Health inspection·May 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for four (4) of seven (7) sampled residents (Residents 3, 51, 15, and 62) by failing to ensure: 1. Resident 3's personal property was protected from loss as indicated on the facility's personal property policy. This deficient practice resulted to multiple personal items unaccounted for during an inventory of Resident 3's belongings list. 2. Resident 51's shared restroom for Room A and B was clean and free from dried brown smear on the wall. 3. Resident 62's wallpaper around the resident's call light panel was not stripping off. 4. Resident 15's wall behind her head of bed was in good repair and free of long scratched up and chipped paint. These deficient practices resulted in unsanitary condition which placed Resident 51 at risk for infection and potential for Residents 15 and 62 not feeling comfortable living in an unmaintained environment. Findings: 1. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a constriction of the airway making it hard and uncomfortable to breathe), and type 2 Diabetes (an impairment in the way the body regulates and uses sugar or glucose as fuel. The condition results in too much sugar- blood sugarcirculating in the blood stream). A review of Resident 3's undated History and Physical (H&P), indicated Resident 3 does not have the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/31/2024, indicated Resident 3 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 3 was dependent (helper does all the effort) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 3 required substantial assistance (helper does more than half the effort) with upper body dressing and partial assistance (helper Page 1 of 31 055548 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0584 does less than half the effort) with eating, oral and personal hygiene. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/30/2024 at 2:00 PM, Responsible Party 1 (RP 1) stated she had brought a whole bunch of belongings for Resident 3 and did not see them in the resident's closet during her recent visit over the weekend. RP 1 also stated she had Resident 1's belongings listed in detail with some of the clothes brought in brand new. Residents Affected - Some During an interview on 5/01/2024 at 10:16 AM, the Social Service Director (SSD) stated inventory list was done during admission, re-admission, and anytime the family brings new items. The SSD also stated the Certified Nursing Assistant (CNA) or charge nurse is responsible to check the residents belongings and then signed by the nursing supervisor. During a concurrent interview and record review of the Resident 3's Inventory (personal belongings list) on 5/01/2024 at 12:20 PM, the Social Service Director (SSD) stated nursing was responsible in making sure the belongings are inventoried and documented in the Resident's Inventory. The SSD also stated it is the resident's rights to have their belongings with them and made sure they are safe. SSD also stated, Resident 3's cane was one of the belongings missing in the resident's room. During an interview on 5/1/2024 at 3:41 PM, the Director of Nursing (DON) stated belongings should be inventoried and logged in the personal belongings list upon admission and readmission of the resident in the facility. The DON also stated the personal belongings list is updated by the social worker when the family brings in additional belongings any time after the admission. The DON further stated it is the facility's responsibility to make sure the residents belongings are safe. During an interview on 5/02/2024 at 10:22 AM, the SSD stated she had performed and inventory of Resident 3's belongings list and confirmed multiple items were missing in Resident 3's closet which included: a) One (1) black T-shirt b) 1 cane c) 1 large (L) Brand A charcoal grey T-shirt d) 1 L Brand A blue T-shirt e) 1 L Brand C jogger pant f) 055548 Page 2 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0584 1 extra-large (XL) black, tan, and white colored plaid short with double pockets Level of Harm - Minimal harm or potential for actual harm g) 1 size 36 black, grey, and white colored plaid short with pockets Residents Affected - Some h) 1 double XL black and dark blue Brand C sweater with front zipper with cream light blue inner collar i) 1 XL light blue Brand D jacket with dark blue collar striped arms A review of the facility's Policy and Procedure titled, Personal Property, revised 7/14/2017, indicated the facility were to ensure it would take reasonable steps to protect residents' personal property. The policy also indicated that if the resident is transferred to the acute hospital, and is expected to return to the facility, the residents CNA will inventory the resident's property at the time of transfer. The policy further states that the facility may decide to keep the resident's property in the residents' room during the bed hold or may pack the items and place them in secured storage pending the residents return. 2. A review of Resident 51's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included peripheral vascular disease (PVD, reduced circulation of the blood to a body part other than the brain or heart) and hypertension (a condition which the blood vessels have persistently raised pressure). A review of Resident 51's MDS, dated [DATE], indicated Resident 3 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 51 required supervision (helper provides verbal cues) with toileting, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS further indicated Resident 51 required set up assistance (helper sets up or cleans up) with oral hygiene and independent with eating. During a concurrent observation of the shared restroom for Rooms A and B, and interview on 4/29/2024 at 1:15 PM, the restroom for Rooms A and B was noted to have dried brown smear on the wall close to the toilet flush handle. Resident 51 stated his restroom was dirty and the dried brown smear on the wall close to the toilet flush handle has been there since morning. Resident 51 also stated he did not want to touch the toilet handle after seeing the brown smear on the wall. During an interview on 5/1/2024 at 10:00 AM, Housekeeping 1 (HK 1) stated the residents' restroom including Room A and B's, should always be clean especially because they are shared with other residents and to ensure they have a clean environment and to prevent spread of infection. During an interview on 5/1/2024 at 10:10 AM, the Infection Prevent Nurse (IPN) stated the residents' restrooms are potential sources of infections to spread and the facility should provide a clean and comfortable environment for the resident. IPN also stated residents' restrooms should be clean for hygienic purposes. 055548 Page 3 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/2/2024 at 12:22 PM, the Certified Nursing Assistant 1 (CNA 1) stated the residents' restrooms should be clean and sanitary for the resident to use. During an interview on 5/02/2024 at 12:40 PM, the Director of Nursing (DON) stated the facility had to make sure the residents' environment was always clean because it contributes to the well-being, comfort, and quality of life for the resident. The DON also stated residents' restrooms should always be clean to prevents spread of any germs or bacteria to residents who might be using them. A review of the facility's Policy and Procedure titled, Resident Rooms and Environment, revised 1/1/2012, indicated the facility was to provide residents with a safe, clean, and homelike environment. The policy also indicated that the facility staff aims to create a personalized, homelike atmosphere, paying close attention to one of the following: cleanliness and order. 3. A review of Resident 62's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (loss of muscle tissue). A review of Resident 62's H&P, dated 1/20/2024 indicated Resident 62 does not have the capacity to understand and make decisions. A review of Resident 62's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 62 required total dependence (helper does all the effort) with toileting, lower body dressing, and putting on/taking off footwear and required substantial assistance (helper does more than half the effort) with shower and upper body dressing. The MDS further indicated that Resident 62 required partial assistance (helper does less than half the effort) with eating, oral and personal hygiene. During an observation on 4/9/2024 at 8:20 AM, the wallpaper around Resident 62's call light panel was stripping off. During an interview on 5/1/2024 at 10:45 AM, the Maintenance Supervisor (MTS) stated he was responsible with fixing wallpapers in the residents' rooms. The MTS also stated Resident 62's room needed to look presentable and properly maintained so resident could feel at home. During an interview on 5/2/2024 at 12:40 PM, the Director of Nursing (DON) stated Resident 62's area/room should be well maintained so it would be more homelike for the resident. A review of facility Policy and Procedure (P&P) titled, Residents Rooms and Environment, revised January 1, 2012, indicated that the facility would provide residents with a safe, clean, comfortable, and homelike environment. A review of facility P&P titled, Maintenance Services, revised January 1, 2012, indicated that the facility's maintenance department maintains all areas of the building in good repair. 