Monrovia Post Acute

F-F641

Findings:

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE REDACTED], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in mental abilities). The AR indicated no diagnosis of Parkinson's disease.

During a review of Resident 2's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make her own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to

the stomach) three times a day for Parkinson's disease.

During a review of Resident's 2's MDS) dated [DATE REDACTED], the MDS indicated Resident 2 was cognitively severely impaired (mental action or process of acquiring knowledge and understanding) for daily decision making.

During a concurrent observation and interview on 5/12/25 at 11:57 a.m. with Resident 2, Resident 2 was sitting up in bed alert and oriented. When Resident 2 raised Resident 2's arms, noticeable tremors were present in both Resident 2's hands and arms. Resident 2 stated, Excuse me shaking, I have Parkinson's.

During a review of Resident 2's medical record on 5/12/25, no care plan for a diagnosis of Parkinson's disease and use of Sinemet was found.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0656 During a concurrent interview and record review on 5/14/25 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's MDS, Section I-Active Diagnoses, dated 4/9/25, and Medication Administration Level of Harm - Minimal harm or Records (MAR), dated 4/1/25 to 4/30/25, and MAR, dated 5/1/25 to 5/31/25 were reviewed. The MDS potential for actual harm indicated Parkinson's Disease was not selected under Section I: Neurological. LVN 3 stated LVN 3 did not know why Parkinson's Disease was not selected. LVN 3 stated LVN 3 would have to check LVN 3's notes. Residents Affected - Few LVN 3 then showed a Neurology (the branch of medicine that deals with diagnosis and treatment of disorder of the nervous system) consultation note for Resident 2 dated 1/27/25. The note indicated Resident 2 was evaluated for concern of Parkinsonism due to recent bilateral upper extremity tremor. The note indicated Resident 2 stated Resident 2 was diagnosed with Parkinson's disease in the past, but Resident 2 was unable to provide details. The note further indicated findings from the evaluation were atypical of Idiopathic (medical condition where the underlying cause is unknown) Parkinson's disease, and after discussion with Resident 2, Resident 2's Neurologist (MD 1- a medical specialist in the diagnosis and treatment of disorders of the nervous system) initiated a levodopa trial. The note indicated per MD 1, Given that Levodopa may worsen or precipitate behavior disturbances, I discussed with staff to contact me right away if there are any concerns for adverse reactions to Levodopa.

During the same concurrent interview and record review on 5/14/25 at 2:55 p.m. with LVN 3, Resident 2's MAR from April 2025 indicated Resident 2 was taking Sinemet from 1/27/25 to 5/7/25 (discontinued) then the MAR from May 2025 indicated Sinemet was restarted on 5/8/25. LVN 3 stated MD 1's note indicated Resident 2's diagnosis of Parkinson's and Resident 2's MDS should reflect that for Resident 2. LVN 3 stated

the diagnosis was not coded in Resident 2's MDS dated [DATE REDACTED], and the MDS was inaccurate. LVN 3 stated

the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event. LVN 3 stated proper monitoring of Resident 2's Sinemet medication should be implemented because Sinemet could result in adverse side effects such as dyskinesia (abnormal, involuntary, and often repetitive movements).

During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P further indicated, Documentation in

the medical record will be objective (not opinionated or speculative), complete, and accurate.

During a review of the facility's P&P titled, Care Planning -Interdisciplinary Team, revised 3/2022, the P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT- brings together knowledge from different health care disciplines to help people receive the care they need).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45553

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the facility's consultant pharmacist (PharmD) identified the irregularities (includes but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences) related to Sinemet use (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors) during the monthly medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four sampled residents (Resident 2).

This deficient practice had the potential to result in unnecessary use of Sinemet or potential adverse side effects for Resident 2.

Cross Reference

F-F656

Findings:

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE REDACTED], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 2's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make her own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to

the stomach) three times a day for Parkinson's disease.

During a review of Resident's 2's MDS) dated [DATE REDACTED], the MDS indicated Resident 2 was cognitively severely impaired (mental action or process of acquiring knowledge and understanding) for daily decision making.

During a concurrent observation and interview on 5/12/25 at 11:57 a.m. with Resident 2, Resident 2 was sitting up in bed alert and oriented. When Resident 2 raised Resident 2's arms, noticeable tremors were present in both Resident 2's hands and arms. Resident 2 stated, Excuse me shaking, I have Parkinson's.

