Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to report an injury of unknown origin (the source
of the injury was not witnessed by any person and the source of the injury could not be explained by the
resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the
number of injuries over time) to California Department of Public Health (CDPH), local law enforcement, and
Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2)
hours from when the resident was noted to have dark purple discoloration on the right eye for one (1) of 2
sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse
Investigation and Reporting. This deficient practice had the potential to place Resident 1 at risk for further
abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting
physical harm, pain or mental anguish) and resulted in a delay in the investigation. Findings: During a
review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the
facility on [DATE] with the diagnoses including but not limited to dependence on respirator (ventilator, a
life-support machine that mechanically assists or replaces spontaneous breathing by moving breathable air
into and out of the lungs) status, nontraumatic intracerebral hemorrhage (a sudden type of stroke caused
by bleeding within the brain tissue) in cerebellum (structure located at the back of the brain), and encounter
for attention to tracheostomy (a surgical procedure to create an opening through the neck into the windpipe
to provide direct airway, bypassing the mouth and nose). During a review of Resident 1's Minimum Data Set
(MDS, a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 1's cognitive (mental
action or process of acquiring knowledge and understanding) skills for daily decision making were severely
impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none
of the effort to complete the activity) for toileting hygiene, personal hygiene, and rolling left and right. During
a review of Resident 1's Change of Condition (COC, tool used by health care professionals when
communicating about critical changes in a resident's status), dated 1/27/2026, the COC indicated Resident
1 was noted with discoloration on right eye. The COC also indicated, upon further assessment, Resident 1
was noted with dark purple discoloration on right eye, skin is intact but discolored. During an observation on
2/4/2026 at 12:09 PM in Resident 1's room, Resident 1 was lying in bed with greenish to yellowish
discoloration on the right corner of the resident's eye with a small red lined mark in the center of the
discoloration. During a concurrent observation and interview on 2/4/2026 at 12:10 PM in Resident 1's room
with the Director of Nursing (DON), the DON stated there is a little bit of bruising that looks grayish in color
and almost like a linear red scratch on Resident 1's right eye. During an interview on 2/4/2026 at 12:18 PM
with Treatment Nurse (TN), TN stated he first saw Resident 1's discoloration on the right eye on 1/27/2026
(8 days ago). TN stated on 1/27/2026 around 3 PM, RN Supervisor (RNS) asked him if he
(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 3
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
02/04/2026
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(TN) had noticed Resident 1's bruise. TN stated he went to look at Resident 1's eye after RNS informed him
and saw Resident 1 had a light purple discoloration on Resident 1's right eye. TN stated staff did not know
the cause of Resident 1's right eye discoloration. TN stated he did not measure the discoloration of
Resident 1's right eye and only reported Resident 1's discoloration on the right eye to the physician and
responsible party. During a concurrent interview and record review on 2/4/2026 at 12:31 PM with the DON,
Resident 1's COC dated 1/27/2026 was reviewed. The DON stated on 1/27/2026 the COC indicated
Resident 1 had right eye discoloration. The DON stated since Resident 1 had a bruise on the resident's
right eye, the most important thing to determine is the cause of the bruise to rule out potential for abuse.
The DON stated the facility needed to investigate to determine if there were any incidents with a particular
staff and to see how staff handled Resident 1. The DON also stated she was unaware of how Resident 1
obtained the discoloration to the resident's right eye. The DON stated since the facility staff did not know
how Resident 1 got the dark purple discoloration on the resident's right eye, this was an injury of unknown
origin and should have been treated as a potential abuse case. The DON stated, since it is a potential for
abuse case it should have been reported within the two- hour time frame from when the injury was
observed or noted on 1/27/2026. During an interview on 2/4/2026 at 12:51 PM with Certified Nursing
Assistant 1 (CNA 1), CNA 1 stated on 1/28/2026 she went into Resident 1's room to turn on the light and
gasped when she saw Resident 1's right eyes with discoloration. CNA 1 stated Resident 1, she has a black
eye. CNA 1 stated Resident 1's eye was purple in color noted underneath the resident's right eye and to the
right side of the eye. During an interview on 2/4/2026 at 1:21 PM with RNS, RNS stated on 1/27/2026
Resident 1 had redness under the resident's eyes where the eye bags were located. RNS stated she was
not sure what happened to cause Resident 1's eyes to become red. RNS stated TN did not inform her of
TN's assessment of dark purple discoloration to the eye. RNS stated TN should have informed RNS so that
they could report to the Administrator (ADM) right away since they were suspecting abuse and it should
have been reported to CDPH, police and ombudsman. During a concurrent interview and record review on
2/4/2026 at 2:01 PM with the ADM, the facility's policy and procedure (P&P) titled Investigating Resident
Injuries dated 04/2021 was reviewed. ADM stated according to the P&P, if the nursing and medical
assessment determines an injury of unknown source the investigation will follow the protocols set forth in
the facility's established abuse reporting and investigation guidelines. During an interview on 2/4/2026 at
2:15 PM with the Licensed Vocational Nurse (LVN), LVN stated on 1/27/2026 she noticed Resident 1 had
some discoloration on the right side of the eye. LVN stated she did not know what happened to Resident 1's
eye and she did not report it to CDPH, ombudsman or police. During a concurrent interview and record
review on 2/4/2026 at 4:08 PM with the DON, the facility's P&Ps titled Abuse Investigation and Reporting
dated 12/2018 was reviewed. The P&P indicated all reports of resident abuse and/or injuries of unknown
source ( abuse') shall be promptly reported to local, state and federal agencies (as defined by current
regulations) and thoroughly investigated by facility management. The P&P also indicated the Administrator
or designated representative will notify law enforcement immediately by telephone of an initial report of
alleged abuse. The DON stated she was not informed of Resident 1's injury of unknown origin and should
have been informed of Resident 1's right eye dark purple discoloration noted on 1/27/2026. The DON
stated promptly in their P&P means within the two- hour time frame from the suspected abuse and
Resident 1's discoloration on the right eye was not reported to CDPH, police, and Ombudsman within two
hours. The DON stated the importance of reporting was to start with the investigations of abuse, to find the
root cause, and to rule out abuse. During an interview on 2/4/2026 at 4:45 PM with the ADM, the ADM
stated staff did not report Resident 1's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056316
If continuation sheet
Page 2 of 3
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
02/04/2026
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)
F 0609
injury of unknown origin noted on 1/27/2026 and should have informed the ADM of Resident 1's right eye
dark purple discoloration.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056316
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the February 4, 2026 survey of CAMELLIA GARDENS CARE CENTER?
This was a inspection survey of CAMELLIA GARDENS CARE CENTER on February 4, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CAMELLIA GARDENS CARE CENTER on February 4, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.