Gem Transitional

F-F742.

Findings:

During a review of Resident 1's admission record indicated the facility admitted Resident 1 on 11/14/2024 with diagnosis which include depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), anxiety (a feeling of fear, dread, and uneasiness) , and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life).

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 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 2/1/2025, indicated Resident 1 was assessed to be cognitively intact (process of thinking and reasoning). The MDS Level of Harm - Actual harm also indicated Resident 1 was set up or clean up assistance (helper set up or cleans up; resident complete

the activity) on eating, oral hygiene, personal hygiene. Residents Affected - Few

During a review of Resident 1's progress notes dated 5/12/2025 at 9:36 AM indicated at 5:20 AM License Vocational Nurse (LVN 1) LVN 1 went to Resident 1's room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal. The progress notes also indicated 911(the telephone number used to reach emergency medical, fire, and police services) transferred Resident 1 to General Acute Care Hospital Emergency (GACH) for further evaluation.

During a review of Local Police District (LPD1) report dated 5/12/2025 indicated, on 5/12/2025 at approximately 10:17 AM LPD1 were dispatched to the facility to respond to a possible overdose. The LPD1 report indicated Resident 1 was unresponsive and was sent to GACH. LPD1 report also indicated according to the interview with ADM, the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed. The report also indicated Resident 1 was taken to GACH on 5/12/2025 at approximately 6AM and according to the interview with ADM, the medications found at Resident 1's bedside were not provided by their facility (from Pharmacy 2) but belonged (was labeled under Resident 1's name) to Resident 1. The LPD 1 repot also indicated the following medications (total of 8 bottles) were found in the resident's belongings:

1. One bottle of ondasentron (medication to prevent nausea and vomiting- (miscellaneous [misc] amount and dosage not indicated.)

2. Two bottles of Doxepin (used to treat anxiety or depression - misc amount and dosage not indicated)

3. One empty bottle of Doxepin (misc amount and dosage not indicated)

4. One bottle of Klonopin (used to control seizures [a sudden, abnormal electrical disturbance in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness. It's often characterized by involuntary muscle contractions, convulsions, and sometimes a loss of awareness] in epilepsy [a chronic neurological disorder characterized by recurrent, unprovoked seizures] and for the treatment of panic disorder- misc amount and dosage not indicated)

5. Two empty bottles of Klonopin (misc amount and dosage not indicated)

6. Blue and tan pills (did not indicate name of medication- misc amount)

During a review of the facility's Final Investigation Summary Report submitted to the surveyor on 5/16/2025,

it indicated, LPD 1 came to the facility at approximately 11 AM (date not specified) and searched Resident 1's room and LPD 1 found pill bottles (bottle of medications) inside a shopping bag and 1.5 Liters bottle of Wine 1. The report also indicated the facility found the following items in Resident 1 belongings on 5/12/2025:

1. Crumpled receipt from Pharmacy 2 shopping bag and the receipt indicated Wine 1 was purchased from Pharmacy 1 on 5/9/2025 at 5:46 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 2. Bottle of medications from Pharmacy 2 labeled with Resident 1's name: Klonopin 0.5 milligrams (mg, unit of measurement) which was found empty; 15 pieces of Dilaudid 2 mg; Zpulenz 4 mg sachet with expiry date Level of Harm - Actual harm of 12/2020; 52 capsules of doxepin 100 mg and 10 tablets of Ondasteron 8 mg with expiry date of 3/2025.

Residents Affected - Few During a review of Reisdent 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was admitted at GACH from 5/12/2025 and was discharged to home with Resident 1's family on 5/20/2025. The GACH record indicated, on 5/12/2025 Resident 1 was brought to GACH's ER with chief complaint of altered mental status at SNF with next to empty pill bottles (name of medication not specified) and Resident 1 with GCS of 3. The GACH record also indicated Resident 1 was brought in by ambulance after the resident was found in the facility somnolent (sleepy) and obtunded this morning (5/12/2025). The GACH record also indicated per paramedic's report, Resident 1 was found next to alcohol bottles (not specified) and a bag of pills (not specified) that were unknown and possibly there was a bottle of Klonopin.

During a review of the same Resident 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was intubated for poor GCS. The GACH records also indicated Resident 1 had intentional TCA overdose +/- (with or without) Kolonopin. The GACH records indicated, Resident 1 was admitted in GACH's ICU from the ER, then downgraded (a reduction in the level of care or status, often in the context of a patient's condition or a medical procedure being changed to a less complex or less expensive) option to Medical Surgical Unit (MSU- a specific area where patients receive care for a variety of medical/ surgical conditions and less critical patient than in ICU) on 5/14/2025.