4. A review of Resident 15's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a problem in the brain) and pulmonary fibrosis (a disease where there is scarring of the lungs which makes it difficult to breathe). A review of Resident 15's History and Physical Examination (H&P), dated 1/24/2024, indicated the resident does not have the capacity to understand and make decisions. 055548 Page 4 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 15's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 4/19/2024, indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 15 needed partial/moderate assistance (helper does less than half the effort) with transfers (how resident moves to and from bed, chair, and wheelchair) and needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with personal hygiene and eating. During an observation on 4/29/2024 at 8:55 AM in Resident 15's room, the wall behind Resident 15's head of bed was observed to have long scratched up and chipped paint. During a concurrent observation and interview on 5/1/2024 at 4:19 PM with Maintenance Supervisor (MTS) in Resident 15's room, the wall behind Resident 15's head of bed was observed to have long scratched up and chipped paint. MTS stated that it was important to provide residents with an environment that was nice and homelike for their comfort and so they do not feel like they were just staying in a hospital room. A review of the facility's Policy and Procedure titled, Resident Rights - Personal Property, revised 1/1/2012, indicated that it's purpose was, To ensure the quality of life of all residents by allowing residents to create a home-like environment. A review of the facility's Policy and Procedure titled, Maintenance Service, revised 1/1/2012, indicated, The Maintenance Department maintains all areas of the building, grounds, and equipment, and Functions of the Maintenance Department may include, but are not limited to: Maintaining the building in good repair and free from hazards. 055548 Page 5 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise a Foley catheter (or urinary catheter is a flexible tube that is inserted into the bladder to empty it and collect urine in a drainage bag) care plan for one (1) of 1 sampled resident (Resident 84) by not updating Resident 84's Foley catheter care plan to include the resident's behavior of placing the resident's Foley catheter drainage bag on the floor. This failure resulted in the facility staff not implementing interventions to prevent Resident 84 from placing his urinary catheter drainage bag on the floor and placed Resident 84 at risk for infection. Findings: A review of Resident 84's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of aphasia (a language disorder that makes it difficult to understand, express, read, and write) and type two (2) diabetes (a disease that occurs when your blood sugar is too high). A review of Resident 84's History and Physical Examination (H&P), dated 3/18/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 84's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 3/15/2024, indicated the resident had adequate hearing (no difficulty in normal conversation, social interaction, listening to TV), had unclear speech (slurred or mumbled words), sometimes understood others (responds adequately to simple, direct communication only), rarely/never understood in his ability to express ideas and wants, was severely impaired (never/rarely made decisions) with decisions regarding tasks of daily life, needed substantial/maximal assistance (helper does more than half the effort) with rolling left to right in bed and going from sitting to lying down in bed, was dependent (helper does all of the effort) with dressing and personal hygiene and needed partial/moderate assistance (helper does less than half the effort) with eating. A review of Resident 84's Order Summary Report dated 4/1/2024 to 5/2/2024, indicated an order for Resident 84 to have an indwelling catheter (Foley/ urinary catheter) with balloon (prevents the catheter from coming out) by way of gravity drainage for urinary retention (a condition in which you are unable to empty all the urine form your bladder) due to benign prostate hyperplasia (BPH, a condition in men in which the prostate gland [a gland in the male reproductive system] is enlarged). During a concurrent observation and interview on 4/30/2024 at 7:55 AM with Licensed Vocational Nurse 1 (LVN 1) in Resident 84's room, Resident 84's Foley catheter drainage bag was observed on the floor. LVN 1 stated that the drainage bag should not be on the floor to prevent contamination. During an observation on 4/30/2024 at 12:55 PM in Resident 84's room, Resident 84's Foley catheter drainage bag was observed on the floor next to the resident's feet. During a concurrent observation and interview on 5/1/2024 at 8:10 AM with Registered Nurse Supervisor 1 (RNS 1) in Resident 84's room, Resident 84's Foley catheter bag was observed on the floor. RNS 055548 Page 6 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 stated that the urinary catheter bag should be hanging on the resident's side of the bed and should not be on the floor for infection control. During a concurrent interview and record review on 5/1/2024 at 8:28 AM with RNS 1, Resident 84's Foley catheter care plan dated 4/29/2024-5/1/2024 was reviewed. The Foley catheter care plan did not address resident's behavior of putting his Foley catheter drainage bag on the floor. During a concurrent interview and record review on 5/1/2024 at 9:02 AM with Minimum Data Set Coordinator 1 (MDS 1), Resident 84's Foley catheter care plan dated 4/29/24- to 5/1/24 was reviewed. The Foley catheter care plan did not address Resident 84's specific behavior of placing his Foley catheter drainage bag on the floor. MDS 1 stated Resident 84's specific behavior should be care planned so that everyone is aware how to manage the problem. During an interview on 5/2/2024 at 8:41 AM with the Director of Nursing (DON), the DON stated, Resident 84's care plan should have been updated to address the resident's specific behavior of placing his Foley catheter drainage bag on the floor so that they could identify the problem and provide proper goals and interventions to address it. A review of the facility's Policy and Procedure (P&P) titled, Indwelling Catheter, revised 9/1/2014, indicated to update the resident's care plan as necessary. A review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised November 2018, indicated under comprehensive care plan that, additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. 055548 Page 7 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure two (2) of 20 sampled residents (Residents 44 and 290) were provided care and services by failing to provide: Residents Affected - Few 1. A communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) to Resident 44 that was readily accessible with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 44 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the resident. 2. A shower to Resident 290 as scheduled and as requested. This failure resulted in violation of Resident 290's right to be showered, receive person centered care (services delivered in a setting and manner that is responsive to individuals and their goals, values and preferences) and potential to decline her ability to carry out showering Activities of Daily Living (ADL). Findings: 1. A review of Resident 44's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform every day activities like eating or dressing) following cerebral (relating to the brain) infarction (tissue death [necrosis] due to inadequate blood supply to the affected area) affecting the left non-dominant side and dementia (the loss of cognitive [thinking, remembering and reasoning] functioning to such an extent that it interferes with a person's daily life and activities). A review of Resident 44's History and Physical Examination (H&P), dated 3/10/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. A review of Resident 44's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 1/26/2024, indicated Resident 44 had severe impairment (difficulty with or unable to make decisions, learn, remember things) in cognitive skills for daily decision making. Resident 44 was sometimes understood (ability was limited to making concrete requests) and sometimes understands (responds adequately to simple, direct communication only). Resident 44 was dependent (helper does all of the effort) with transfers (how resident moves to and from bed, chair, wheelchair, standing position) and lower body dressing (the ability to dress and undress below the waist). Resident 44 needed substantial/maximal assistance with upper body dressing (the ability