Health inspection·October 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside of the body) was covered with a dignity bag (a bag that covers and holds a foley catheter drainage bag to keep it out of sight) for one of 18 residents (Resident 225). This deficient practice had the potential to result in Resident 225 having decreased feelings of self-worth and/or self-esteem. Findings: During a review of Resident 225's admission Record, the admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), muscle wasting (deterioration of muscle tissue) and atrophy (deterioration of a part of the body) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system). During a review of Resident 225's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/15/2024, the MDS indicated Resident 225 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. Resident 225 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral and personal hygiene, and dependent (helper does all effort needed to complete activity) with toileting. During a review of Resident 225's Initial History & Physical (H&P), dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During a review of Resident 225's Order Summary Report, dated 10/17/2024, the Order Summary Report indicated foley catheter 18 French (F- a measurement of the foley catheter's diameter) for benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty). During on observation on 10/15/2024 at 10:12 AM at Resident 225's bedside, Resident 225's urinary catheter bag was observed uncovered without a dignity bag. During an interview on 10/17/2024 at 9:07 AM with Treatment Nurse 1 (TN1), TN1 stated facility Page 1 of 45 555119 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0550 policy is to have a dignity bag on every foley catheter bag. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/17/2024 at 10:11 AM with Director of Nursing (DON), the DON stated the dignity bags are to be used according to the facility policy and are important because they keep the dignity and privacy for Resident 225. The DON stated the dignity bags are a way to maintain Resident 225's self-esteem in a positive way and not having it could cause his self esteem to be low if he or other residents were to see the urinary catheter bag without a dignity bag to cover. Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated each resident will be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, residents are always treated with dignity and respect. The P&P also stated demeaning practices and standards of care that compromise dignity are prohibited and staff are expected to promote dignity and assist residents with keeping the urinary catheter bag covered. 555119 Page 2 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

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 accommodate the needs of one (1) of three (3) sampled residents (Resident 63) by failing to provide a pad call light (a device for residents who have difficulty using a call light cord). Residents Affected - Few This failure had the potential for Resident 63's needs to not be met, resulting in a lowered quality of care and quality of life. Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), pain in right shoulder, weakness (lack of strength), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 63's Minimum Data Set (MDS- a federally mandated assessment tool), dated 9/2/2024, the MDS indicated Resident with clear speech, usually having the ability to express her ideas and wants when prompted or given time and moderately impaired cognitive skills (ability to understand and make decisions) with daily decision making. The MDS indicated Resident 63 had a functional limitation in range of motion (ROM- the distance and direction a joint or muscle can move) that interfered with daily functions to both left and right upper extremities (shoulder, elbow, wrist, hand). The MDS also indicated Resident 63 dependent (helper does all the effort needed to complete the activity) with toileting, bathing, upper and lower body dressing, personal hygiene and rolling left and right and substantial/maximal assistance (helper does more than half the effort needed to complete the activity by lifting, holding, or supporting the trunk or limbs) with eating (the ability to use the utensils to bring food/liquids to the mouth and swallow) and oral hygiene (the ability to use items to clean teeth). During a review of Resident 63's Initial History & Physical (H&P), dated 4/21/2024, the H&P indicated Resident 63 has deformity (condition when a part of the body is not developed in the normal way or with the normal shape) to the extremities. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:45 AM with Resident 63, Resident 63 was observed with a call cord (a string that allows residents in healthcare settings to remotely call for help from a nurse or other medical staff) attached to a silver clip, clipped to the bedsheet on the left side of Resident 63's head. Resident 63 stated she was not aware of a cord she could use to call for assistance and stated she normally will wait for staff to come into her room to ask for assistance. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:55 AM with Resident 63, Resident 63 was informed of the cord on the left side of her head and attempted to reach and pull the call cord but was unable to see and reach it. Resident 63 stated she cannot see the clip and is unable to reach it. Resident 63 stated, I'd love to be able to have a button to push for when I need help just to make sure I get to the bathroom and back safely. 555119 Page 3 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/15/204 9:08 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 63 has restricted movement in her arms and Resident 63 does not use the call cord for assistance but will verbally call for assistance. CNA 1 stated Resident 63 should have a call button for the contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of her hands, not her current call cord. Residents Affected - Few During an interview on 10/17/2024 at 3:52 PM with CNA 2, CNA 2 stated Resident 63 has limited mobility in both her hands, and when Resident 63 needs assistance from staff she will yell or let staff know during rounding. CNA 2 also stated he has not seen Resident 63 use her call cord due to the limitation of her hand movement and the pulling, I believe there is not enough energy in her hands to pull it. During an interview on 10/18/2024 at 9:16 AM with Registered Nurse 3 (RN3), RN 3 stated Resident 63 has limitation with her upper extremities due to her left and right-hand contractures in her fingers. RN 3 stated Resident 63 cannot use the call cord [due to her hand contractures] so staff round every two hours to check if any assistance was needed. RN 3 stated if resident needs assistance between the rounds or has an emergency, she will yell for assistance. During a concurrent observation in Resident 63's room and interview on 10/18/2024 at 9:22 AM with RN 3, Resident 63 was observed trying to pull the call cord to see if accessible with Resident 63's contractures. Resident 63 was observed unable to grasp the call cord in her hand. Resident 63 stated I guess I can't get to it. RN 3 stated Resident 63 was unable to use her call cord. RN 3 stated if Resident 63 needed help at this time It would be impossible to call for help using her string [call cord]. RN 3 stated Resident 63 has not been evaluated for a different type of call light device like the pad call light (a device for residents who have difficulty using a call light cord) and could benefit from the padded call light. RN 3 also stated it was important for Resident 63 to have a call light that accommodates her limitations to ensure her needs were met including during emergencies. RN 3 stated if Resident 63 does not have an accessible call light, she may fall and/or be neglected. