Coordinator believes (upon admission or during the resident's stay) that Medicare Part A of the Fee for Service Medicare Program would not pay for an otherwise covered skilled service(s), the resident or representative must be notified in writing why the service(s) might not be covered and of the resident's potential liability for payment of the non-covered service(s).

2. The facility must issue the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers but might not pay for because the care is considered not medically reasonable and necessary, or custodial.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42307

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 75) was provided with a home-like environment by not allowing Resident 75 to use the [NAME] and [NAME] restroom (a restroom that has two doors and is usually accessible from two bedrooms to share) of other residents.

This failure had the potential to result in invasion of privacy for Resident 75 and other residents.

Findings:

During a review of Resident 75's Admission Record (AR), the AR indicated, Resident 75 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including End Stage Renal Disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure).

During a review of Resident 75's History and Physical Examination (H&P), dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions.

During a review of Resident 75's Minimum Data Sheet (MDS, an assessment and screening tool) dated 6/25/2024, the MDS indicated Resident 75 had intact cognition (ability to think and process information).

During a concurrent observation and interview on 7/23/2024 at 8:59 a.m. with LVN 2, LVN 2 opened the door of the [NAME] & [NAME] restroom and saw Resident 75 using the restroom. LVN 2 stated, Resident 75 was from another room.

During an interview on 7/24/2024 at 12:44 p.m. with the Infection Preventionist (IP), the IP stated, residents from another room should not use the shared restroom (Jack and [NAME] restroom) for privacy. The IP stated, it would be a problem if the resident using the restroom was a male and the resident in the room sharing the restroom were females.

During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, he used the other residents' restroom on 7/23/2024 because Resident 75's [NAME] and [NAME] restroom was occupied, and

the other restroom was not in use. Resident 75 stated, he had an appointment yesterday (7/23/2024) and had to urgently use a restroom. Resident 75 stated, a staff (unnamed) told Resident 75 to use the [NAME] and [NAME] restroom across the hallway.

During an interview on 7/25/2024 at 3:11 p.m. with the Director of Nursing (DON), the DON stated, if residents are not from that area (adjoining rooms sharing the [NAME] and [NAME] restroom), staff should not allow other residents to use the restroom for reasons of privacy and dignity. The DON stated, even family members were encouraged not to use the resident's restroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life - Homelike Environment, revised May 2017, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike Level of Harm - Minimal harm or environment and encouraged to use their personal belongings to the extent possible. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 555729 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555729 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Center 1601 S Baldwin Ave. Arcadia, CA 91007

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44027

Residents Affected - Some Based on observation, interview, and record review, the facility failed to implement fall safety intervention for two of three sampled residents (Residents 55 and 279) in accordance with the facility's Policy and Procedure (P&P) titled, Falls - Clinical Protocol,, by failing to:

a. Ensure the facility staff provided supervision when Resident 279 ambulated in her room and/or while ambulating to the bathroom.

b. Ensure the bed for Resident 55 who was assessed as high risk for fall and had a history of falling, was at

the lowest position and floor mats were in place.

These failures had the potential to result in falls/injury for Residents 55 and 279.

(Cross reference