During an interview on 5/14/2025 at 7:05 AM with LVN 3, LVN 3 stated on 5/12/2025 at around 5AM, Resident 1 was unresponsive and LVN 3 tried to wake the resident for 10 minutes, but the resident was not responding. LVN 3 stated, Resident 1 was laying across the bed horizontally and snoring loud. LVN 3 also stated LVN 3 saw 2 opened prescription plastic containers of doxepin (unknown dosage) and 1 bottle of ondansetron (unknown dosage). LVN 3 also stated the medications were not dispensed from the facility's pharmacy (Pharmacy 1). LVN 3 stated the residents are not allowed to have medications from outside the facility and all medications should be prescribed by the primary physicians and medication supplies should be coming from Pharmacy 1.

During a concurrent interview and record review on 5/14/2025 at 7:25 AM with LVN 1, Resident 1's progress notes dated 5/12/2025 was reviewed. LVN 1 stated, LVN 1 started her shift on 5/11/2025 at around 11:30 PM making rounds and check Resident 1 and did not check on Resident 1 until 5/12/2025 around 5:20 AM. LVN 1 stated at 5:20 AM Resident 1 was laying across the bed, snoring, and unresponsive to stimuli. LVN 1 also stated, Resident 1 had 2 opened prescription plastic containers of doxepin and 1 bottle of ondansetron

on the resident's bedside table both labeled under Resident 1's name and from Pharmacy 2. LVN 1 stated, Resident 1 was transferred to GACH ER via 911 around 6 AM and police came approximately 4 to 5 hours after. LVN 1also stated, LPD 1 searched Resident 1's belongings and found four (4) additional plastic containers/ bottles of prescription medication labeled under Resident 1's name from Pharmacy 2. LVN 1 stated, the 4 additional plastic bottles of prescription medications were as follows: Klonopin (unable to recall dosage), and Clonazepam (unable to recall dosage- another name for Klonopin-produces a calming effect on

the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation) were inside

the plastic bag with a bottle of open Wine 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 5/14/2025 at 10:16 AM with the Registered Nurse Supervisor (RNS 1), RNS 1 stated all medications from outside pharmacy such as Pharmacy 2 were not allowed, it was for residents' safety. Level of Harm - Actual harm RNS 1 stated only Pharmacy 1 (facility's own pharmacy) can deliver/ dispense medication in a bubble pack (an entire week's worth of medications is sorted into a single blister pack, with one blister for each dosing Residents Affected - Few period) for the licensed nurses to give to the resident.

During an interview on 5/14/2025 at 12 PM with LVN 2, LVN 2 stated we do not check residents' belongings,

the residents usually present whatever they have.

During an interview on 5/15/2025 at 12:55 PM with LVN 4, LVN 4 stated Resident 1 was able to bring alcohol and medications from Pharmacy 2 inside the facility and this caused danger to the resident. LVN 4 also stated we did not follow the facility policy and procedures (P&P) to ensure contraband/ prohibited items such as alcoholic beverage to be brought in the facility.

During an interview on 5/16/2025 at 2PM with the administrator (ADM), the ADM stated the facility failed to prevent Resident 1 from bringing alcohol to and 7 prescription bottles of medications from Pharmacy 2, because of all this the resident may have overdosed with medications and wine and was found unresponsive

on 5/12/2025 and was transferred to GACH, and was admitted at GACH's intensive care units (ICU, an organized system for the provision of care to critically ill patients).

During a record review of the facility's P&P titled Restricted Item /Contraband revised on 3/2016, indicated restricted items include any item that is prohibited on the facility grounds. Such items include those that are illegal, or that present a safety risk to residents, staff, visitors, or the facility. The P&P also indicated, all facility staff is responsible for observing environment for potentially unsafe items. The P&P also indicated, Administrator, physician (or other clinical staff with hospital privilege), Nursing leadership or their designee can authorize a search based on reasonable suspicion of the presence of restricted items. The P&P indicated: facility residents and staff will be informed of identified restricted items (this may be done via training, posters, resident handbook or similar means) including:

Drugs/medications not prescribed by facility Physicians, or with their knowledge and approval.