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P also indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. During a review of the undated P&P titled,Call Lights, indicated the purpose is to assure that residents receive prompt service. 555119 Page 4 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) interventions for one (1) of 18 residents (Resident 3), were applicable and resident-centered. This failure had the potential for Resident 3 to receive inappropriate and/or inadequate services which could harm the resident. Findings: During a review of Resident 3's admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD longstanding disease of the kidneys leading to renal failure), retention of urine (inability to completely empty the bladder), dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and gross hematuria (a condition where blood is visibly present in the urine). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool), dated 7/19/2024, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 3 was dependent (helper does all effort needed to complete activity) with toileting, bathing, and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene. During a concurrent interview and review on 10/17/2024 at 8:38 AM with Registered Nurse 1 (RN1), Resident 3's Indwelling Foley Catheter, care plan, dated 9/13/2024 was reviewed. The care plan indicated to provide adequate fluid via percutaneous endoscopic gastrostomy tube (PEG- a feeding tube that is surgically inserted through the abdominal wall and into the stomach to allow access for food, fluids, and medications) as ordered. RN 1 stated this intervention was not appropriate because Resident 3 does not have a PEG tube and eats foods and liquids by mouth only. RN 1 stated this intervention should have not been included in the care plan. During a concurrent interview and review on 10/17/2024 at 9:43 AM with RN 1, Resident 3's Hematuria on Foley Catheter, care plan, dated 9/1/2024 and Order Summary Report, dated 10/17/2024, were reviewed. The care plan indicated cranberry as ordered for urinary tract infection (UTI) prophylaxis. Registered Nurse 1 (RN 1) stated the summary report failed to indicate any order for cranberry. RN 1 stated Resident 3 has never had an order for cranberry and the intervention was not implemented. RN 1 stated a resident's care plan needs to be applicable to the resident's current needs. RN 1 stated it was important to make sure the care plan was applicable to the resident to ensure the interventions will be effective or beneficial to the resident. A review of the facility's Policy and Procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated: 1. 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 555119 Page 5 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0656 each resident. Level of Harm - Minimal harm or potential for actual harm 2. Care plan interventions are chosen only after data gathering. proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Residents Affected - Few 555119 Page 6 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 licensed nursing staff failed to meet professional standards of quality for assessing one (1) of five sampled residents (Resident 72) by failing to ensure Resident 72 was assessed and evaluated by Medical Doctor (MD) before adding a new diagnosis of schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others ) according to accepted standards of clinical practice. Residents Affected - Few This deficient practice had the potential to result in provision of unnecessary care for Resident 72. Findings: During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). During a review of Resident 72's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 72 did not have the capacity to understand and make decisions. During a review of Resident 72's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/24/2023, the MDS indicated Resident 72 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 72 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, and toilet transfer. Resident 72 required supervision or touching assistance with eating. Resident 72 did not have a diagnosis of schizophrenia. During a review of Resident 72's Order Summary Report, dated 2/29/2024, the Order Summary Report indicated a physician order, with a start date of 10/23/2023 for Seroquel Oral Tablet give 25 milligrams (mgunit of measurement) by mouth (po) two times a day (bid) for dementia with behavioral disturbances manifested by (m/b) being aggressive towards other people which impedes own self health and performing activities of daily living (ADLs). During a review of Resident 72's Physician Order, dated 3/7/2024, the Physician's Order indicated an order to continue Seroquel oral tab (Quetiapine Fumarate) give 25 mg by mouth every (q) twelve hours for schizophrenia m/b being aggressive towards other people which impedes own self health and performing ADLs. During a review of Resident 72's Psychiatric Follow Up Note, signed by the Certified Nurse Practitioner 1 (CNP 1), dated, 3/7/2024, the Psychiatric Follow Up Note indicated that Resident 72's case was reviewed and discussed with Interdisciplinary Team (IDT- a group of healthcare professionals who work together to help residents receive the care they need). Resident 72 was presently stable without any new symptoms and no need for any medication adjustment at this time. Resident 72's Mental Status Examination on the Psychiatric Follow Up Note did not indicate any paranoid interactions, delusions (an unshakable belief in something untrue), or hallucinations (an experience in which you see, hear, feel, or smell something that does not exist). The Psychiatric Follow Up Note assessment 555119 Page 7 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0658 Level of Harm - Minimal harm or potential for actual harm indicated Resident 72's psychiatric condition was generally unchanged and Resident 72's weaknesses were impaired insight and judgment, inability to function in less structured setting, and significantly impaired coping skills. The Psychiatric Follow Up Note indicated Resident 72's diagnosis was Major Depressive Disorder (MDD, mental condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable. Residents Affected - Few During an observation of Resident 72 on 10/15/2024, at 9:08 AM, Resident 72 was sitting in bed eating breakfast. Resident 72 was quiet and folded tissues while chewing her food. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 10/17/2024, at 12 PM, Resident 72's admission Record and H&P were reviewed. RN 2 stated the admission Record and H&P did not indicate Resident had a diagnosis of schizophrenia. RN 2 stated CNP 1 added the schizophrenia diagnosis on 3/7/2024. RN 2 stated she did not know why CNP 1 diagnosed Resident 72 with schizophrenia. During an interview with CNP 1 on 10/17/2024, at 3:18 PM, the CNP 1 stated Resident 72 was diagnosed with Alzheimer's Disease on admission. The CNP 1 stated he diagnosed Resident 72 with schizophrenia on 3/7/2024 because Resident 72 had delusions and disorganized thoughts based on his evaluation and reports from the facility staff. The CNP 1 stated the delusions could be from Alzheimer's Disease but Resident 72 was misdiagnosed. The CNP 1 stated he did not document Resident 72's delusions on the Psychiatric Follow Up Note but he will write a late entry psychiatry note on 10/17/2024. During an observation of Resident 72 on 10/17/2024, Resident 72 was observed sitting on her wheelchair in the Activity Room. Resident 72 did not have any outbursts or demonstrated aggressive behavior towards other residents in the Activity Room. During an interview with the Director of Nursing (DON), on 10/18/2024, at 4:55 PM, the DON stated there was no documentation that CNP 1 spoke to Resident 