Health inspection·October 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for one of two sample residents (Resident 1) when transferring from chair/bed to chair transfer. This deficient practice has the potential to cause injury and/or fall to Resident 1. Findings: During a review of Resident 1's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of repeated falls, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and spondylolisthesis (one of the bones in the spine, called the vertebra, slips forward). During a review of Resident 1's fall risk assessment, dated 4/8/2024, indicated resident is at high risk for falls. During a review of Resident 1's History and Physical (H&P), dated 4/9/2024, indicated the resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/20/2024, indicated resident is independent in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills with daily decision making. MDS also indicated resident required partial/moderate assistance (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with tub/shower transfer, toileting hygiene and shower/bathe self. MDS indicated, Resident1 required supervision/touching assistance with upper body dressing, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, walk 10 feet and walk 50 feet with two turns. During a review of Resident 1's Care Plan with focus Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), revised 4/22/2024, indicated resident is at risk for further decline and at risk for fluctuating ADLs due to mood/behavior. Care Plan also indicated to monitor for complication from impaired ADLs functioning. Page 1 of 6 055548 055548 10/15/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Care Plan with focus on falls, dated 4/22/2024, indicated interventions to assist the resident with ADLs. During a review of Resident 1's Care Plan with focus on Physical Therapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery), dated 9/25/2024, indicated the resident presents tendency to lose balance during transfers. During a review of Resident 1's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/8/2024, indicated resident had a sharp pain of 8/10 (10 as the most painful) to her right elbow and forearm and have difficulty moving her arm. SBAR also indicated resident had a new physician order for an X-ray (imaging creates pictures of the inside of resident's body). During a review of Resident 1's X-ray result, dated 10/8/2024 at 10:06 AM, indicated resident has a possible acute impacted radial neck fracture (elbow fracture [break in the bone, either partial or complete]). During a review of Resident 1's Magnetic Resonance Imaging (MRI - is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body.), dated 10/10/2024 at 12:45 PM, indicated resident has partial tearing of the distal biceps (a fibrous tissue that attaches the biceps, the muscle in the front part of the upper arm, to the radius bone in the lower arm, just below the elbow) and brachialis (muscle in the upper arm that flexes the elbow) tendons (a cord of strong, flexible tissue, similar to a rope). During an interview on 10/15/2024 at 10:50 AM, Resident 1 stated her injury is caused by her transferring from bed to chair and form chair to bed on her own (unable to recall when). During an interview on 10/15/2024 at 11:23 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 transfers from bed to chair and from chair to bed on her own. During an interview on 10/15/2024 at 12:45 PM, Resident 1 stated 8 out of 10 times she would transfer from bed to chair or chair to bed by herself. During an interview on 10/15/2024 at 12:50 PM, the Director of Nursing (DON) stated the purpose of the MDS is to assess the resident and make sure they have the right plan of care. The DON stated it is important to provide the care the reisdent needed such as providing supervisions/ touching assistance during transfer from sitting to standing up/ transfer from bed to chair/ chair to bed. During an interview on 10/15/2024 at 3:30 PM, the DON stated there is no care plan that addressed the resident's behavior of getting up on her own without calling for assistance. During a review of the facility's Policy and Procedure (P&P) titled, Fall Management Program, revised 11/7/2016, indicated to provide a safe environment that minimizes complications associated with falls. During a review of the facility's P&P titled Resident Safety, revised 4/15/2021, indicated during the quarterly care plan review, when there is a change in condition or if an accident or incident occurs that involves the Resident's safety, the resident's safety risk will be reevaluated. The P&P 055548 Page 2 of 6 055548 10/15/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0689 also indicated a resident-centered care plan will be developed to mitigate safety risk factors. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning, revised 8/24/2023, indicated care plan documents the interim approaches for meeting the resident's immediate needs, it must also reflect changes to approaches, as necessary and resulting from significant changes in condition or needs. Residents Affected - Few 055548 Page 3 of 6 055548 10/15/2024 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 services for 2 (two) of 3 (three) sampled residents (Resident 1 and 3) by: Residents Affected - Few 1. Failing to administer oxygen according to physician's order to Resident 1 when resident's oxygen saturation level (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage; normal range 95%-100%) was below 92%. 