Alcohol and items containing significant amounts of alcohol that may he abused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Immediate disorder. jeopardy to resident health or safety 47362

Residents Affected - Few Based on observation, interview, and record review the facility to provide treatment and services to attain the highest practicable mental and psychosocial well- being of one of two sampled residents (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) anxiety (a feeling of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life) and who was identified as being danger to self and others (DTSO- the probability that a person will inflict serious physical injury upon the person or another person in the near future) on 4/28/2025 by failing to:

1. Ensure 1:1 sitter (provide one to one nursing or observation care to an individual patient for a period of time) intervention were put in place for Resident 1 who refused to be sent to General Acute Care Hospital (GACH) on 4/28/2025 due to DTSO.

2. Monitor and document Resident 1 behavior of verbalizing possibly hurting self or other after the resident was identified to be danger to self and to others on 4/28/2025.

3. Develop and implement a care plan to address Resident 1's refusal to be sent to GACH on 4/28/2025 in accordance with the physician's order.

4. Ensure additional follow up and intervention was developed for Resident 1 to ensure Resident 1's safety and prevent injury and harm to self or to others after resident refused psychiatrist (the branch of medicine concerned with the study, diagnosis, and treatment of mental illness) consultation on 5/8/2025.

5. Develop and implement a care plan when Resident 1 was identified to be DTSO on 4/28/2025 to ensure

the resident's safety and security and prevention of injuries.

As a result of noncompliance, on 5/12/2025 at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). Resident 1 was sent to GACH via 911 (the telephone number used to reach emergency medical, fire, and police services) and was assessed in GACH' ER with Glascow Coma Scale (GCS- neurological assessment tool used to evaluate a patient's level of consciousness. The score ranges from 3 [deep comatose {state of deep unconsciousness for a prolonged or indefinite period, especially as a result of injury or illness}] to 15 [full consciousness]) of 3. Resident 1 was intubated (a process where healthcare professional inserts a tube into a patient's mouth or nose into the trachea [airway/ windpipe] to help the patient to breath) for poor GCS and was admitted to GACH's Intensive care units (ICU, an organized system for the provision of care to critically ill patients) from 5/12/2025 to 5/14/2025. Resident 1's urine toxicology (screen analyzes a urine sample to identify the presence of drugs or other chemicals) report indicated Resident 1 was positive for tricyclic antidepressant (TCA- a class of medications used to treat anxiety and/ or depression).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 On 5/14/2025 at 4:51 PM, while onsite at Facility 1, the California Department of Public Health (CDPH) called

an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more Level of Harm - Immediate requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a jeopardy to resident health or resident) in the presence of Administrator ( ADM), and Medical Record Director ( MDR) due to the facility's safety failure to prevent further occurrence of serious harm, serious impairment, and or death of residents with diagnosis of depression, anxiety, and borderline personality disorder and or who were assessed to be DTSO. Residents Affected - Few

On 5/16/2025 at 3:16 PM the facility submitted an acceptable IJ removal plan (IJRP- action to correct the deficient practice) to CDPH. The IJ was removed after the surveyor verified and confirmed the facility implemented the facility's IJRP while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, MRD, and Director of Operations (DOO).

The IJ Removal Plan dated 5/16/2025 included the following:

1. Immediate Action Taken on 05/14/5025:

o Starting on 05/13/2025 the charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist (someone who studies the human mind and human emotions and behavior, and how different situations have an effect on people).

o Starting on 5/14/2025, if a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior (not specified), and refused to be transferred to the hospital licensed nurse will immediately notify MD.

o The Director of Social Services completed (date not indicated) a Psychosocial Assessment of nine (9) identified residents who has a diagnosis of depression, reviewed and updated 9 Care Plan as necessary. There are no other identified residents who has a diagnosis of anxiety, borderline personality disorder and DTSO.

o Licensed staff were instructed to document behavioral observations in the monitoring log such DTSO every hour and notify the nurse or RN supervisor and/or designee

2. Ongoing Monitoring and Documentation:

o On 5/14/25 the Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.

o The facility has a total census of 61 on 5/14/2025, there were 9 residents that have a diagnosis of depression, and no other residents have a diagnosis of anxiety and borderline personality disorder.

o The Director of Social Services completed a psychosocial assessment of all 9 residents with a diagnosis of depression to identify residents who may be DTSO on 5-14-2025 and o other residents were identified at risk of harming themselves or others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 o Starting on 05/13/2025 Situation, Background, Assessment, and Recommendation (SBAR, structured communication framework that can help teams share information about the condition of a patient or team Level of Harm - Immediate member or about another issue your team needs to address), / Change in Condition (COC change in a jeopardy to resident health or resident's condition may mean that he or she is at risk) was implemented, and in-service was conducted by safety Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental Residents Affected - Few condition and/or status.

o On 05/14/2025, 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service (starting 5/14/2025) to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.