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 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0641 During a concurrent interview and record review on 5/14/25 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's MDS, Section I-Active Diagnoses, dated 4/9/25, and Medication Administration Level of Harm - Minimal harm or Records (MAR), dated 4/1/25 to 4/30/25, and MAR, dated 5/1/25 to 5/31/25 were reviewed. The MDS potential for actual harm indicated Parkinson's Disease was not selected under Section I: Neurological. LVN 3 stated LVN 3 did not know why Parkinson's Disease was not selected. LVN 3 stated LVN 3 would have to check LVN 3's notes. Residents Affected - Few LVN 3 then showed a Neurology (the branch of medicine that deals with diagnosis and treatment of disorder of the nervous system) consultation note for Resident 2 dated 1/27/25. The note indicated Resident 2 was evaluated for concern of Parkinsonism due to recent bilateral upper extremity tremor. The note indicated Resident 2 stated Resident 2 was diagnosed with Parkinson's disease in the past, but Resident 2 was unable to provide details. The note further indicated findings from the evaluation were atypical of Idiopathic (medical condition where the underlying cause is unknown) Parkinson's disease, and after discussion with Resident 2, Resident 2's Neurologist (MD 1- a medical specialist in the diagnosis and treatment of disorders of the nervous system) initiated a Levodopa trial. The note indicated per MD 1, Given that Levodopa may worsen or precipitate behavior disturbances, I discussed with staff to contact me right away if there are any concerns for adverse reactions to Levodopa.

During the same concurrent interview and record review on 5/14/25 at 2:55 p.m. with LVN 3, Resident 2's MAR from April 2025 indicated Resident 2 was taking Sinemet from 1/27/25 to 5/7/25 (discontinued) then the MAR from May 2025 indicated Sinemet was restarted on 5/8/25. LVN 3 stated MD 1's note indicated Resident 2's diagnosis of Parkinson's and Resident 2's MDS should reflect that for Resident 2. LVN 3 stated

the diagnosis was not coded in Resident 2's MDS dated [DATE REDACTED], and the MDS was inaccurate. LVN 3 stated

the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event. LVN 3 stated proper monitoring of Resident 2's Sinemet medication should be implemented because Sinemet could result in adverse side effects such as dyskinesia (abnormal, involuntary, and often repetitive movements).

During an interview on 5/15/25 at 2:10 p.m. with Resident 2's Neurologist (MD 1), MD 1 stated MD 1 only saw Resident 2 one time on 1/27/25, and there was no follow-up by MD 1 because the facility did not contact MD 1 again about Resident 2. MD 1 stated follow-up on Resident 2's Levodopa (Sinemet) trial could be done

in a day or two after Resident 2 started taking Sinemet.

During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised 10/2023,

the P&P indicated, A comprehensive assessment of each resident is completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act- nursing home reform act to improve the quality of care in nursing homes) regulations and PPS (Prospective Payment System- healthcare payment system by Centers for Medicare and Medicaid Services [CMS] for reimbursement for services provided) requirements. The P&P indicated, Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline . Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45553

Residents Affected - Few Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to address medication administration and side effects of Sinemet (a medication commonly used to manage Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything

the body does) that affects movement, often including tremors] symptoms, can cause a range of side effects, both mild and serious) for one of four sampled residents (Resident 2).

This deficient practice had the potential to result in medication side effects not being identified and addressed for Resident 2.

Cross Reference

F-F756

Findings:

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE REDACTED], and then readmitted on [DATE REDACTED] and 5/8/25 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atrial fibrillation (an irregular and often rapid heart rhythm that starts in the heart's upper chambers [atria]), iron deficiency anemia (a condition where the body does not have enough healthy red blood cells), unspecified dementia (a progressive state of decline in mental abilities), hypothyroidism (thyroid gland can't make enough thyroid hormone to keep the body running normally), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), acute embolism and thrombosis of veins of right upper extremity (when a blood clot [thrombosis] or a clot traveling through the bloodstream [embolism] blocks a vein in the arm or shoulder), and hypotension (a condition where blood pressure is too low.).

During a review of Resident 2's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to

the stomach) three times a day for Parkinson's disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0757 During a review of Resident's 2's Minimum Data Set (MDS, a resident assessment tool) dated 4/9/25, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge Level of Harm - Minimal harm or and understanding) for daily decision making. The MDS indicated Resident 2 required substantial/maximal potential for actual harm assistance with eating, upper body dressing, and personal hygiene. The MDS further indicated Resident 2 was dependent for oral hygiene, toileting hygiene, showering/bathing self, lower body dressing, and putting Residents Affected - Few on/taking off footwear.

During an observation on 5/12/25 at 11:57 a.m., Resident 2 was observed sitting up in bed alert and oriented. Resident 2 had noticeable tremors in both upper extremities when raised.