to dress and undress above the waist) and personal hygiene. Resident 44 needed partial/moderate assistance (helper does less than half the effort) with eating. During an observation on 4/29/2024 at 9:21 AM in Resident 44's room, Resident 44 was observed speaking in another language other than English. There was no communication board observed on Resident 44's bedside table, nightstand or hanging anywhere on the wall near the resident's bed. 055548 Page 8 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 4/30/2024 at 8:10 AM in Resident 44's room, there was no communication board observed near the resident, on her bedside table, on her rolling bedside table, underneath her bed or hanging on the wall near her bed. During a concurrent observation and interview on 4/30/2024 at 8:19 AM with Certified Nursing Assistant 1 (CNA 1) in Resident 44's room, CNA 1 stated that Resident 44 does not speak English and stated that there was no communication board present at the resident's bedside. CNA 1 also stated that it was important for Resident 44 to have a communication board in a language that resident understands so that she is able to communicate her needs. During a concurrent observation and interview on 4/30/2024 at 8:27 AM with Social Services Director (SSD) in Resident 44's room, SSD stated that Resident 44 did not have a communication board at the bedside and that it was important for residents who do not speak English to have a communication board that is readily accessible so that they are able to communicate their needs. During an interview on 4/30/2024 at 3:57 PM with Resident 44, Resident 44 stated that she does not speak English and when staff speak to her in English, if she was able to pick up some words & understood, then she responded but if she did not understand she just left it alone. Resident 44 also stated that staff do not use a communication board when communicating with her. During a concurrent observation and interview on 5/1/2024 at 7:57 AM with Resident 44 in her room, there was no communication board observed at Resident 44's bedside or hanging on the wall on top or near her nightstand. During an concurrent observation and interview on 5/1/2024 at 8:04 AM with CNA 4 in Resident 44's room, CNA 4 stated that the resident does not have a communication board at her bedside. During a concurrent observation and interview on 5/1/2024 at 8:07 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated there was no communication board at the resident's bedside and that a communication board should always be readily accessible because it was a means for the resident to get her needs across. During and interview on 5/1/2024 at 8:43 AM with Director of Nursing (DON), the DON stated that residents who do not speak English should always have a communication board. The DON further stated that not having one puts Resident 44 at risk for her needs not being met. A review of the facility's Policy and Procedure (P&P) titled, Translation or Interpretation Services, revised 12/1/2013, indicated it's purpose was, to ensure that resident with Limited English Proficiency or who have hearing deficiencies, have the same access to Facility services as other residents, and translation and interpretation are provided in a way that is culturally relevant and appropriate to the Limited English Proficiency individual. A review of the facility's P&P titled, Accommodation of Residents' Communication Needs, revised March 2017, indicated, The facility provides assistance to residents with communication challenges through a number of adaptive services, and indicated procedures including: Staff will provide adaptive devices as needed to enable the resident co communicate as effectively as possible 055548 Page 9 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0676 The following are examples of adaptive devices the staff may provide the resident: Level of Harm - Minimal harm or potential for actual harm Communication Boards/Charts. Residents Affected - Few 2. A review of Resident 290's admission Record indicated Resident 290 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), spinal stenosis (the narrowing of the spine which puts pressure on the spinal cord and nerves causing pain), abnormalities of gait and mobility (manner of walking or moving on foot), and polyosteoarthritis (when four or more joints in the body are painful and inflamed [red or swollen]). A review of Resident 290's Baseline Care Plan, dated 4/27/2024, indicated Resident 290 as alert with intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 290 required moderate assistance (staff does less than half the effort to complete the activity) with showering/bathing and dressing. A review of a facility form titled, ADL Flowsheet, dated 4/2024, indicated to document SB (sponge bath) or S (shower) when given. The flowsheet failed to indicate Resident 290 received a shower or bath from the date of admission, Saturday 4/26/2024 through Tuesday 4/30/2024. During an interview on 4/30/2024 at 8:58 AM Resident 290 stated she did not get a shower since being admitted into the facility on 4/26/2024. Resident 290 stated she informed facility staff on Monday, 4/29/2024 and Tuesday, 4/30/2024 that she has not received a shower and wanted a shower, but stated has been unable to receive a shower. During an interview on 4/30/2024 at 4:10 PM with LVN 1, LVN 1 stated residents were assigned shower days based off their bed numbers. LVN 1 stated showers were important for the residents because they feel good, refreshed and so much better after receiving their showers. A review of the facility's undated Shower Schedule - [NAME] Station, indicated Resident 290 was scheduled to receive showers on Mondays and Thursdays. The schedule also indicated newly admitted residents must be offered a shower upon admission or the next day, regardless of the shower schedule, with all shifts being able to provide showers based on resident's preference. During an interview on 5/1/2024 at 8:41 AM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated CNAs can give showers to the residents during any shift and upon request of the resident. RNS 1 also stated, If residents were not getting showers, it affects the residents' satisfaction, and they will not be satisfied. During a concurrent record review of the ADL Flowsheet, dated 4/2024, and interview with CNA 8 on 5/1/2024 at 3:26 PM, the flowsheet indicated dash mark entries, blank entries or the letter n for Resident 290's bathing/showering documentation from 4/26/2024 through 4/30/2024. CNA 8 stated the dash marks and n means shower/bathing was not done. CNA 8 also stated she cared for Resident 290 on 4/30/2024 during the evening (3PM to 11PM) shift and did not give Resident 290 a shower because showers were not given to residents during the evening shift. A review of the facility's Policy and Procedure (P&P) titled, Shower and Bathing, revised 1/1/2012, indicated showers or tub baths are to be given to the residents if not contraindicated and to provide cleanliness, comfort, and to prevent body odors. 055548 Page 10 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents Coban wrap (a self-adherent elastic wrap that provides a reliable hold while maintaining mild compression) and Unna boot dressing (medicated moist gauze with zinc oxide) was applied to the resident's bilateral lower extremities (BLE, both legs) as indicated on the physician's order for one (1) of two (2) sampled residents (Resident 20). Residents Affected - Few These deficient practices had the potential for unresolved and worsening edema (swelling caused by fluids trapped in the body's tissues) to Resident 20's BLE affecting the resident's physical comfort and well-being. Findings: A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease (CKD, a condition characterized by a gradual loss of kidney function over time) and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). A review of Resident 20's History and Physical (H&P), dated 7/30/2023 indicated Resident 20 had the capacity to understand and make decisions. A review of Resident 20's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/25/2024, indicated Resident 20 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 20 required partial assistance (helper does less than half the effort) with toileting and personal hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 20 required supervision (helper provides verbal cues) with oral hygiene and set-up assistance with eating. A review of Resident 20's Physician's Order, dated 3/31/2024 at 8:40 AM, indicated BLE management to include application of Unna boot from foot to knee, then wrapped with Coban self-adhering wrap every day on for 5 days and off for 2 days. The physicians order also indicated to apply the dressing every Friday and to remove every Wednesday. During an observation in Resident 20's room on 4/29/2024 at 8:51 AM, a used Coban and Unna boot dressing was seen on top of Resident 20's bedside dresser next to an unlabeled water pitcher. Resident 20 did not have dressing on the residents BLE. During a concurrent observation in Resident 20's room and interview on 4/30/2024 at 9 AM, the Treatment Nurse 1 (TN 1) opened Resident 20's bed sheet to check on the resident's BLE. Resident 20 did not have any bandage wrapped around the resident's BLE exposing 3 + pitting (5 to 6 mm of depression, rebounding in 60 seconds) edema to BLE. Resident 20's BLE was not wrapped with Coban wrap and Unna boot dressing in place. The TN 1 stated the Coban wrap, and Unna boot dressing was applied on Fridays and removed on Wednesdays (2 days off and 5 days on schedule). TN 1 also stated today is Tuesday and Coban wrap, and Unna boot dressing was supposed to be on Resident 20's BLE to help with the swelling of BLE and should not have been removed. 