3. Care Plan Development and Implementation:

o On 05/14/2025 the care plan was reviewed and updated for 9 identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis (any situation in which a person's behavior puts them at risk of hurting themselves or others) and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.

o On 05/14/2025 the Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety

o Crisis Intervention Plan included:

o Provide safe and clean environment

o Visual check and document monitoring of resident behavior every hour for resident safety

o Administer medication as ordered

o Diet as ordered

o Encourage to verbalize feelings

o Always approach in calm and friendly manner and unhurriedly

o To ensure all needs are met

o Provide emotional support

o Maintain comfort and dignity

o To call doctor of medicine (M.D) for any noted change of condition

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 4. Follow-Up after Refusal of Psychiatrist Consultation on 5/8/2025:

Level of Harm - Immediate o Starting on 05/13/2025, Social Services will re-evaluate and update initial psychosocial assessment of the jeopardy to resident health or resident when a resident refused for psychiatric consult and licensed nurse will inform MD. safety o Starting on 05/14/2025, Social services will make daily visits to re-engage the resident and residents who Residents Affected - Few are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in

the progress notes and provide resident's education on the importance of psychiatric evaluation.

5. Revised Care Plan for DTSO:

o Starting on 05/14/2025, behavioral and Crisis intervention care plan (Crisis intervention Plan under #3) will be implemented to reflect ongoing risk for harm to self and others. Interventions included:

o AS needed (PRN) and scheduled psychiatric medication management

o Behavior tracking and psychiatric consultation follow-up

o Staff re-education on management of residents with psychosocial adjustment difficulties

o Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques

6. Systemic Measures to Prevent Recurrence

o Starting on 5/13/2025 the ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.

o Licensed staff in-services will continue until compliance is met.

o All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant immediately on 05/14/2025 regarding the existing policies and procedures:

o Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others.

o Requesting, Refusing and/or Discontinuing Care or Treatment

o Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy

7. Monitoring for Sustained Compliance

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 o The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x Level of Harm - Immediate 4 weeks, then monthly x 3 months. jeopardy to resident health or safety o All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician. Residents Affected - Few o Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.

Findings:

During a review of Resident 1's admission record indicated the facility admitted Resident 1 on 11/14/2024 with diagnosis which include depression, anxiety, and borderline personality disorder.

During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 2/1/2025, indicated Resident 1 was assessed to be cognitively intact (process of thinking and reasoning). The MDS also indicated Resident 1 was set up or clean up assistance (helper set up or cleans up; resident complete

the activity) on eating, oral hygiene, personal hygiene.

During a review of Resident 1's progress notes dated 4/28/2025 at 10:45 PM indicated Resident 1 stated the facility is a sh*thole because the people in the facility make it a shithole. It should have been burned down in

the fire so all of us suffering from this d*ck could have somewhere better. The progress notes also indicated

an order to transfer the resident to hospital for DTSO.

During a review of Resident 1's Order sheet dated 4/28/2025 indicated notes: schedule for psychiatrist and psychologist consult. Frequency: one time daily for one day starting 4/28/2025.

During a review of Resident 1's Physicians Order Sheet print date on 5/13/2025 indicated Transfer to acute hospital: transfer resident due to danger to self and others, order date 4/28/2025.

During a review of Resident 1's medical records from 4/28/2025 to 5/11/2025, it did not indicate documented evidence Resident 1 was transferred to GACH due to DTSO.

During a review of Resident 1's progress notes dated 5/12/2025 at 9:36 AM indicated at 5:20 AM License Vocational Nurse (LVN 1) LVN 1 went to Resident 1's room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal. The progress notes also indicated 911 transferred Resident 1 to General Acute Care Hospital emergency room (GACH ER) for further evaluation.