72's family to confirm her mental history or schizophrenia diagnosis. The DON stated schizophrenia develops at a younger age. The DON stated there was no indication from Resident 72's admission records and H&P that Resident 72 was diagnosed with schizophrenia. The DON stated Resident 72's family never mentioned to facility staff that Resident 72 had schizophrenia. The DON stated CNP 1 should have assessed Resident 72 according to standard practice. During a review of the American Psychiatric Association's website, reviewed on 3/2024, titled, What is Schizophrenia, the website indicated the following: Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions (when a person has strong beliefs that are not true and may seem irrational to others), hallucinations (when a person sees, hears, smells, tastes or feels things that are not actually there), disorganized speech, trouble with thinking and lack of motivation. When the disease is active, it can be characterized by episodes in which the person is unable to distinguish between real and unreal experiences. As with any illness, duration and frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person becomes older. Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six 555119 Page 8 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few months for a diagnosis to be made. Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms may mimic schizophrenia. https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia 555119 Page 9 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 one (1) of 18 sampled residents (Resident 2) with limitations in mobility was provided assistance while eating as indicated in the care plan and facility policy. Residents Affected - Few This deficient practice had the potential for decline and not to maximize Resident 2's functional ability to perform activities of daily living (ADL), which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 2's nutritional needs which could lead to malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included reduced mobility and Parkinson's disease (a progressive disease of the nervous system marked by rhythmic movement in one or more parts of the body, inability of the muscles to relax normally, and slow, non-precise movement affecting middle aged and elderly people). During a review of Resident 2's Care Plan initiated on 9/26/2024, the Care Plan indicated a problem with Resident 2's right hand contracture and an approach plan to assist Resident 2 in attending to activities of daily living (ADL, basic tasks that people need to do to live independently). During a review of Resident 2's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Occupational Therapy Daily notes with a service date of 10/3/2024, the Occupational Therapy Daily notes indicated Resident 2 preferred assistance when presented with plate guard (a dining aid that fits around the rim of a plate to help prevent food from falling off and to make it easier to eat with one hand) option to maximize independence in self-feeding. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/4/2024, the MDS indicated Resident 2 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 2 required substantial assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene and required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS also indicated Resident 2 had a functional limitation in range of motion (ROMhow far one can move or stretch a part of the body, such as a joint or a muscle) that interfered with daily functions that involved impairment on 1 side of Resident 2's upper extremity (shoulder, elbow, wrist, and hand). During a dining observation on 10/15/2024 at 12:26 PM, Resident 2 was observed with contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) left hand and was only able to use his right hand while trying to get 555119 Page 10 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few food from his plate onto the spoon. Resident 2 was also observed spilling some of the food from his plate to his clothes and onto the floor. There were no staff providing assistance to Resident 2. During another dining observation on 10/17/2024 at 12:20 PM, Resident 2 was observed eating at the dining room area using his right hand to spoon food from his plate. A plate guard recommended by occupational therapy (OT) was not observed being used by Resident 2. Resident 2 was observed with food particles on the front of the residents' clothes. There were no staff providing assistance to Resident 2 while eating. During an interview on 10/17/2024 at 4:09 PM, Registered Nurse 3 (RN 3) stated if Resident 2 refused the plate guard, the staff should have assisted the resident with eating to ensure Resident 2's nutritional needs were met. During an interview on 10/18/2024 at 9:15 AM, Resident 2 stated he prefers to be assisted by staff as opposed to using the plate guard when eating. Resident 2 stated it made him upset when food gets all over his clothes and floor when eating and stated, I could do better than that. Resident 2 further stated that he does need help with eating. During an interview with the Director of Nursing (DON) on 10/18/2024 at 9:22 AM, the DON stated Resident 2 does tend to spill food and stated staff should be assisting the resident since Resident 2 only had 1 hand to use and to accommodate his needs and adequate food intake provided. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living, revised March 2018, indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also indicated that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining. During a review of the facility's P&P titled, Accommodation of Needs, revised March 2021, indicated that the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The policy also indicated that the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 555119 Page 11 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

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** Based on interview and record review the facility failed to provide the necessary treatment and services for one of one sampled residents (Resident 24) by failing to ensure Resident 24 received treatment for right heel (ankle) stage 3 (full-thickness loss of skin, dead and black tissue may be visible) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from 10/1/2024 to 10/7/2024 as indicated in Resident 24's wound treatment plan. Residents Affected - Few This deficiency had the potential for Resident 24's right heel stage 3 pressure injury to worsen and had the potential to develop an infection. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's History and Physical Examination (H&P), dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/4/2024, the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance (helper does more than half the effort) with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated an order with a start date of 10/1/2024, for the resident's treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing (a wound dressing that absorbs but does not retain moisture), wrap with Kerlix roll (a bandage made of 100% woven gauze that's used to protect wound areas) every day shift for 30 days. During a concurrent interview and record review on 10/18/2024, at 9:30 AM, with Registered Nurse 2 (RN 2), Resident 24's Wound Care Physician (WCP) Progress Note, dated 10/1/2024 was reviewed. RN 2 stated WCP comes to the facility to assess and treat Resident 24's right heel pressure injury every Tuesday. RN 2 stated Resident 24's treatment plan from the WCP Progress Note, dated 10/1/2024, indicated to cleanse with wound cleanser, pat dry with gauze pad, apply collagen to the size of the wound bed, cover with calcium alginate (a highly absorbent wound dressing that is a combination of alginic acid and calcium ions, ideal for wounds with moderate to heavy drainage) and bordered gauze dressing, wrap with rolled gauze and secure with tape. RN 2 also stated, the WCP progress note indicated dressing change frequency: every 3 days and as needed (PRN) for loss of integrity/soiling. RN 2 stated the treatment plan did not match what was in the physician's order dated 10/1/2024. 