055548 Page 11 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the same interview on 4/30/2014 at 9 AM, Resident 20 stated she was unaware what happened to the Coban wrap and Unna boot dressing and who took them off. During an interview on 5/02/2024 at 9:24 AM, the Director of Nursing (DON) stated the nursing staff should have monitored Resident 20 to ensure the Coban wrap, and Unna boot dressing was still on the resident. The DON also stated the dressing was intended to help control Resident 20's BLE's edema. A review of the facility's Policy and Procedure titled, Resident Rights - Quality of Life, revised March 2017, indicated the facility was to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, psychological well-being, consistent with the resident's comprehensive assessment and plan of care. 055548 Page 12 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement intervention to prevent pressure ulcer (wound that occurs as a result of prolonged pressure on a specific area of the body) for two (2) of three (3) sampled Residents (Residents 17 and 54) by failing to ensure the residents' low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress and distribute the resident's body weight over a broad surface area and help prevent skin breakdown) mattress was set according to the residents' weight. Residents Affected - Some This deficient practice had the potential for Residents 17 and 54 to develop pressure ulcers. Findings: 1. A review of Resident 17's admission Record indicated the facility admitted the resident on 6/11/2020, with diagnoses that included Parkinson's disease (a brain condition that affects the movement, mood and other health issues), peripheral vascular disease, and dementia (loss of memory and other mental abilities severe enough to interfere with daily life). A review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/1/2024, indicated the resident was severely impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 17 was dependent (helper does all of the effort) with toileting hygiene, shower, dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting on side of the bed. MDS indicated Resident 17 was at risk of developing pressure ulcers/injuries. Skin and ulcer treatments included pressure reducing device for bed, nutrition or hydration, application of ointments and dressings. A review of Resident 17's History and Physical Examination (H&P), dated 3/10/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 17's Physician's order, dated 5/3/2022, indicated low air loss mattress for skin management. A review of Resident 17's Care Plan titled, At Risk for Skin Breakdown and or Development of Pressure Injury, dated 12/8/2023, indicated staff interventions included were to reposition at least every 2 hours, LAL mattress for skin management, and to encourage resident to be out of bed daily. During an observation on 4/29/2024 at 8:46 AM, Resident 17 was observed lying on a LAL mattress, which was at 320 pound (lb) setting. During an observation on 4/30/2024 at 7:38 AM, Resident 17 was observed lying on a LAL mattress, which was at 320 lb setting. During a concurrent observation and interview with the Director of Nursing (DON) on 4/30/24 at 4:24 PM, the DON confirmed that Resident 17 was observed lying on a LAL mattress, which was at 320 lb setting. The DON stated, Resident 17's weight was 112 lbs as of 4/3/2024. The DON stated the mattress should not have been set at 320 lbs because if the LAL setting was high, it will be firm and it would defeat its purpose. The DON stated this will place the resident at high risk for skin breakdown. 2. A review of Resident 54's admission Record indicated the facility admitted the resident on 055548 Page 13 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9/16/2019, with diagnoses that included Alzheimer's disease (a brain disorder that disables a person from performing everyday activities) and contractures (deformity from permanent shortening of muscle, tendon, or scar tissue). A review of Resident 17's History and Physical Examination (H&P), dated 3/10/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 54's MDS, dated 3/292024, indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 54 was dependent with toileting hygiene, shower, dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting on side of the bed. MDS indicated Resident 54 was at risk of developing pressure ulcers/injuries. Skin and ulcer treatments included were pressure reducing device for bed and nutrition or hydration. A review of Resident 54's Physician's Order, dated 4/30/2024, indicated may have low air loss mattress for skin management. May adjust setting per resident's weights and/or resident's comfort for skin management. During an observation on 4/29/2024 at 8:37 AM, Resident 54 was observed lying on a LAL mattress, which was at 180 lb setting. During an observation on 4/30/2024 at 7:51 AM, Resident 54 was observed lying on a LAL mattress, which was at 180 lb setting. During a concurrent observation and interview with the DON on 4/30/24 at 4:25 PM, the DON confirmed that Resident 54 was observed lying on a LAL mattress, which was at 180 setting. The DON stated, Resident 54's weight was 106 lbs as of 4/3/2024. The DON stated the mattress should not have been set at 180 lbs because if the LAL setting was high, it will be firm and it would defeat its purpose. The DON added, this will place the resident at high risk for skin breakdown. 055548 Page 14 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care service for one (1) of five sampled residents (Residents 34) in accordance with the facility's policy and procedure when an oxygen humidifier (a device designed to increase the moisture in the air and avoid dryness of the nasal passage [nose to lungs]) being used was empty and did not have sterile water (water that is free of any microbes [tiny living things that are found all around us and are too small to be seen by a naked eye], used to prevent growth of organisms and bacteria in the water). Residents Affected - Few This deficient practice had the potential to create discomfort and dryness to Resident 34's nasal passages which can lead to serious complications. Findings: A review of Resident 34's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen to the blood or eliminate enough carbon dioxide from the body) and pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity). A review of Resident 34's History and Physical (H&P), dated 1/17/2024 indicated Resident 34 does not have the capacity to understand and make decisions. A review of Resident 34's Physician's Order, dated 4/3/2024, timed at 8:36 PM indicated to change humidifier as needed for oxygen use. A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/15/2024, indicated the resident had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding). The MDS also indicated Resident 34 required total dependence (helper does all the effort) with eating, oral, toileting and personal hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During an observation on 4/29/2024 at 9:14 AM, Resident 34 was seen lying in bed with oxygen nasal cannula (a medical device, plastic tube used to provide supplemental oxygen therapy to people who have lower oxygen levels) at 3 L/minute (Liter per minute, unit of flow rate) with an empty oxygen humidifier labeled 4/24/2024. During an interview on 4/30/2024 at 4:20 PM, the Minimum Data Set 1 (MDS 1) stated the oxygen humidifier should have been changed when the sterile water was out because it is needed to help with moisturization of Resident 34's nasal passages so the resident's nose would not feel dry. During an interview on 5/01/2024 at 3:56 PM, the Director of Nursing (DON) stated the oxygen humidifier should have been changed when it was empty to help keep Resident 34's nasal passages from getting dry and for Resident 34's comfort. A review of the facility's policy and procedure titled, Oxygen Therapy, revised November 2017, indicated its purpose was to ensure the safe administration of oxygen in the facility. The policy also indicated to administer oxygen under safe and sanitary conditions to meet resident's needs. The 055548 Page 15 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0695 policy further indicated to administer oxygen per physicians' orders. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055548 Page 16 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure the Nurse Staffing Information posted was accurate and complete in accordance with the facility's policy and procedure by failing to: Residents Affected - Some 1. Remove the 4/26/2024 Nurse Staffing Information posted on 4/29/2024 and post the Nurse Staffing Information for 4/29/2024. 2. Reflect the correct total number and actual hours of unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential for the Nurse Staffing Information not to be available to the residents and visitors at any given time. Findings: During an observation on 4/29/2024 at 11:20 AM, the Daily Posted Nurse Staffing (Nurse Staffing Information), located at the front lobby area was dated 4/26/2024. During a concurrent record review of the Daily Posted Nurse Staffing, dated 4/26/2024, and interview with the Director of Staff Development (DSD) on 5/2/2024 at 12:27 PM, the DSD stated the posted Nurse Staffing on 4/29/2024 was not and should have been posted. DSD stated the posted Nurse Staffing indicated a date of 4/26/2024, which was for last Friday. During an interview on 5/2/2024 at 12:38 PM, the Director of Nursing (DON) stated it was important to post accurate and complete nurse staffing for the facility to show transparency for residents and visitors, and resources available for the residents' care. The DON also stated posted nurse staffing would generally show if the facility had adequate staffing for residents' safety. During a concurrent record review of the Daily Posted Nurse Staffing, dated 4/29/2024 and interview with DSD on 5/2/2024 at 5:19 PM, DSD stated the Posted Nurse Staffing for 7 AM to 3 PM shift, indicated 16 Certified Nursing Assistants (CNAs)/Restorative Nursing Assistants (RNAs). DSD stated the posting should have reflected 13 CNAs and RNAs and the correct total number of hours. During a concurrent record review of the Daily Posted Nurse Staffing, dated 5/1/2024 and interview with DSD on 5/2/2024 at 5:20 PM, DSD stated the Posted Nurse Staffing for 7 AM to 3 PM shift, indicated 17 CNAs/RNAs. DSD stated the posting should have reflected 16 CNAs and RNAs and the correct total number of hours. During an interview on 5/2/2024 at 5:22 PM, DSD stated an accurate posted nurse staffing was necessary for the visitors and family members to know the actual facility's staffing ratio for the day. The DSD also stated based on the regulation the facility was required to post accurate daily nurse staffing at the beginning of each day. A review of the facility's Policy and Procedure titled, Nursing Department - Staffing, Scheduling, and Posting, revised January 1, 2012, indicated that the facility will post the current date for nurse staffing postings daily. The policy also indicated that the facility will post the total number of unlicensed nursing staff directly responsible for residents care per shift. 055548 Page 17 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately record and implement the food preferences for one of four sampled Residents (Resident 25). This failure resulted in a violation of Resident 25's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition. Findings: A review of Resident 25's admission Record indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (weakness one side of the body), acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in body tissues, causing confusion, bluish skin, and changes in breathing and heart rate), dysphagia (difficulty swallowing) and gastro esophageal reflux disease (chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus). A review of Resident 25's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 3/25/2024, indicated Resident 25 has severely impaired (weakened) cognitive skills (relating to the mental process involved in knowing, learning, and understanding things) for daily decisions. Resident 25 was usually able to express ideas and wants and clearly understood others. The MDS also indicated Resident 25 was dependent (staff does all the effort to complete activity) with toileting, showering/bathing, dressing and personal hygiene and moderate assistance (staff does less than half the effort) with eating. A review of Resident 25's Diet Order & Communication Form, dated 3/18/2024, indicated a preference for no raw onions and Resident 25's food allergies of pepper and chili. During a concurrent interview and record review of Resident 25's Dietary Tray Card on 4/29/2024 at 8:27 AM with Resident 25, the tray card indicated dietary dislikes of bacon, pork and ham. Resident 25 stated her dietary profile was incorrect because she never informed facility of a dislike to pork, bacon and/or ham. Resident 25 stated she enjoys eating them. During an interview on 5/1/2024 with Family Member 1 (FM 1), FM1 stated when Resident 25 was first admitted to the facility on [DATE], she met with DS and informed DS of Resident 25's allergies and dislikes but never indicated pork, ham or bacon as a dislike. FM 1 also stated she does not know where the incorrect information came from and spoke with multiple staff to correct the error of pork product dislikes, but nothing has changed. During a concurrent record review of Resident 25's Dietary Profile dated 4/10/2024 and interview on 5/2/2024 at 1:33 PM with Dietary Supervisor (DS), the dietary profile indicated an update of no pork products. DS stated she cannot recall and has no documentation of who she spoke with when she updated Resident 25's dietary profile to no pork products. DS stated it was very important to honor resident's food preferences because their nutrition is a part of their medication and treatment that allows them to recover and have the ability to participate in rehab. DS also stated the risks of not honoring resident's dietary preferences include residents not wanting to eat, as well as feeling that 055548 Page 18 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0806 they are not getting what they like, and not eat, which could cause weight loss. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure (P&P) titled, Dietary Profile and Resident Preference Interview, revised 4/21/2022, indicated the dietary profile of residents are to reflect current nutritional needs and food preferences and additional documentation of nutritional preferences will be documented on the progress notes. The P&P also indicated dietary will provide resident with meals consistent with their preferences and residents' preferences will be updated in the medical record and tray card in a timely manner. Residents Affected - Few 055548 Page 19 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policies and procedures on safe food storage by not: 1. Labeling four (4) gallons of milk in the kitchen refrigerator with an open and/or use by date. 2. Labeling food items in the resident's fridge with a date and/or resident's name. 3. Ensuring Kitchen Staff 1 (KS 1) performed hand hygiene and changed gloves after washing dishes in the sink and went from the dirty area to the clean area. This failure had the potential for residents to be at risk of a food-borne illness (illness caused by food contaminated with bacteria). Findings: During an observation on 4/29/2024 at 7:46 AM in the kitchen, one opened and used gallon of milk in the refrigerator was found to have been labeled with an open date but no used by date, and another open and used gallon of milk was found to have no open date or used by date. During a concurrent observation of the resident's refrigerator located at the west nurse's station and interview on 5/1/2024 at 10:53 AM with Registered Dietician (RD)) observed a plastic bag with a sandwich inside a Ziplock bag was found to be labeled with a room number but not labeled with open date/ first used, a small white paper espresso cup covered with a black lid containing white liquid was found to have no label of resident's name and not labeled with date opened or first used. In addition, a plastic bag with a plastic container with chicken and another plastic container of salad was found to be labeled with a room number but was not labeled with date opened or first used. Also observed a black and white gift bag filled with different fruits and a plastic container of prunes was found with no label of resident's name and/ or date of first use. RD stated that the food items with either no label of resident's name and/or date need to be thrown out. During an observation on 5/1/2024 at 11:00 AM in the kitchen, two gallons of opened and used milk were found in the refrigerator with no label of date opened and/ or used by date. During a concurrent observation and interview on 5/1/2024 at 11:04 AM with RD in the kitchen, KS 1 was observed wearing gloves and washing dishes in the sink next to the cooking stove. After KS 1 was finished washing dishes, she was then observed walking to the clean area of the dishwashing side and did not perform hand hygiene or change her gloves prior to touching a crate with clean utensils. RD stated that KS 1 should have washed her hands and changed her gloves before going from the dirty