Health inspection·February 27, 2026

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 interview and record review, Certified Nursing Assistants (CNAs) failed to fill out the stop and watch form on 2/10/2026 and 2/11/2026 for one (1) of two (2) sampled residents (Resident 1), when Resident 1 was coughing, congested and having difficulty swallowing.This deficient practice had the potential for Resident 1 experiencing respiratory distress which can result in hospitalization and/or death.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory distress (a serious condition characterized by rapid/labored breathing, shortness of breath, gasping, wheezing, and skin/chest retractions), and dysphasia (difficulty swallowing) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/2/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making, The MDS also indicated the resident 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 eating, oral hygiene, upper body dressing and personal hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.During an interview on 2/26/2026 at 4:20 PM, Resident 1's Responsible Party (RP) stated Resident 1 was hot to touch on 2/10/2026.During an interview on 2/27/2026 at 10:17 AM, CNA 1 stated on 2/10/2026 at 7:15am, CNA 1 noticed Resident 1 was congested with a lot of phlegm and was having a hard time swallowing her food.During an interview on 2/27/2026 at 11:07AM, CNA 2 stated on 2/10/2026 during 3pm -11pm shift (unable to tell the time), Resident 1 was hot to touch and had diarrhea.During an interview on 2/27/2026 at 11:31AM, Licensed Vocational Nurse 1 (LVN 1) stated when a CNA notices a change of condition (COC -a deviation in a person's physical, mental, or functional health status compared to their baseline) on the resident, the CNAs must fill out a Stop and Watch Form describing what they see in the resident and report it to the licensed nurse. LVN 1 also stated when the CNA gives the form to the licensed nurse, the license nurse must sign and acknowledge it.During an interview on 2/27/2026 at 12:30PM, CNA 3 stated on 2/11/2026 at 7am-3pm shift, CNA 3 observed Resident 1 was coughing and was congested.During an interview on 2/27/2026 at 1PM with Director of Staff Development (DSD), the Stop and Watch binder, was reviewed. DSD stated when a resident experiences a change of condition, the CNAs would have to fill out a Stop and Watch form, give one copy to the license nurse and give one copy to the DSD. DSD also stated the nurses should acknowledge the Stop and Watch form that is given to them. DSD stated even if the resident is discharged , the Stop and Watch form should still be in the binder. DSD also stated there was no Stop and Watch form for Residents Affected - Few (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 2 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 02/27/2026 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)