555119 Page 12 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 10/18/2024 at 9:56 AM, with Treatment Nurse 1 (TN 1), Resident 24's WCP Preliminary Wound Report, dated 10/2/2024 was reviewed. TN 1 stated she followed the Preliminary Wound Report which indicated under post debridement (removal of damaged tissue or foreign objects from a wound)/procedure to irrigate/cleanse with NS, pat dry, apply collagen, cover/wrap with border gauze daily. TN 1 stated she did not read or follow the treatment plan on the WCP Progress Note after it was sent to the facility. TN 1 stated it was important to follow the treatment plan on the WCP Progress Note to prevent infection and prevent the wound from getting worse. TN 1 stated she did not follow the treatment plan from 10/1/2024 to 10/7/2024. During an interview with the Director of Nursing (DON), on 10/18/2024 at 4:47 PM, the DON stated TN 1 should have confirmed that the treatment plan on the WCP was correct before filing and implementing. The DON stated Resident 24's WCP treatment plan should have been followed to provide proper wound treatment and promote wound healing. During a review of the facility's policy and procedure (P&P), titled, Pressure Ulcers/Skin BreakdownClinical Protocol, revised on 4/2018, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. 555119 Page 13 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) was elevated at 30 degrees angle for one (1) of 1 sampled Resident (Resident 28) while receiving gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) feeding in accordance with the facility's policy. This failure has the potential for Resident 28 to aspirate (feeding could enter the windpipe and lungs) which could lead to lung problem such as pneumonia (an infection/inflammation of the lungs). Findings: During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 28's Care Plan, initiated on 4/9/2024, the Care Plan indicated, to administer tube feeding as ordered and to always elevate the HOB during GT feeding. During a review of Resident 28's History and Physical (H&P), dated 8/28/2024, the H&P indicated Resident 28 does not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 28 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 28 was dependent (helper does all the effort) oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 28 had a feeding tube. During a concurrent observation in Resident 28's room and interview with LVN 1 on 10/18/2024 at 8:49 AM, Resident 28 was observed receiving gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding of Glucerna (tube feeding formula) at 55 cubic centimeters (cc - units of volume on liquids) per hour with the HOB less than 30 degrees elevation. LVN 1 stated Resident 28's HOB should be at least 30 to 45 degrees to prevent aspiration which can cause pneumonia if resident vomits and end up in the resident's lungs. During an interview on 10/18/2024 at 8:51 AM, the Director of Nursing (DON) stated Resident 28's HOB should be elevated to at least 30 degrees when receiving tube feeding to prevent aspiration due to possible food back up. During a review of Resident 28's Order Summary, recapitulated 10/18/2024, indicated an order on 8/28/2023 for enteral feeding (a method of delivering nutrition directly to the stomach) and to elevate HOB 30 to 45 degrees at all times during feeding. During a review of the facility's Policy and Procedure titled, Enteral Feedings - Safety Precautions, revised November 2018, the P&P indicated to ensure the safe administration of enteral nutrition 555119 Page 14 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0693 and to prevent aspiration, the HOB must be elevated at least 30 degrees during tube feeding. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555119 Page 15 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of three (3) sampled residents (Resident 35) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 35 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 23's quality of life. Findings: During a review of Resident 35's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included post traumatic PTSD and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 35's History and Physical (H&P), dated 7/6/2024, the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 35 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 35 required partial assistance (helper does less than half the effort) shower, upper body dressing, and putting on/taking off footwear. The MDS further indicated Resident 35 required supervision (helper provides verbal cues) with oral and personal hygiene, toileting, and lower body dressing and required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had an active diagnosis of PTSD. During an interview on 10/17/2024 at 12:44 PM, Resident 35 stated that his PTSD triggers is seeing a gun. Resident 35 also stated he was robbed before with a person whose face was covered and seeing violence involving guns on television (TV) triggers his PTSD. Resident 35 further stated he just lays down in bed, turns his head away from the TV, tries to relax, and avoid watching when he sees violence involving guns on TV. Resident 35 also stated he had mentioned his PTSD triggers to the staff (unable to recall who). During an interview on 10/17/2024 at 12:56 PM, Certified Nursing Assistant 4 (CNA 4) stated he was unaware that Resident 35 had a diagnosis of PTSD. CNA 4 also stated it was important to know Resident 35's trigger to help avoid reminding the resident of the past incident that caused the PTSD. During an interview on 10/17/2024 at 1:02 PM, Licensed Vocational Nurse 1 (LVN 1) was unaware of Resident 35's PTSD diagnosis. LVN 1 stated it was important to know Resident 35's diagnosis of PTSD to 555119 Page 16 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few avoid triggers which could cause extreme anxiety (a feeling of fear, dread, and uneasiness that may occur as a reaction to stress) and to prevent Resident 35 from reliving the incident that happened in the past that caused the PTSD. During an interview on 10/17/2024 at 3:12 PM, the Social Services Director (SSD) stated and confirmed Resident 35 did not have a care plan for trauma informed care. The SSD also stated Resident 35 was assessed during initial admission but should have been reassessed for trauma informed care upon readmission so the facility would know what the resident's PTSD triggers were. The SSD further stated it was important to identify Resident 35's PTSD triggers to be able to know what type of approach the staff should provide to the resident to help prevent triggers. During a review of the facility's Policy and Procedure (P&P) titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, the P&P indicated its purpose was to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. The policy also indicated that they are used to address the needs of the trauma survivors my minimizing triggers and/or re-traumatization. The policy further indicated to utilize initial screening to identify the need for further assessment and care and to recognize that trust is earned over time and that individuals may not disclose information until a relationship has been established. 