area to the clean area. During a concurrent observation and interview on 5/1/2024 at 1:20 PM with DS in the kitchen, two gallons of open and used milk were observed in the kitchen refrigerator. The two gallons of open and used milk was not labeled with opened date or use by date. DS stated, for labeling, once something is opened, they need to label it with an open date and a use by date. 055548 Page 20 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/1/2024 at 4:17 PM with RD, RD stated it is important that all food containers in the resident's refrigerator need to be properly labeled with the resident's name and open date for the resident's safety, so staff can know how long it has been in the refrigerator and when they must throw it out. During an interview on 5/2/2024 at 9:31 AM with DS, DS stated it is important that staff who are washing dishes in the kitchen and using the dishwasher, wash their hands and change gloves when going from the dirty area to the clean area to prevent any cross contamination from germs and bacteria from going from the dirty dishes to the clean ones. During an interview on 5/2/2024 at 9:45 AM with DS, DS stated it is important that all food items are labeled correctly with an open and use by date because it is in their policy and also because it is for the safety of the residents' to prevent them from getting sick from any cross contamination of bacteria getting into their food. A review of the facility's Policy and Procedure (P&P) titled, Dietary Department - Infection Control for Dietary Employees, revised 11/9/2016, indicated its purpose was, To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins, with the policy stating, All dietary employees will follow Infection Control Policies as established and approved by the facility's infection control Committee. The P&P further indicated, Proper Handwashing by Personnel will be done as follows: Immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils, and unwrapped single-use food containers and utensils. After handling soiled equipment or utensils. After engaging in any other activities that contaminate the hands. A review of the facility's P&P titled, Food [NAME] in by Visitors, revised June 2018, indicated, When food is [NAME] into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose and, Perishable food requiring refrigeration will be discarded after two (2) hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. A review of the facility's P&P titled, Food Storage, revised 7/25/2019, indicated, Food items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. A review of the facility's P&P titled, Labeling and Dating of Foods, dated 2020, indicated, All food items in the storeroom, refrigerator and freezer need to be labeled and dated, and further stated that, Newly opened food items will need to be closed and labeled with an open date and used by date. 055548 Page 21 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure two of three outside garbage cans were covered and closed per facility policy and procedure (P&P). Residents Affected - Some This failure had the potential to attract pests (any living thing - a plant, an animal or a microorganism that has a negative effect on humans such as insects and insects to the facility and its residents. Findings: During a concurrent observation and interview on 4/29/2024 at 10:18 AM with Dietary Supervisor (DS), outside on the left side of the building next to the facility's parking lot, one blue trash can filled with trash was uncovered with no lid and one grey trash can overflowing with trash was not covered with a lid. DS stated the trash bins outside should always be covered to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another), rodents and pests) from getting into the trash. During a concurrent observation and interview on 4/29/2024 at 10:18 AM with Maintenance Supervisor (MS) outside on the left side of the building next to the facility's parking lot, one blue trash can filled with trash was uncovered with no lid and one grey trash can overflowing with trash was not covered with a lid. MS stated the blue and grey trash can should have been covered. During a review of the facility's policy and procedure titled, Waste Management revised 4/21/2022, the P&P indicated: Maintain appropriate regulated waste containers. Container must be: o Closable, puncture resistant, and leak proof. Dispose of all regulated or potentially regulated waste. o Close and dispose regulated waste according to state and federal regulations. Dispose of non-regulated waste in appropriate, non-combustible waste containers. o When waste bags are ¾ full, close bag and remove from area. Dispose bag into large, covered waste bin or cart in soiled utility room. Food waste will be placed in covered garbage and trash cans. 055548 Page 22 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to follow its policy on infection control for five (5) of 5 sampled Residents (Resident 25, 81, 294, 11, and 84) by failing to ensure: Residents Affected - Some 1. Resident 25's humidifier bottle (bottle of water that adds moisture to oxygen therapy) was labeled with the oxygen tubing connected to it. Facility also failed to store Resident 25's Bilevel positive airway pressure (BiPAP, a mechanical breathing device with a mask that is used to help breathing) mask in a plastic bag. 2. Contact isolation (interventions used and intended to prevent spreading of infectious agents by direct or indirect contact) was initiated and implemented for Resident 81 while resident had Methicillin-resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to several antibiotics) infection. 3. Resident 294's oxygen tubing remained off the floor during oxygen administration. 4. Resident 11's oxygen nasal cannula (a medical device that delivers oxygen to the nose through a tube with two prongs that sit below the nose) tubing was labeled with a date and off the floor. 5. Resident 84's Foley catheter (urinary catheter, a flexible tube that is inserted into the bladder to empty it and collect urine in a drainage bag) was kept off the floor. These failures had the potential to result in placing the residents at risk for infection and transmission to residents, staff, and visitors. Findings: 1. A review of Resident 25's admission Record indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses that include hemiplegia (inability to move one side of the body) and hemiparesis (weakness one side of the body), acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate), acute pulmonary edema (a condition caused by too much fluid in the lungs), and obstructive sleep apnea (OSA, occurs when the upper airway becomes blocked, leading to brief pauses in breathing during sleep). A review of Resident 25's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 3/25/2024, indicated Resident 25 has severely impaired (weakened) cognitive skills (relating to the mental process involved in knowing, learning, and understanding things) for daily decisions. Resident 25 was usually able to express ideas and wants and clearly understood others. The MDS also indicated Resident 25 was dependent (staff does all the effort to complete activity) with toileting, showering/bathing, dressing and personal hygiene and moderate assistance (staff does less than half the effort) with eating. A review of Resident 25's Order Summary, dated 5/2/2024, indicated active orders for oxygen at two (2) liters per minute via nasal cannula (NC, device that delivers extra oxygen through a tube and into the resident's nose) and BiPAP mask on at bedtime at 9 PM and remove in the morning at 7 AM. 055548 Page 23 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation in Resident 25's room and interview on 4/29/2024 at 8:44 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 25's humidifier bottle was undated. LVN 2 stated there was no tubing connected to the humidifier bottle. LVN 2 added, Resident 25's BiPAP mask was placed on the nightstand unbagged and was touching the nightstand surface. LVN 2 stated humidifiers were to be labeled with an open date, and BiPAP equipment should be placed in a labeled bag when not in use. LVN 2 stated because the tubing was disconnected from the humidifier bottle, this created an open system that was exposed to bacteria. LVN 2 also stated having the BiPAP mask unbagged and the humidifier bottle that was not labeled with a date placed the equipment at risk for exposure to bacteria which could potentially lead to a respiratory infection for Resident 25. During an interview on 5/2/2024 at 11:07 AM with Infection Preventionist Nurse (IPN), IPN stated having Resident 25's humidifier and tubing disconnected and open can allow bacteria to get inside the tubing and water located in the humidifier bottle potentially causing bacterial infections like Legionnaires' disease (a serious type of pneumonia [lung infection] caused by legionella bacteria). IPN stated NC tubing should have been connected to the humidifier bottle and the BiPAP mask should have been placed inside of the plastic bag per facility