During a concurrent interview and record review on 5/14/25 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's MDS, Section I-Active Diagnoses, dated 4/9/25, and Medication Administration Records (MAR), dated 4/1/25 to 4/30/25, and MAR, dated 5/1/25 to 5/31/25 were reviewed. The MDS indicated Parkinson's Disease was not selected under Section I: Neurological. LVN 3 stated LVN 3 did not know why Parkinson's Disease was not selected. LVN 3 stated LVN 3 would have to check LVN 3's notes. LVN 3 then showed a Neurology (the branch of medicine that deals with diagnosis and treatment of disorder of the nervous system) consultation note for Resident 2 dated 1/27/25. The note indicated Resident 2 was evaluated for concern of Parkinsonism due to recent bilateral upper extremity tremor. The note indicated Resident 2 stated Resident 2 was diagnosed with Parkinson's disease in the past, but Resident 2 was unable to provide details. The note further indicated findings from the evaluation were atypical of Idiopathic (medical condition where the underlying cause is unknown) Parkinson's disease, and after discussion with Resident 2, Resident 2's Neurologist (MD 1- a medical specialist in the diagnosis and treatment of disorders of the nervous system) initiated a Levodopa trial. The note indicated per MD 1, Given that Levodopa may worsen or precipitate behavior disturbances, I discussed with staff to contact me right away if there are any concerns for adverse reactions to Levodopa.

During the same concurrent interview and record review on 5/14/25 at 2:55 p.m. with LVN 3, Resident 2's MAR from April 2025 indicated Resident 2 was taking Sinemet from 1/27/25 to 5/7/25 (discontinued) then the MAR from May 2025 indicated Sinemet was restarted on 5/8/25. LVN 3 stated MD 1's note indicated Resident 2's diagnosis of Parkinson's and Resident 2's MDS should reflect that for Resident 2. LVN 3 stated

the diagnosis was not coded in Resident 2's MDS dated [DATE REDACTED], and the MDS was inaccurate. LVN 3 stated

the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event. LVN 3 stated proper monitoring of Resident 2's Sinemet medication should be implemented because Sinemet could result in adverse side effects such as dyskinesia (abnormal, involuntary, and often repetitive movements).

During an interview on 5/15/24 at 2:10 PM with Resident 2's Neurologist (MD 1), MD 1 stated he only saw Resident 2 one time on 1/27/25, and there was no follow-up by MD 1 because the facility did not contact MD 1 again about Resident 2. MD 1 stated follow-up on Resident 2's Levodopa (Sinemet) trial could be done in a day or two after Resident 2 started taking Sinemet.

During a review of Resident 2's Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for January 2025 through April 2025, the MMR indicated there were no identitied irregularities and/or recommendations for Resident 2's use of the Sinemet from the facility's consultant pharmacist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0757 During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised 10/2023,

the P&P indicated, A comprehensive assessment of each resident is completed at intervals designated by Level of Harm - Minimal harm or OBRA (Omnibus Budget Reconciliation Act- nursing home reform act to improve the quality of care in potential for actual harm nursing homes) regulations and PPS (Prospective Payment System- healthcare payment system by Centers for Medicare and Medicaid Services [CMS] for reimbursement for services provided) requirements. The P&P Residents Affected - Few indicated, Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline . Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

During a review of the facility's P&P titled, Medication Regimen Reviews, revised 5/2019, the P&P indicated,

The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . inadequate monitoring for adverse consequences . potentially significant medication related adverse consequences or actual signs and symptoms that could represent adverse consequences. The P&P further indicated, An irregularity refers to the use of medicine that is inconsistent with accepted pharmaceutical services standards of practice; is not support by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 055259

F-F757

Findings:

During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE REDACTED], and then readmitted on [DATE REDACTED] and 5/8/25 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atrial fibrillation (an irregular and often rapid heart rhythm that starts in the heart's upper chambers [atria]), iron deficiency anemia (a condition where the body does not have enough healthy red blood cells), unspecified dementia (a progressive state of decline in mental abilities), hypothyroidism (thyroid gland can't make enough thyroid hormone to keep the body running normally), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), acute embolism and thrombosis of veins of right upper extremity (when a blood clot [thrombosis] or a clot traveling through the bloodstream [embolism] blocks a vein in the arm or shoulder), and hypotension (a condition where blood pressure is too low.).

During a review of Resident 2's History and Physical (H&P) dated 10/22/24, the H&P indicated Resident 2 did not have the capacity to make own decisions.

During a review of Resident 2's Physician Order (PO) dated 1/27/25, the PO indicated Resident 2 had an order for Sinemet (combination drug containing levodopa and carbidopa used to treat symptoms of Parkinson's disease) oral tablet 10-100 milligrams (mg- unit of measurement) give one (1) tablet via gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition and medication directly to

the stomach) three times a day for Parkinson's disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0756 During a review of Resident's 2's Minimum Data Set (MDS, a resident assessment tool) dated 4/9/25, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge Level of Harm - Minimal harm or and understanding) for daily decision making. The MDS indicated Resident 2 required substantial/maximal potential for actual harm assistance with eating, upper body dressing, and personal hygiene. The MDS further indicated Resident 2 was dependent for oral hygiene, toileting hygiene, showering/bathing self, lower body dressing, and putting Residents Affected - Few on/taking off footwear.