555119 Page 17 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure Registry (a placement service that provides staff on a temporary or day-to day basis in a facility) Certified Nursing Assistant 1 (RCNA 1) had the competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skill sets necessary before providing care to residents in the facility. RCNA 1 worked in the facility on 10/17/2024. This deficient practice had the potential for residents to not receive appropriate nursing services and had the potential to place residents at risk for injury or harm. Findings: During an interview with the Director of Staff Development (DSD), on 10/18/2024, at 12:30 PM, DSD stated the facility uses a registry when there is not enough staff to work in the facility. The DSD stated RCNA 1 was from a registry and worked during the 7AM to 3PM shift on 10/17/2024. The DSD stated she did not check and did not ask for a copy of RCNA 1's competency skills check and RCNA 1's certificate verification (the process of confirming that a certified nursing assistance has a valid certification and is legally qualified to practice). The DSD stated the registry informed her only over the phone regarding RCNA 1's competency but did not know which competency skills and in-services RCNA 1 has completed. The DSD stated she did not have a copy of RCNA1's competency skills before RCNA 1 began working in the facility on 10/17/2024. The DSD stated it was important to know the CNA's competency skills, certifications, and in-service trainings that staff have completed to ensure they can take care for the resident's needs, to protect and for the safety of the residents. The DSD stated it was the DSD and the Director of Nursing's (DON) responsibility to make sure facility staff had the competency skills completed before providing resident care in the facility. During an interview with the DON on 10/18/2024, at 5:07 PM, the DON stated it was important for the facility to know which skill sets the staff was competent to ensure the staff is able to provide proper care for the residents and for the residents' safety. The DON stated the facility did not have any documentation or information of RCNA 1's competency skill sets before. During a review of the facility's policy and procedure (P&P), titled, Competency and Training- All Staff, dated 9/12/2019, the P&P indicated the Facility will develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. The P&P indicated competency Based Education and Training is defined as measurable pattern of knowledge, skills, abilities, behaviors, communication abilities to perform specific tasks and assignments with success. The P&P further indicated that a continuing competency-based education program is conducted for all staff at the facility to promote and measure specific competencies and skill sets necessary to provided related services to meet Resident needs, safety of the resident while considering the Resident's choice, rights, physical, mental, and psychosocial well-being based on the facility assessment. The P&P's definition of staff included employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs of from affiliated academic institutions. 555119 Page 18 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 68) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to have a clinical justification for the use of Risperdal (medication used to treat schizophrenia [a serious mental illness that affects a person's ability to think, feel, and behave], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs], and autism spectrum disorder [ASD - a complex developmental condition that affects how people interact, communicate, and behave]) without a clinical justification for use. This deficient practice had the potential to place Resident 68 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 68's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). During a record review of Resident 68's Discharge Medication Order from General Acute Care 1 (GACH 1), dated 2/6/2024, the discharge order medication included a new prescription of Risperdal 0.5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) twice a day as directed for 30 days. During a review of Resident 68's H & P dated 2/7/2024, the H&P indicated that Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS- a federally mandated assessment tool), MDS dated [DATE], the MDS did not indicate Resident 68 had a diagnosis of Schizophrenia. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 68 required supervision (helper provides verbal cues) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 68 required setup assistance (helper sets up; resident completes activity) with eating, oral hygiene and personal hygiene and upper body dressing. Resident 68 had little interest or pleasure in doing things and feeling down, depressed, or hopeless for two (2) to six (6) days in the last 2 weeks. The MDS also indicated Resident 68 sometimes feel lonely or isolated from those around him. The MDS further indicated Resident 68 had other behavioral symptoms not directed towards others which occurred 1 to three (3) days over the last 2 weeks. During a review of Resident 68's Order Summary, recapitulated 10/18/2024, the order summary included an order for Risperdal 0.5 mg two times a day on 2/6/2024 for schizophrenia bipolar type 555119 Page 19 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manifested by fluctuation of mood from being pleasant, calm, and sweet to being cranky and having sudden outburst of anger towards people around him. During a concurrent interview and review on 10/18/2024 at 11:49 AM, the Director of Nursing (DON) stated that she had reviewed all of Resident 68's records but was unable to find any evidence to support the resident's diagnosis of schizophrenia. The DON stated Resident 68 was given Risperdal without a diagnosis of Schizophrenia. The DON stated Resident 68 received an unnecessary medication and Resident 68 could develop potential adverse reactions. During a concurrent interview and review on 10/18/2024 at 12:15 PM, Registered Nurse 3 (RN 3) stated Resident 68 was readmitted from GACH 1 with discharge order for a new prescription of Risperdal 0.5 mg twice a day for 30 days without any indication of diagnosis. RN 3 also stated the process was to call the primary physician (MD) as soon as the resident is admitted to the facility and inform MD of all the medications the resident was receiving. RN 3 confirmed that she transcribed Resident 68's GACH transfer order of Risperdal on 2/6/24 and indicated the antipsychotic medication was for Schizophrenia. During a concurrent interview and review on 10/18/2024 at 1:27 PM, the DON stated Resident 68's initial Psychiatric Evaluation dated, 2/8/2024 did not indicate the resident had Schizophrenia and did not include Risperdal under the current medication. The DON stated Risperdal was not listed under Resident 68's current medications during the subsequent psychiatric evaluations dated, 5/15/2024, 6/14/2024, 8/17/2024, and 9/13/2024. During a concurrent review of Resident 68's H & P, dated 2/7/2024 and interview on 10/18/2024 at 2:23 PM with the DON, the DON stated a diagnosis of Paranoid Schizophrenia from the primary physician. During an interview on 10/18/2024 at 4:11 PM, RN 3 stated Resident 68's Risperdal would be considered unnecessary since the resident did not have Schizophrenia diagnosis. During a review of the facility's Policy and Procedure titled, Antipsychotic Medications, revised July 2022, the Policy and Procedure indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. The policy also indicated that residents who are transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. 555119 Page 20 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the resident personal food choices for one of eighteen (18) sampled residents (Resident 68) in accordance with the care plan and facility policy by failing to: 1. Follow Resident 68's food preference for Mexican food on 11/20/2023 and 5/10/2024. 2. Provide Resident 68 requested tacos on 1/25/2024, 1/30/2024 and 2/8/2024. 