Health inspection·August 13, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for two (2) of three (3) sampled residents (Resident 2 and 3). Residents Affected - Some This had the potential to result in a delay in care for Resident 2 and 3 and not receive the necessary care and services which can lead to illness or serious injury. Findings: 1. During a review of Resident 2's admission record indicated the facility admitted Resident 2 on 8/2/24 with diagnosis which include fall on the same level, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (when the pressure in your blood vessels is too high). During a review of Resident 2's Minimum Data Set (MDS, standardized care and screening tool), dated 07/28/24, indicated Resident 2 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 2 was setup or cleaning assistance (helper set up of clean up; resident completes activity) on eating, oral hygiene and supervision or touching assistance (helper provides verbal cues and or touching steadying and/or contact guard assistance as resident completes activity) on toilet hygiene, upper and lower body dressing, personal hygiene. During a review of Resident 2's Morse Fall Assessment (a rapid and simple method of assessing a patient's likelihood of falling) dated 7/28/2024 score was 75 which means Resident 2 was high risk for fall. During a review of Resident 2's care plan date initiated 10/12/2020 revised date 8/5/2024 indicated Focus: Fall risk - Resident 1 at risk for fall related to decrease strength, endurance, cognitive impairment. The care plan also indicated call light within reach all the time. During concurrent observation in Resident 2's room and on 8/13/2024 at 6:40 AM with License Vocational Nurse (LVN 2), LVN 2 stated Resident 2 sleeping on the bed, call light on the floor and was out of Resident 2's reach. LVN2 also stated call light should be within resident's reach all the time specially for fall risk residents. 2. During a review of Resident 3's admission record indicated the facility admitted Resident 3 on 10/26/2023 with diagnosis which include quadriplegia (a condition where all four limbs experience Page 1 of 6 056080 056080 08/13/2024 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0558 paralysis), respiratory failure, hyperlipidemia (an excess of lipids or fats in your blood). Level of Harm - Minimal harm or potential for actual harm During a review of 3's MDS, dated [DATE], indicated Resident 3 was severely impaired in cognition. The MDS indicated Resident 3 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, upper body dressing and personal hygiene. Residents Affected - Some During a review of Resident 3's care plan date initiated 10/26/2023 indicated Focus: Fall risk - Resident 3 at risk for fall related to poor safety awareness, decrease strength /endurance/ unsteady gait/ visual deficits, medications, and cognitive impairment. The care plan interventions indicated keep call light in reach at all times. During a review of Resident 3's Fall Assessment (checks your risk of falling) dated 1/6/2024 score was 17 which means Resident 3 was at risk for fall. During concurrent observation in Resident 3's room and interview on 8/13/2024 at 6:21 AM with LVN 1, LVN 1 stated Resident 3's call light was wrapped around the side rails facing down towards the floor. LVN 1 also stated the call light should be within Resident 3's reach, so the resident can call for help specially for fall risk residents. During interview on 8/13/2024 at 1:42 PM with the Assist Director of Nursing (ADON), ADON stated call lights should be within residents' reach all the time, and it should be readily or easily accessible for the residents. During a review of facility's P&P titled Care Plan Comprehensive Person Centered revised date 12/2016 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person -centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care. During a review of facility's Policy and Procedure(P&P) titled Call lights revised date 3/2018 indicated purpose to assure residents received prompt assistance. All staff knows how to place the call light for a resident and how to use the call light system. The P&P also indicated nursing and care duties: Included ensure that the call light is within the resident's reach when in his/her room or when on the toilet. 056080 Page 2 of 6 056080 08/13/2024 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

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 ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of three (3) sampled residents (Resident 1) was switched on. Residents Affected - Few This deficient practice had the potential for Resident 1's pressure ulcer to worsen and for the resident to develop new pressure injury. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/22/2023. Resident 1's diagnoses lack of coordination, muscle weakness, and dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 1's Order Summary Report order date 2/23/2024 indicated: Treatment: LAL mattress for pressure distribution and skin integrity management every shift. During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 5/20/2024 indicated Resident 1 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort) on toileting, shower /bath self, personal hygiene. The MDS also indicated Resident 1 has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS indicated Resident 1 was at risk for developing pressure ulcer/injuries and skin and ulcer injury treatment included pressure reducing device for bed. During a review of Resident 1's History and Physical (H&P) dated 8/25/2024 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Skin Assessment (Pressure Injury) dated 8/6/2024 