policy, to prevent contamination and infection, which could cause a significant decline to Resident 25's already compromised respiratory condition. A review of the facility's Policy and Procedure (P&P) titled, BiPAP and Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while you sleep), dated 9/10/2020, indicated all equipment must be stored in a plastic bag or container labeled with the Resident's name when not in use. 2. A review of Resident 81's admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, generalized muscle weakness, overactive bladder (a sudden urge to urinate that is uncontrolled or difficult to control and can lead to the involuntary loss of urine [incontinence]), cerebral ischemia (condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain), and dysarthria (slow or slurred speech). A review of Resident 81's MDS, dated [DATE], indicated Resident 81 was severely impaired with cognitive skills for daily decision making. Resident 81 was dependent (staff does all effort to complete activity) with eating, toileting hygiene and showering/bathing and was always incontinent of urinating and having bowel movements.? A review of Resident 81's Order Summary, dated 5/2/2024, indicated an order for a urinalysis (a test that examines the visual, chemical and microscopic aspects of your urine), culture and sensitivity (C and S, detects and identifies bacteria and yeasts in the urine) on 4/12/2024 and an order for sulfamethoxale-trimethoprim (antibiotic used to treat infections) twice a day for urinary tract infection (UTIan infection in any part of your urinary system: kidneys, bladder, ureters, and urethra). During a concurrent interview and record review of Resident 81's Laboratory (lab) Results Report and Order Summary on 5/2/2024 at 10:36 AM with IPN, IPN stated Resident 18's lab report indicated positive MRSA result for the urine culture on 4/12/2024. IP stated Resident 18 did not have an order for isolation and contact precautions for the?positive MRSA result. IPN stated Resident 81 was not and should have been put on isolation precautions. IPN stated per facility protocol, once staff are aware of positive MRSA, the doctor is notified, and staff receive an order for isolation of the affected resident. IPN stated isolating the residents with infection such as MRSA was important to prevent the further spread of the infection. IPN also stated MRSA is resistant to multiple types of 055548 Page 24 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 antibiotics, causing treatment to include the need for stronger antibiotics. Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled, Multi Drug Resistant Organisms (MDRO, bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs), revised 3/2017, indicated MRSA as an MDRO and licensed staff and attending doctor will evaluate each individual known or suspected of an MDRO infection for room placement and initiation of contact precautions (interventions used and intended to prevent transmission of infectious agents, spread by direct or indirect contact). The P&P also indicated factors in determining the need for contact precautions to include the resident's ability to contain infected body fluids, personal hygiene of the resident and risk of transmission including uncontrolled secretions and total dependence for activities of daily living. Residents Affected - Some A review of the facility's P&P titled, Resident Isolation - Initiating Transmission Based Precautions, revised 4/22/2016, indicated transmission-based precautions are initiated when there is reason to believe a resident has a communicable infectious disease (illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air). 3. A review of Resident 294's admission Record indicated Resident 294 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate), acute pulmonary edema (condition caused by excess fluid in the lungs), congestive heart failure (CHF - a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs), and pneumonia (an infection in your lungs caused by bacteria, viruses or fungi). A review of Resident 294's MDS, dated [DATE], indicated Resident 294 was moderately impaired with cognitive skills for daily decision making and Resident 294 required moderate assistance (helper does less than half of the effort to complete the activity) with eating and oral hygiene and maximal assistance (helper does more than half the effort) with toileting and bathing. A review of Resident 294's Order Summary, dated 5/2/2024, indicated an order for oxygen four (4) to 5 liters per min via NC every shift for pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). During an observation on 4/29/2024 at 9:59 AM with the Director of Nursing (DON), in Resident 294's room, the DON stated that the NC tubing was touching the floor underneath Resident's bed while Resident 294 was receiving oxygen therapy. The DON stated the floor carries bacteria and there was a risk of Resident 294 getting an infection by having the oxygen tubing on the floor. The DON stated the tubing should be off the floor to maintain infection control. During an interview on 5/2/2024 at 11:07 AM with IPN, IPN stated having the oxygen tubing on the floor was not appropriate because the floor is dirty and ultimately the NC is going into resident's nose. IPN stated this can put the resident at greater risks for infection. IPN also stated Resident 294 currently has a respiratory infection and exposure to more bacteria can worsen the infection and cause a decline in the resident's health as opposed to improvement. A review of the facility's P&P titled, Oxygen Therapy, revised 11/2017, indicated oxygen is to be administered under safe and sanitary conditions and that oxygen and humidifier equipment will be 055548 Page 25 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 changed every seven (7) days and dated each time they are changed. Level of Harm - Minimal harm or potential for actual harm 4. A review of Resident 11's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a brain condition that affects the movement, mood and other health issues) without dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk [the main part of a resident's body]) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Residents Affected - Some A review of Resident 11's History and Physical Examination (H&P), dated 3/4/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 11's MDS, dated [DATE], indicated the resident had severe impairment (difficulty with or unable to make decision, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 11 needed substantial/maximal assistance (helper does more than half the effort) going from a sitting to a standing position, and rolling left and right in bed. Resident 11 was dependent (helper does all of the effort) with toileting and showering but needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During an observation on 4/30/2024 at 7:38 AM in Resident 11's room, Resident 11's oxygen nasal cannula tubing was observed with no labeled date. During a concurrent observation and interview on 4/30/2024 at 7:59 AM with Certified Nursing Assistant 2 (CNA 2) in Resident 11's room, Resident 11's oxygen nasal cannula tubing was observed to have no labeled date and was touching the floor. CNA 2 stated that the resident's oxygen tubing had no date and that it was touching the floor. During an interview on 4/30/2024 at 8:32 AM with Central Supply (CS), CS stated that he changes the oxygen tubing for the residents every Wednesday and labels them with the date he changed them. CS further stated that it's important that the oxygen tubing is changed and labeled so that the staff is able to know if the tubing is new or old. During an interview on 5/2/2024 with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated that it's important that oxygen nasal cannula tubing is labeled with a date so that staff know if it's new or old and that it should not be touching the floor to prevent and control infection. A review of the facility's P&P titled, Oxygen Therapy, revised November 2017, indicated, Oxygen is administered under safe and sanitary conditions to meet resident needs, and, The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. 