Health inspection·May 13, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide care consistent with the professional standards of practice (the set of guidelines, principles, and expectations that govern the conduct and performance of nursing professionals) to prevent worsening of the pressure ulcer (PU, a localized area of skin damage caused by prolonged pressure on the skin) for one of two sampled residents (Resident 1) by failing to: Residents Affected - Few 1. Assess and document detailed observations in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) of Resident 1's change with skin condition and/ or wound condition on the resident's left trochanter area (a small, conical projection located on the medial side of the upper femur, specifically at the junction of the femoral neck and shaft) on 4/10/2025, 4/17/2025 and 4/24/2025. 2. Resident 1's change of skin condition and/ or wound condition on the resident's sacral area (lower back region specifically triangular- shaped bone called the sacrum) on 4/24/2025. These failures placed Resident 1 at risk for worsening of the PUthat can lead to serious illness and/ or hospitalization. Findings: A review of Resident 1's admission Record, the admission Record indicated Resident is a 84- years- oldfemale who was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain, essential hypertension (high blood pressure that doesn't have a known underlying cause), and other pulmonary embolism without acute core pulmonale (pulmonary embolism, blood clot, that is not severe enough to immediately cause damage to the right side of the heart). During a review of Resident 1's History and Physical (H&P), dated 2/16/2025, the H&P indicated Resident 1 has no capacity to understand and make decisions. During a review of Resident 1's MDS (a resident assessment tool) dated 2/11/2025, indicated Resident 1 was independent, (helper does more than half the effort) with roll on the left and right, sit to lying, and personal hygiene. The MDS also indicated Resident 1 was assessed to be dependent (helper does all of the effort to complete the activity) on sit to stand, chair/bed-to-chair transfer and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056316 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056316 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camellia Gardens Care Center 1920 N. Fair Oaks Avenue Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)