3. Provide Resident 68 requested beef soup on 1/26/2024. This deficient practice failed to accommodate Resident 68's food preference which had the potential to result in weight loss and affect the resident's psychological, physical, and emotional well-being. Findings: During a review of Resident 68's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), and dementia (a progressive state of decline in mental abilities). During a review of Resident 68's History and Physical (H&P), dated 2/7/2024, the H&P indicated Resident 68 does not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 68 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 68 required supervision (helper provides verbal cues) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 68 required setup assistance (helper sets up; resident completes activity) with eating, oral hygiene and personal hygiene and upper body dressing. During a review of Resident 68's Order Summary Report, dated 2/28/2024, the Order Summary Report, indicated no added salt diet (NAS), mechanical soft texture, regular consistency, ice cream lunch and dinner, and High Protein Nourishment (HPN) 4 ounces (oz) for lunch and dinner. During a review of Resident 68's Nutritional Care Plan, dated 2/6/2024, the Nutritional Care Plan interventions indicated: 555119 Page 21 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0806 Mechanical Soft, No added salt diet Level of Harm - Minimal harm or potential for actual harm Monitor amount of food intake every meal Honor Resident's reasonable food preference. Residents Affected - Few Offer substitute. Discuss with Resident personal goals for weight, weight history nutritional status and food preferences. During a record review of Resident 68's Food Preference Record, dated 11/20/2023, the Food Preference Record indicated Resident 68 special preferences were Mexican food, Jello, pudding, and sweets. During a record review of Resident 68's Nutritional Assessment Form, dated 11/24/2023, the Nutritional Assessment Form indicated, Resident 68 food preferences were Mexican food, and pudding. During a record review of Resident 68's Speech/Language Pathology Daily Note indicated: 1. On 1/25/2024, Resident 68 communicated he wanted, tacos. 2. On 1/26/2024, Resident 68 communicated he wanted, beef soup. 3. On 1/30/2024, Resident 68 continued to stated that he wants, tacos. 4. On 2/8/2024, Resident 68 communicated he wanted, tacos. During a record review of Resident 68's Dietary Progress Notes, dated 5/10/2024, the Dietary Progress Notes indicated, Resident 68 likes Mexican Food (enchilada), Jello and Pudding. During a record review of Resident 68's Food Preference Record dated 8/8/2024, the Food Preference Record indicated, Resident 68 special preferences were Mexican Food, enchiladas, and pudding. During a record review of Resident 68's Daily Meal Eating Log and Weekly Menu for the month of 9/2024, Eating Log indicated Resident 68 refused lunch and dinner meals on the following dates: 9/2/2024, 9/3/2024, 9/8/2024, 9/14/2024, 9/15/2024, 9/18/2024, 9/20/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/29/2024 and 9/30/2024. There were no Mexican food included in the following dates in the facility's September weekly menu. During a concurrent observation and interview with Resident 68 on 10/16/2024 at 11:13 AM, Resident 68 was observed with no upper and lower dentures. Resident 68 stated he does not look at the food 555119 Page 22 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because he does not have dentures. Resident 68 has no teeth to chew the food. Resident 68 stated he likes to eat beans, but he cannot chew it. Resident 68 stated he felt sad because he cannot eat solid food. During concurrent observation and interview with the Dietary Service Supervisor (DSS) on 10/17/2024 at 12:52 PM, Resident 68's food ticket indicated Mechanical Soft, No Added Salt. DSS was not aware of Resident 68's food preference and stated, Resident 68 did not and should have Mexican food listed as food preference on his meal ticket. During a concurrent interview with the Director of Nursing (DON) and review of Resident 68's dietary progress notes on 10/17/2024 at 3:33 PM, the DON stated, There was no documentation from the DSS that Resident (Resident 68)'s food preference was being offered. During a concurrent record review of Resident 68's Food Preference Record, dated 8/8/2024, and interview with the DSS on 10/17/2024 at 3:38 PM, DSS stated, Resident 68's food preference will not always be served because it was just what he likes but not what he wants. During an interview with the DSS on 10/17/2024 at 3:44 PM, DSS stated, Cinco de mayo is the only day we serve tacos to the residents. We serve residents with Mexican food, only during the days that we have it on the Menu. During a concurrent interview with DON and record review of Resident 68's nurses' progress notes on 10/17/2024 at 4PM, the DON stated, There were no documentation that nursing and dietary staff offered tacos to Resident (Resident 68) on the dates that he requested it. The DON stated, If Resident (Resident 68) will not receive his meal preference, he will continue to refuse his meals and there is a possibility that the resident will start losing weight. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs revised on 03/2021, the P&P indicated the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would been endangered. During a review of the facility's undated P&P titled, Food Preferences indicated Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. P&P also indicated updating of food preferences will be done as the Resident's needs change and/or during the quarterly review. 555119 Page 23 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: Residents Affected - Some 1. Properly store frozen food items in the kitchen freezer. 2. Properly store and label dry pasta in sealed containers. 3. Ensure there were no expired foods in the kitchen. These deficient practices had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 67 residents consuming food by mouth. Findings: 1. During a concurrent observation in the facility kitchen with [NAME] 1 on 10/15/2024 at 8:02 AM, a box of sliced bacon and a box of frozen meat were observed in the freezer. Both boxes were observed opened, with the top box flaps folded and the contained meats were not in an airtight moisture resistant wrapper. During an interview on 10/16/2024 at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated the kitchen staff do not remove frozen meats from the original box to store in a sealed bag for the freezer, instead the kitchen staff only need to close [fold] the flaps of the original box because sealed storage is not necessary for the frozen meats. During a review of the facility's Policy and Procedure (P&P) titled Procedure for Freezer Storage, dated 2023, indicated facility is to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. 2. During a concurrent observation in the kitchen's dry storage room and interview with [NAME] 1 on 10/15/2024 at 8:10 AM, a ripped clear bag of dry twisted pasta noodles and a bag of unlabeled and undated dry egg noodles were observed. [NAME] 1 stated the bag of twisted pasta was opened and not sealed because of the rip in the bag and should have been placed in a Ziploc bag to be sealed properly. [NAME] 1 also stated the bag of egg noodles should have been labeled and dated with an open and use by date. During a review of the facility's P&P titled, Storage of Food and Supplies, Procedures for Dry Storage, dated 2023, the P&P indicated: 1. Food and supplies will be stored properly and in a safe manner. 2. Dry bulk foods should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. 3. Dry food items which have been opened such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. 