During a review of Local Police District (LPD1) report dated 5/12/2025 indicated, on 5/12/2025 at approximately 10:17 AM LPD1 were dispatched to the facility to respond to a possible overdose. The LPD1 report indicated Resident 1 was unresponsive and was sent to GACH. LPD1 report also indicated according to the interview with ADM, the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed. The report also indicated Resident 1 was taken to GACH on 5/12/2025 at approximately 6AM and according to the interview with ADM, the medications found at Resident 1's bedside were not provided by their facility (from Pharmacy 2) but belonged (was labeled under Resident 1's name) to Resident 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 During a review of Reisdent 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was admitted at GACH from 5/12/2025 and was discharged to home with Resident 1's family on 5/20/2025. The Level of Harm - Immediate GACH record indicated, on 5/12/2025 Resident 1 was brought to GACH's ER with chief complaint of altered jeopardy to resident health or mental status at SNF with next to empty pill bottles (name of medication not specified) and Resident 1 with safety GCS of 3. The GACH record also indicated Resident 1 was brought in by ambulance after the resident was found in the facility somnolent (sleepy) and obtunded this morning (5/12/2025). The GACH record also Residents Affected - Few indicated per paramedic's report, Resident 1 was found next to alcohol bottles (not specified) and a bag of pills (not specified) that were unknown and possibly there was a bottle of Klonopin.

During a review of the same Resident 1's GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was intubated for poor GCS. The GACH records also indicated Resident 1 had intentional TCA overdose +/- (with or without) Kolonopin. The GACH records indicated, Resident 1 was admitted in GACH's ICU from the ER, then downgraded (a reduction in the level of care or status, often in the context of a patient's condition or a medical procedure being changed to a less complex or less expensive) option to Medical Surgical Unit (MSU- a specific area where patients receive care for a variety of medical/ surgical conditions and less critical patient than in ICU) on 5/14/2025.

During an interview on 5/14/2025 at 7:05 AM with LVN 3, LVN 3 stated on 5/12/2025 at around 5AM, Resident 1 was unresponsive and LVN 3 tried to wake the resident for 10 minutes, but the resident was not responding. LVN 3 stated, Resident 1 was laying across the bed horizontally and snoring loud. LVN 3 also stated LVN 3 saw 2 opened prescription plastic containers of doxepin (unknown dosage) and 1 bottle of ondansetron (unknown dosage). LVN 3 also stated the medications were not dispensed from the facility's pharmacy (Pharmacy 1). LVN 3 stated the residents are not allowed to have medications from outside the facility and all medications should be prescribed by the primary physicians and medication supplies should be coming from Pharmacy 1.

During a concurrent interview and record review on 5/14/2025 at 7:25 AM with LVN 1, Resident 1's progress notes dated 5/12/2025 was reviewed. LVN 1 stated, LVN 1 started her shift on 5/11/2025 at around 11:30 PM making rounds and check Resident 1 and did not check on Resident 1 until 5/12/2025 around 5:20 AM. LVN 1 stated at 5:20 AM Resident 1 was laying across the bed, snoring, and unresponsive to stimuli. LVN 1 also stated, Resident 1 had 2 opened prescription plastic containers of doxepin and 1 bottle of ondansetron

on the resident's bedside table. LVN 1 stated, Resident 1 was transferred to GACH ER via 911 around 6 AM and police came approximately 4 to 5 hours after.

During a concurrent interview and record review on 5/14/2025 at 3:30 PM with LVN 2, Resident 1's medical chart dated from 4/28/2025 to 5/13/2025 were reviewed. There was no documented evidence of the facility monitored Resident 1 after being assessed as DTSO and when Resident 1 refused to be transferred to GACH. LVN 2 stated no monitoring and documentation from 4/28/2025 to 5/11/2025 regarding resident's danger to self and others on the resident's progress notes. LVN 2 also stated Resident 1 did not have care plan developed to address Resident 1's refusal to be transferred to GACH on 4/28/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 During a concurrent interview and record review on 5/14/2025 at 3:35 PM with LVN 2, Resident 1's progress notes dated 5/8/2025 at 5:09 PM and Resident 1's medical chart dated from 5/9/2025 to 5/13/2025 were Level of Harm - Immediate reviewed. The progress notes dated 5/8/2025 indicated offered Psychiatric consult but declined and stated jeopardy to resident health or that she (Resident 1) had her own psychiatrist. In addition, there was no documented evidence that the safety facility made a follow up and provided additional interventions after resident refused psychiatrist consult. LVN 2 stated there was no additional follow up and intervention was made for Resident 1 to ensure Resident 1's Residents Affected - Few safety and prevent injury and harm to self or to others after resident refused psychiatrist consultation on 5/8/2025.