at 2:45 PM indicated special equipment preventative measures included LAL mattress. The form also indicated, Resident 1 have pressure ulcer stage 2 (some of the outer surface of the skin [the epidermis] or the deeper layer of skin [the dermis] is damaged, leading to skin loss. The ulcer looks like an open wound or a blister), site sacrococcyx (the tailbone) measuring length 3.5 centimeter (cm, a unit of measurement of length [distance lengthwise]), width (wideness) 0.5 cm, depth (distance downward) 0.1 cm. During concurrent observation and interview on 8/13/2024 at 6:11 AM with License Vocational Nurse (LVN 1), LVN 1 stated Resident 1 was sleeping on bed, the LAL mattress was turned off and it was supposed to be turned on all the time. LVN 1 further stated the plug ( a part at the end of an electric cord that has two or three metal pins that connect the cord to a source of electricity) was disconnected from the electrical source. During interview on 8/13/2024 at 6:15 AM with the treatment nurse (TN), TN stated Resident 1's LAL mattress was supposed to be turned on all the time. LAL mattress was for support and pressure distribution, and it helps with wound healing. TN also stated, if it was not turned on, Resident 1's stage 2 pressure ulcer can worsen, or the resident can develop new pressure ulcers. During concurrent interview and record review on 8/13/2024 at 1:42 PM with the Assistant Director 056080 Page 3 of 6 056080 08/13/2024 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0686 Level of Harm - Minimal harm or potential for actual harm of Nursing (ADON), ADON stated they do not have specific policy and procedure (P&P) regarding LAL mattress plugged in or switched on all the time. ADON also stated all equipment were supposed to be in good functioning condition like LAL were supposed to be plug in properly, if not plug in properly it will not do its job or defeats the purpose of the LAL mattress to prevent pressure ulcers. Residents Affected - Few 056080 Page 4 of 6 056080 08/13/2024 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for one (2) of four (4) sampled residents (Resident 3 and 4) by not ensuring that Resident 3 and 4's trash can was not overflowing, and there were no clutters on the floor. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for injury. Findings: 1. During a review of Resident 3's admission record indicated the facility admitted Resident 3 on 10/26/2023 with diagnosis which include quadriplegia (a condition where all four limbs experience paralysis), respiratory failure, and hyperlipidemia (an excess of lipids or fats in your blood). During a review of Resident 3's Fall Assessment (checks your risk of falling) dated 1/6/2024 score was 17 which means Resident 3 was at risk for fall. During a review of Resident 3's Minimum Data Set (MDS, standardized care and screening tool), dated 6/21/2024, indicated Resident 3 was severely impaired in cognition (processes of thinking and reasoning). The MDS indicated Resident 3 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, upper body dressing and personal hygiene. 2. During a review of Resident 4's admission record indicated the facility admitted Resident 4 on 8/6/2024 with diagnosis which include asthma (is a condition in which your airways narrow and swell and may produce extra mucus), sepsis (a serious condition in which the body responds improperly to an infection), and overactive bladder (a condition in which the bladder squeezes urine out at the wrong time). During a review of Resident 4's MDS, dated [DATE], indicated Resident 4 cognition was intact. The MDS indicated Resident 4 was dependent (helper does all the effort to complete the activity or, the assistance of 2 or more helper required for the resident to complete the activity) on oral hygiene, toileting hygiene, shower / bathe self, upper body dressing and personal hygiene. During a review of Resident 4's Morse Fall Assessment (Fall Risk Assessment tool that predicts the likelihood that a patient will fall) dated 8/6/2024 score was 45 which means Resident 4 was at risk for fall. During a review of Resident 4's care plan date initiated 8/6/2024 indicated Focus Resident 4 was at risk for fall related to Morse score 45 and interventions included maintain clear pathway, free of obstacles/clutters. During concurrent observation and interview on 8/13/2024 at 6:19 AM outside Resident 3 and 4's room with the License Vocational (LVN 1), LVN 1 stated room [ROOM NUMBER]'s trashcan was overflowing with used personal protective equipment (PPE). LVN 1 also stated there was black plastic bag on the floor, used tissue papers, used alcohol pads on the floor. LVN 1 stated there was clutters on the floor 056080 Page 5 of 6 056080 08/13/2024 The Bellefontaine Healthcare Center 150 Bellefontaine St Pasadena, CA 91105

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and the floor should be free of clutters. LVN 1 also stated, trashcans need to be emptied all the time to avoid content overflow because of infection control issue. During interview on 8/13/2024 at 1:42PM with the Assistant Director of Nursing (ADON), ADON stated all rooms are supposed to be clutter free, and it is important for the safety of the residents and staff. ADON also stated, clutters can cause fall or accidents to residents and staff. ADON added, trashcans were not supposed to be overflowing for sanitary purposes. During a review of facility's Policy and Procedure (P&P) titled Homelike Environment date revised 5/20217 indicated Residents are provided with a safe, clean, comfortable, and homelike environment and encourage to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment. 056080 Page 6 of 6