2. Failing to ensure the oxygen via nasal cannula (NC, a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered according to physician's order for Resident 3. This deficient practice placed Resident 1 and 3 at risk for experiencing respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and lob blood oxygen level) that can lead into serious illness and/ or death. Findings: 1. During a review of Resident 1's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dependence on supplemental oxygen, acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty breathing). During a review of Resident 1's History and Physical (H&P), dated 4/9/2024, indicated the resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/20/2024, indicated resident is independent in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. MDS also indicated resident required partial/moderate assistance (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with tub/shower transfer, toileting hygiene and shower/bathe self. Resident required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with upper body dressing, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, walk 10 feet and walk 50 feet with two turns. MDS indicated resident is on oxygen therapy. During a review of Resident 1's Care Plan with focus oxygen therapy, dated 4/22/2024, indicated give medications as ordered by physician. Care Plan also indicated Resident 1 is on supplemental continuous oxygen therapy for COPD. 055548 Page 4 of 6 055548 10/15/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Physician Order, dated 5/20/2024, indicated oxygen at 2 liters (l - unit of measure)/minute (LPM) via NC to keep O2 Sat at or above 92% every shift. The order did not indicate if the O2 should be given continuous or as needed. During an observation in the Resident 1's room on 10/15/2024 at 10:50 AM, Resident 1 was observed with no oxygen/ NC on. During an interview on 10/15/2024 at 12:50 PM, Director of Nursing (DON) stated Resident 1's Physician Order for oxygen should be continuous. During an observation in Resident 1's room and interview on 10/15/2024 at 1:15 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 1 was observed with no oxygen/ NC on. Resident 1's O2 sat was 90-91% when LVN 1 checked. Resident 1 also stated she would get shortness of breath (SOB - difficult or labored breathing). During an interview on 10/15/2024 at 1:52 PM, LVN 1 stated she did not know if Resident 1's order for oxygen is continuous or as needed. LVN 1 also stated she did not know when or how often she should check the O2 Sat of Resident 1. During a concurrent interview and record review with the DON on 10/15/2024 at 3:30 PM, Resident 1's September 2024 medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and October 2024 MAR was reviewed. The DON stated the MARs does not indicate that continuous supplemental oxygen was given per physician's order. 2. During a review of Resident 3's admission Record indicated resident was admitted on [DATE] with the following diagnoses of acute respiratory failure with hypoxia, pulmonary hypertension (makes the heart work harder than normal to pump blood into the lungs), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 3's H&P, dated 7/19/2024, indicated resident has the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], indicated resident is severely impaired in cognitive skills for daily decision making. The MDS also indicated resident required partial/moderate assistance with oral hygiene, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene and shower/bathe self. MDS indicated resident is on oxygen therapy. During a review of Resident 3's Care Plan with focus on respiratory, dated 7/30/2024, indicated Resident 3 is at risk for SOB and respiratory distress. The care plan also indicated medications as ordered. During a review of Resident 3's Care Plan with focus on Oxygen Therapy, dated 7/30/2024, indicated give medications as ordered by physician. During a review of Resident 3's Physician's Order, dated 10/15/2024 at 9:54 AM, indicated O2 at 3 to 5LPM via NC to keep O2 Sat at or above 92% as needed for SOB. 055548 Page 5 of 6 055548 10/15/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation in Resident 3's room and interview on 10/15/2024 at 1:35 PM, LVN 3 stated Resident 3's oxygen was set at 2.5 LPM and the oxygen tubing's are not labeled with the date and time it was first used. LVN 3 also stated the oxygen tubing should have been labeled with date and time it was first used but was not labeled. During an interview on 10/15/2024 at 1:58 PM, LVN 3 stated Resident 3's O2 should have been set between 3 to 5 LPM and not on 2.5 LPM. LVN 3 also stated Resident 3's order for O2 was to set it at 3 to 5 LPM and should have been followed. During an interview on 10/15/2024 at 3:30 PM, the DON stated the oxygen tubing's should have been labeled with date and time it was first used so the licenses nurses know when to replace it with a new tubing. The DON also stated the physician's order should be followed especially for oxygen therapy. During a record review of the facility's Policy and Procedure (P&P) titled, Oxygen Therapy, revised November 2017, indicated administer oxygen per physician orders and obtain O2 Sat levels as ordered by physician. If O2 Sat falls below the level identified by the physician, the physician will be notified immediately. P&P also indicated the tubing should be changed no more than every 7 days and labeled with the date of change. 055548 Page 6 of 6