During an observation on 5/12/25, at 11:57 a.m., Resident 2 was observed sitting up in bed alert and oriented. Resident 2 had noticeable tremors in both upper extremities when raised.

During a concurrent interview and record review on 5/14/25 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 2's MDS, Section I-Active Diagnoses, dated 4/9/25, and Medication Administration Records (MAR), dated 4/1/25 to 4/30/25, and MAR, dated 5/1/25 to 5/31/25 were reviewed. The MDS indicated Parkinson's Disease was not selected under Section I: Neurological. LVN 3 stated LVN 3 did not know why Parkinson's Disease was not selected. LVN 3 stated LVN 3 would have to check LVN 3's notes. LVN 3 then showed a Neurology (the branch of medicine that deals with diagnosis and treatment of disorder of the nervous system) consultation note for Resident 2 dated 1/27/25. The note indicated Resident 2 was evaluated for concern of Parkinsonism due to recent bilateral upper extremity tremor. The note indicated Resident 2 stated Resident 2 was diagnosed with Parkinson's disease in the past, but Resident 2 was unable to provide details. The note further indicated findings from the evaluation were atypical of Idiopathic (medical condition where the underlying cause is unknown) Parkinson's disease, and after discussion with Resident 2, Resident 2's Neurologist (MD 1- a medical specialist in the diagnosis and treatment of disorders of the nervous system) initiated a Levodopa trial. The note indicated per MD 1, Given that Levodopa may worsen or precipitate behavior disturbances, I discussed with staff to contact me right away if there are any concerns for adverse reactions to Levodopa.

During the same concurrent interview and record review on 5/14/25 at 2:55 p.m. with LVN 3, Resident 2's MAR from April 2025 indicated Resident 2 was taking Sinemet from 1/27/25 to 5/7/25 (discontinued) then the MAR from May 2025 indicated Sinemet was restarted on 5/8/25. LVN 3 stated MD 1's note indicated Resident 2's diagnosis of Parkinson's and Resident 2's MDS should reflect that for Resident 2. LVN 3 stated

the diagnosis was not coded in Resident 2's MDS dated [DATE REDACTED], and the MDS was inaccurate. LVN 3 stated

the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event. LVN 3 stated proper monitoring of Resident 2's Sinemet medication should be implemented because Sinemet could result in adverse side effects such as dyskinesia (abnormal, involuntary, and often repetitive movements).

During an interview on 5/15/24 at 2:10 PM with Resident 2's Neurologist (MD 1), MD 1 stated MD 1 only saw Resident 2 one time on 1/27/25, and there was no follow-up by MD 1 because the facility did not contact MD 1 again about Resident 2. MD 1 stated follow-up on Resident 2's Levodopa (Sinemet) trial could be done in a day or two after Resident 2 started taking Sinemet.

During a review of Resident 2's Medication Regimen Review (MRR) for January 2025 through April 2025, the MMR indicated there were no identified irregularities and/or recommendations for Resident 2's use of the Sinemet from the facility's consultant pharmacist (PharmD).

On 5/15/25 at 2:27 PM and 3:35 PM, attempts were made to contact PharmD, however PharmD did not answer or return the call.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0756 During a follow-up interview on 5/16/25 at 2:25 PM with PharmD, PharmD stated PharmD did not have any concerns with Resident 2's use of Sinemet and monitoring of Resident 2 related to Sinemet use. PharmD Level of Harm - Minimal harm or stated the facility staff did not report any adverse effects to PharmD while Resident 2 was on the medication. potential for actual harm

During a review of the facility's P&P titled, Medication Regimen Reviews, revised 5/2019, the P&P indicated, Residents Affected - Few The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . inadequate monitoring for adverse consequences . potentially significant medication related adverse consequences or actual signs and symptoms that could represent adverse consequences. The P&P further indicated, An irregularity refers to the use of medicine that is inconsistent with accepted pharmaceutical services standards of practice; is not support by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 055259 Department of Health & Human Services Printed: 08/27/2025 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 055259 B. Wing 05/15/2025

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

Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45553 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident who was receiving Residents Affected - Few Sinemet (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors]) was free from unnecessary medication for one of four sampled residents (Resident 2) by failing to:

1. Ensure there was a documented adequate indication for the use of Sinemet medication.

2. Ensure Resident 2 was monitored for effectiveness and/or any potential adverse side effects of Sinemet.

These deficient practices had the potential to result in unnecessary use of Sinemet by not monitoring the effectiveness of Sinemet or potential adverse side effects.

Cross Reference