During a concurrent interview and record review on 5/14/2024 at 4:35 PM with the Registered Nurse Supervisor (RNS 1), Resident 1's medical chart dated from 4/28/2025 to 5/13/2025 were reviewed. There was no documented evidence the facility monitored Resident 1's behavior of verbalizing wanting or planning to hurt self and/ or others after the resident was identified to be DTSO and after the resident refused to be transferred to GACH on 4/28/2025. RNS 1 stated there was no Interdisciplinary Care Team (IDT, means a group of professional and direct care staff that have primary responsibility for the development of a Service Plan for an individual receiving services) meeting done, no monitoring for Resident 1's behavior of verbalizing wanting or planning to hurt self and/ or others and no care plan initiated regarding residents behavior of DTCO since 4/28/2025.

During an interview on 5/16/2025 at 12:05 PM with RNS 1, RNS 1 stated the intervention to monitor Resident 1 closely at least every hour or designate 1:1 sitter for the safety of the residents and staff should have been done immediately for Resident 1. RNS 1 stated most of the staff do not go to check on Resident 1 because of the resident's behavior very mean and yells at staff.

During an interview on 5/16/2025 at 12:38 PM with RNS 1, RNS 1 stated the facility should have developed Resident 1's care plan for danger to self and others and document Resident 1's behavior verbalizing wanting to burn the facility and or hurt self or others.

During an interview on 5/16/2025 at 12:43 PM with RNS 1, RNS 1 stated Resident 1 refused the psychiatrist consultation on 5/8/2025, the facility did not make additional attempts for psychiatric evaluation or follow up

after that. RNS 1 stated RNS 1 checked Resident 1's medical chart, and RNS 1 did not find any documentation regarding additional interventions done after Resident 1 refused. RNS 1 stated, the facility licenses nurse was supposed to monitor Resident 1's behavior of verbalizing wanting to burn the facility and/ or wanting to hurt others or self after being identified as DTSO. RNS 1 also stated, the facility was supposed to have an IDT meeting and care plan developed regarding Resident 1's refusal to be sent to GACH and to be seen by a psychiatrist.

During an interview on 5/16/2025 at 12:53 PM with RNS 1, RNS 1 stated Resident 1 was DTSO, and the facility did not ensure Resident 1's safety and provide a safe environment. RNS 1 stated Resident 1 was sent to GACH's ER via 911 and admitted to the GACH's Intensive Care Unit (ICU, specialized treatment given to patients who are acutely unwell and require critical medical care) on 5/12/2025.

During an interview on 5/16/2025 at 1:29 PM with LVN 2, LVN 2 stated no documentation in Resident 1's medical chart regarding monitoring of Resident 1's behavior of verbalization of wanting to burn the facility and/ or wanting to hurt others or self, after the resident was identified as DTSO. The care plan for DTSO was not initiated, no SBAR, no change of condition (COC- similar to a SBAR) documentation done and no monitoring of Resident 1 to ensure the resident's safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 During an interview on 5/16/2025 at 2:00 PM with the Administrator (ADM), ADM stated the facility failed to assess, supervise and monitor for being danger to self and others Resident 1 who was identified DTSO on Level of Harm - Immediate 4/28/2025, and because of all these Resident 1 was found unresponsive on 5/12/2025 and was transferred jeopardy to resident health or to GACH and admitted in GACH's ICU. safety

A record review of the facility's Policy and Procedure (P&P) titled Resident Examination and Assessment Residents Affected - Few revised date 2001, it indicated the purpose of this procedure is to examine and assess the resident of any abnormalities in health status, which provides a basis for the care plan.

A record review of the facility's P&P titled Change in a Resident's Condition or Status revised date 2/2021 indicated a significant change of condition is a major decline or improvement in the residents' status that requires interdisciplinary review and /or revision to the care plan. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. The P&P indicated the nurse will record in the resident's medical record information relative to change in the resident's medical / mental condition status.

A record review of the facility's P&P titled Charting and Documentation date 2/2001 indicated all services to

the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional pr psychosocial condition shall be documented in the resident's medical record.

A record review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring dated 3/2019 under assessment indicated the nursing staff will identify, document and inform the physician about specific details regarding change in an individual's mental status, behavior and cognition. The P&P also indicated under Management:

1.The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.

a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress.

b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior.

6. If the resident lacks decision-making capacity and does not have effective family support, the IDT will contact social services to provide assistance to the resident.

7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 055341 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 055341 B. Wing 05/16/2025

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

Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105

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 0742 8. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental Level of Harm - Immediate reasons for the behavior jeopardy to resident health or safety Monitoring:

Residents Affected - Few 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function.

2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 055341