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 Page 1 of 2 056316 056316 02/27/2026 Camellia Gardens Care Center 1920 N. Fair Oaks Avenue Pasadena, CA 91103

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 and there should be a Stop and Watch form.During a concurrent interview and record review on 2/27/2026 at 1:30PM with Director of Nursing (DON), the facility's Policy and Procedure titled Acute Condition Changes, revised 3/1028, was reviewed. DON stated per policy, if a resident has congestion, lots of phlegm, difficulty swallowing and diarrhea, that would be an acute condition change because the resident cannot breathe properly, it can affect her eating and cause dehydration. DON also stated the CNAs need to fill out the Stop and Watch form.During a review of the facility's P&P titled Acute Condition Changes, revised 3/1028, the P&P indicated nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. 056316 Page 2 of 2