5. During a review of Resident 84's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of aphasia (a language disorder that makes it difficult to understand, express, read, and write) and type two (2) diabetes (a disease that occurs when your blood sugar is too high). During a review of Resident 84's H&P, dated 3/18/2024, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 84's MDS, dated [DATE], indicated the resident had adequate hearing (no 055548 Page 26 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some difficulty in normal conversation, social interaction, listening to TV), had unclear speech (slurred or mumbled words), sometimes understood others (responds adequately to simple, direct communication only), rarely/never understood in his ability to express ideas and wants, was severely impaired (never/rarely made decisions) with decisions regarding tasks of daily life, needed substantial/maximal assistance (helper does more than half the effort) with rolling left to right in bed and going from sitting to lying down in bed, was dependent (helper does all of the effort) with dressing and personal hygiene and needed partial/moderate assistance (helper does less than half the effort) with eating. During a concurrent observation and interview on 4/30/2024 at 7:55 AM with LVN 1 in Resident 84's room, Resident 84's urinary catheter drainage bag was observed on the floor. LVN 1 stated that the drainage bag should not be on the floor to prevent contamination. During an observation on 4/30/2024 at 12:55 PM in Resident 84's room, Resident 84's urinary catheter drainage bag was observed on the floor next to the resident's feet. During a concurrent observation and interview on 5/1/2024 at 8:10 AM with Registered Nurse Supervisor 1 (RNS 1) in Resident 84's room, Resident 84's urinary catheter drainage bag was observed on the floor. RNS 1 stated that the urinary catheter drainage bag should be hanging on the resident's side of the bed and should not be on the floor for infection control. During an interview on 5/2/2024, the DON stated that Resident 84's urinary catheter drainage bag should not be on the floor to prevent infection. A review of the facility P&P titled, Infection Control - Policies & Procedures, revised 1/1/2012, indicated, The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections, with objectives including, Prevent, detect, investigate, and control infections in the facility. 055548 Page 27 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four (4) of 44 resident bedrooms (Rooms 12, 14, 35, and 37) met the requirements of 80 square feet (sq. ft.) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care. Findings: During an observation of the facility and resident's rooms from 4/29/2024 to 5/2/2024, Rooms 12, 14, 35, and 37 did not meet the minimum requirement of 80 sq. ft. per resident in multiple residents' rooms. A review of the facility's Client Accommodation Analysis Form, dated 5/1/2024, the facility had several rooms that measured less than the required 80 square footage per resident in multiple bedrooms. The following resident rooms were: 1) room [ROOM NUMBER] (4 beds) and measured 312.8 sq. ft., to equal 78.2 sq. ft. per resident. 2) room [ROOM NUMBER] (4 beds) and measured 312.8 sq. ft., to equal 78.2 sq. ft. per resident. 3) room [ROOM NUMBER] (4 beds) and measured 312.8 sq. ft., to equal 78.2 sq. ft. per resident. 4) room [ROOM NUMBER] (4 beds) and measured 312.8 sq. ft., to equal 78.2 sq. ft. per resident. During an observation of the facility and residents' room from 4/29/2024 to 5/2/2024, the residents residing in the rooms (Rooms 12, 14, 35, and 37) with an application for variance were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and side tables with drawers. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to these residents. The Department is recommending approval of the room waiver request for 4 of 44 resident rooms (Rooms 312, 14, 35, and 37). 055548 Page 28 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for two (2) out of 20 sampled residents (Residents 18 and 34) as indicated on the facility's communication-call system policy. Residents Affected - Few This deficient practice had the potential for Residents 18 and 34 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: 1. A review of Resident 18's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), blindness on one eye, and history of fall. A review of Resident 18's History and Physical (H&P), dated 11/14/2023, indicated Resident 18 does not have the capacity to understand and make decisions. A review of Resident 18's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 2/26/2024, indicated Resident 18 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 18 was dependent (helper does all the effort) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 18 required substantial assistance (helper does more than half the effort) with upper body dressing and required supervision (helper provides verbal cues) with eating and oral hygiene. During an observation on 4/29/2024 at 8:04 AM, Resident 18's call light was seen on the floor on the right side of the resident's bed. During an interview on 4/30/2024 at 10:54 AM, Resident 18 stated she used the call lights if she needed something. During an interview on 4/30/2024 at 11:01 AM, the Licensed Vocational Nurse 3 (LVN 3) stated that the call light was a way for Resident 18 to call for assistance and should be within the resident's reach. LVN 3 also stated the call lights needed to be within the Resident 18's reach for the safety of the resident and to quickly assist whenever the resident needed help. 2. A review of Resident 34's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen to the blood or eliminate enough carbon dioxide from the body) and pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity). A review of Resident 34's H&P, dated 1/17/2024 indicated Resident 34 does not have the capacity to understand and make decisions. 055548 Page 29 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 34's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills. The MDS also indicated Resident 34 required total dependence with eating, oral, toileting and personal hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 4/30/2024 at 10:05 AM, the call light of Resident 34 was seen stuck in between the bed mattress and the bed rail on the right side of the resident's bed. Resident 34 attempted to reach the call light using his left arm and stated he could not reach them. During an interview on 5/01/2024 at 3:59 PM, the Director of Nursing (DON) stated that the call light is there to let the staff know if they need help and assistance with anything. The DON added, without access to the call light, the resident would be at risk for their needs not being met. A review of the facility's Policy and Procedure titled, Communication - Call System, revised 1/1/2012, indicated its purpose was to provide a mechanism for residents to promptly communicate with nursing staff and enable residents to alert the nursing staff from their rooms. The policy also stated that the call cords will be placed within the residents reach in the residents' room. 055548 Page 30 of 31 055548 05/02/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe and sanitary environment by failing to: Residents Affected - Some 1. Empty the sharps container (made of rigid puncture resistant plastic which is used to ensure safe containment and disposal of items such as needles, scalpels, and other sharp medical instruments and prevent needlestick injuries) located in residents' restroom per facility policy. This failure resulted in unsafe conditions putting residents and staff at risk for injury. 2. Ensure unused toilet tissue rolls were clean, unopened, and stored in a sanitary manner. This failure resulted in unsanitary conditions putting residents at risk for urinary tract infection (UTI, an infection in any part of the urinary tract, the system of organs that makes urine) with the use of contaminated toilet tissue. Findings: 1. During a concurrent observation and interview on 4/29/2024 at 11:10 AM with Central Supply (CS) in Resident Restroom [ROOM NUMBER] (RR 1), the sharps container was observed with sharps products (needles, syringes, and other unidentifiable objects) above the fill line of the container, indicating container as full. CS stated the sharps container was full and needed to be changed for infection control and for safety measures. CS also stated, having a full sharps container in the resident's restroom creates a safety risk, because the resident can access a sharp object and get a hurt including a wound, which also creates a risk for an infection. A review of the facility's Policy and Procedure (P&P) titled, Waste Management, revised 4/21/2022, indicated the purpose of the policy is to maintain appropriate handling and disposable of all waste including sharps (needles, scalpel blades, glass, and pipettes) and the sharps container must be closable and replaced when ¾ full. 2. During a concurrent observation on 4/29/2024 at 11:27AM and interview with Infection Preventionist (IPN) in RR 2, four (4) toilet tissue rolls were observed stacked on top of a towel rack on the wall with the wrapping of three rolls torn and opened exposing the tissue and one (1) roll with a brown water mark residue line vertically down the entire roll from the top. IPN stated the toilet tissues should not be stacked on the towel bar because they can fall to the floor and become contaminated with bacteria and used by residents. IPN also stated the toilet tissue rolls were opened and dirty and if the residents use them, they are at risks for UTIs by using contaminated toilet tissue. A review of the facility's P&P titled, Infection Controls, revised 1/1/2012, indicated a policy objective of maintaining a safe, sanitary, and comfortable environment for staff, residents, visitors, and the general public. 055548 Page 31 of 31