555119 Page 24 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0812 Level of Harm - Minimal harm or potential for actual harm 4. Liquid foods such as syrup oils, vinegar, honey, corn syrup, Worcestershire sauce, and molasses which have been opened will be closed, labeled, and dated. 3. During a concurrent observation in the kitchen and interview with [NAME] 1 on 10/15/2024 at 8:18 AM, the following expired items were observed: Residents Affected - Some a. Bottle of Worchester sauce labeled with an expiration date of 8/15/2024. b. Container of peanut butter labeled with an expiration date of 8/27/2024. c. Baking Soda labeled with an expiration date of 1/30/2024. d. Package of Seasoning (Red shade) labeled with unreadable expiration date. Cook 1 stated the food items that have already expired should have been discarded. [NAME] 1 stated the peanut butter was only good for 30 days after it has been opened so it should have been discarded. [NAME] 1 stated he was unable to identify the expiration date of the seasoning so it should have been discarded and replaced. During an interview on 10/16/2024 at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated once any food items were opened, there should be a label with the date the item was opened and a use by date. DSS also stated the use by date indicates the date the item expires and needs to be discarded. During a review of the facility's P&P titled, Labeled and Dating Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P also indicated opened food items need to be used by the date that follows storage guidelines. During an interview on 10/17/2024 at 12:21 PM with DSS, DSS stated it is important to follow the facility protocol with the storage of frozen to prevent freezer burn, which would damage the food. DSS stated it is important to store opened dry foods in a tight closed manner to prevent contamination. DSS stated it is important to label all foods because if food is mislabeled, not labeled, or expired, the food can be given to the residents, and they can experience illnesses. 555119 Page 25 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure two (2) of 2 garbage container (dumpster) lids remained closed and were not overflowing with trash in accordance with the facility's policy. Residents Affected - Some This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g. rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation and interview on 10/16/2024 at 8:32 AM, with Maintenance Supervisor (MS) and Maintenance Assistant (MA), in the facility's parking lot dumpster area, two dumpsters were observed with trash overflowing out of the sides and top of both dumpsters, with the dumpster lids opened due to overflowing trash. MA stated, The trash is overflowing, and the dumpster lids are not closed. Facility may need bigger trashcans. MS stated per facility policy, the dumpster lids should not be open and are to stay closed to make sure rodents, flies and insects [pests] do not go to dumpsters and possibly the facility. MS stated if pests entered the facility, that would be a danger to the everyone, including residents and staff. During a review of the facility's Policy and Procedure (P&P) titled, Exterior Maintenance: Grounds, Sidewalks, Patios, and Parking Lots, dated 1/1/2018, the P&P indicated facility is to make sure garbage and trash containers are maintained in a clean and pest free condition. Trash must be packed down, boxes folded, and container lids must stay closed when not in use. 555119 Page 26 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). Residents Affected - Some During a review of Resident 28's History and Physical (H&P), dated 8/28/2024, the H&P indicated Resident 28 does not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 28 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 28 was dependent (helper does all the effort) with oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During an observation on 10/18/2024 at 8:49 AM, Resident 28 was receiving gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding of Glucerna (tube feeding formula) at 55 cubic centimeters (cc - units of volume on liquids) per hour. During a concurrent observation and interview with Certified Nursing Assistant 3 (CNA 3) on 10/18/2024 at 9:11 AM, there was no isolation cart for Personal Protective Equipment (PPE - Personal Protective Equipment (PPE - is a specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) and no signage to indicate Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of resistant organism by using PPE's during high contact resident care activities) was needed outside Resident 28's room. CNA 3 stated she cleaned and changed Resident 28's diaper using gloves and did not wore any gowns. During an interview on 10/18/2024 at 9:14 AM, Licensed Vocational Nurse 1 (LVN 1) stated he only wears a mask and gloves when giving medications via GT to Resident 28. LVN 1 also stated he believed an isolation gown was not required when providing care to Resident 28. During an interview on 10/18/2024 at 10:16 AM, CNA 3 stated she should have worn an isolation gown when providing care to Resident 28 to protect the resident from getting infections from the staff and prevent the resident prevent the resident from getting sick. During an interview on 10/18/2024 at 10:22 AM, LVN 1 stated the staff should use EBP for residents that had open wounds, indwelling catheter (a flexible tube that passes through the urethra [a tube through which the urine leaves the body] and into the bladder to drain urine) and GT to prevent transmission of any infections to the resident. LVN 1 also stated EBP should be used to prevent facility acquired infections that could be transmitted from one resident to another. During an interview on 10/18/2024 at 10:39 AM, the Director of Nursing (DON) stated the staff should use PPE when providing care to residents with open wounds, GT, and indwelling catheters to prevent transmission of infections to other residents. The DON also stated the facility should have a small cart for PPEs and signage posted outside the rooms for all residents that required EBP's. 555119 Page 27 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/18/2024 at 10:47 AM, the Infection Prevention Nurse (IPN) stated the facility only uses EBP for residents with indwelling catheters, GT, and those with wounds that had multidrug - resistant organism (MDRO, bacteria that resist treatment with more than one antibiotic) to prevent the spread of infection. 10. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included bladder-neck obstruction (a condition that occurs when the bladder neck doesn't open properly, which can slow or stop urine flow), encounter for attention to gastrostomy, and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was assessed having severely impaired cognitive skills for daily decision making. Resident 1 was dependent with oral/toileting hygiene, upper/lower body dressing, sit to lying, and toilet transfer. Resident 1 had a feeding tube. During a review of Resident 1's Physician Order, dated 8/22/2024, Resident 1 had an enteral (Gtube) feed order to check tube placement every shift. During an observation of Resident 1's medication administration on 10/17/2024, at 8:26 AM, LVN 2 disconnected Resident 1's Gtube feeding and administered Resident 1's medications thru the Gtube. LVN 2 did not wear a gown prior to Resident 1's medication administration. 11. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's H&P, dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated a physician order, with a start date of 10/1/2024, for treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing, wrap with Kerlix roll every day shift for 30 days. During an observation of Resident 24's wound treatment on 10/18/2024, at 9AM, TN 1 cut Resident 24's old wound dressing with bandage scissors and provided wound care to Resident 24. TN 2 was observed not wearing a gown while providing wound treatment. TN 1 did not clean the bandage scissor with sanitizing wipes before placing it back in the treatment cart. 555119 Page 28 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with TN 1 on 10/18/2024, at 9:09 AM, TN 1 stated she only needed to wash her hands and wear gloves before providing wound treatment to Resident 24. TN 1 stated a gown was only worn for wound treatment if a resident was in isolation (process of separating sick residents with contagious disease from residents who are not sick). TN 1 stated she washed the bandage scissors with soap and water before placing it back in the treatment cart. TN 1 stated she did not follow the facility's policy to clean and disinfect the bandage scissor with a disinfectant wipe before placing it back in the treatment cart. During an interview with the Infection Preventionist Nurse (IPN), on 10/18/2024, at 11:54 AM, the IPN stated drainage from wounds can get on bandage scissors during wound dressing change. The IPN stated bandage scissors should be cleaned and disinfected with disinfectant wipe and not soap and water. The IPN stated disinfectant wipes have the proper chemicals to kill and remove microorganisms that cause infection. The IPN stated infection can get transferred from one resident to another if a bandage scissor was not cleaned and disinfected properly before placing it back in the treatment cart. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 9/2022, the P&P indicated the following: 1. Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 2. Non-critical items are those that come in contact with intact skin but not mucous membranes. 3. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). a. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPAregistered hospital disinfectants with an HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. b. Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly 555119 Page 29 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. Level of Harm - Minimal harm or potential for actual harm 4. Residents Affected - Some Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only). Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - an infection control practice that involves wearing gloves and gowns during high-contact patient care activities to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms that are resistant to multiple classes of antibiotics and antifungals]) for 11 of 11 sampled residents on EBP (Residents 27, 3, 7, 21, 23, 42, 69, 225, 28, 1, and 24) as indicated in the facility policy, by failing to ensure: 1. Licensed Vocational Nurse 3 (LVN 3) wore indicated personal protective equipment (PPE- protective clothing or equipment designed to protect the body from injury or infection) of a gown while administering medications through Resident 27's gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) on 10/18/2024. Facility also failed to implement signage posted and PPE cart at the resident's door per policy. 2. - 8. Facility implemented posted signage in the door or wall outside the rooms of Residents 3, 7, 21, 23, 42, 69 and 225, that indicated EBP, and specific PPE required. The facility also failed to ensure PPE is available outside Residents 3, 7, 21, 23, 42, 69 and 225 room per policy. 9. Certified Nurse Assistant 3 (CNA 3) wore a gown while providing diaper change for Resident 28 on 10/18/2024. Facility also failed to implement posted signage and have available PPE for Resident 28's room. 10. Ensure LVN 2 observed infection control measures for Resident 1 by not donning (wear) a gown 555119 Page 30 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 before administering medications for Resident 1 who had a GT. Level of Harm - Minimal harm or potential for actual harm 11. Ensure Treatment Nurse 1 (TN 1) observed infection control measures for Resident 24 by not donning a gown before providing wound care. TN 2 also failed to ensure the wound bandage scissor was disinfected with the appropriate disinfectant solution before returning it to the treatment cart after providing wound treatment to Resident 24. Residents Affected - Some These deficient practices placed the residents at a higher risk for cross-contamination and increased spread of infection in the facility. Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs). During a review of Resident 27's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/5/2024, the MDS indicated Resident 27 was severely impaired with cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 27 was partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral and personal hygiene, and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with toileting. The MDS also indicated Resident 27 had a feeding tube (nasogastric or abdominal) while a resident in the facility. During a review of Resident 27's Initial History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 27 does not have the capacity to understand and make decisions and had an abdominal GT in place. During a concurrent observation and interview on 10/18/2024 at 10:16 AM with LVN 3, at Resident 27's bedside, LVN 3 was observed checking the GT placement, flushing the GT with water, and administering medications into the GT without a gown. LVN 3 stated she only needs to perform hand hygiene and apply gloves while caring for Resident 27's GT and medication administration. LVN 3 also stated EBP is only utilized for residents with foley catheter (a medical device that drains urine from the bladder) or GT when the resident has a current infection. During an observation and interview on 10/18/2024 AT 11:10 AM with IPN outside of Resident 27's room was observed with no EBP signage and PPE [NAME] outside the doorway. IPN stated per policy, it should be an EBP sign and PPE cart outside of Resident 27's room. 2. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD longstanding disease of the kidneys leading to renal failure), dementia and urinary retention (inability to completely empty the bladder). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was severely impaired with cognitive skills for daily decision making. Resident 3 was dependent (helper does all effort needed to complete activity) for toileting, bathing, and lower body dressing. The MDS also 555119 Page 31 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 indicated Resident 3 had an indwelling catheter (Foley catheter). Level of Harm - Minimal harm or potential for actual harm 3. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, heart failure and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). Residents Affected - Some During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was severely impaired with cognitive skills for daily decision making. Resident 7 was dependent with oral and personal hygiene, toileting, and dressing. The MDS also indicated Resident 7 with an indwelling catheter and a feeding tube. During a review of Resident 7's H&P, dated 9/15/2024, the H&P indicated Resident 7 does not have the capacity to understand and make decisions and had an abdominal GT. 4. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was readmitted to the facility on [DATE] with diagnoses that included gastro esophageal reflux disease (GERD chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), adult failure to thrive (AFTT - a condition that describes a gradual decline in a person's physical and mental health) and dementia. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was moderately impaired with cognitive skills for daily decision making. Resident 21 was dependent with toileting and bathing and partial/moderate assistance with oral and personal hygiene. The MDS also indicated Resident 21 had a feeding tube. During a review of Resident 21's H&P, dated 9/30/2024, the H&P indicated Resident 21 does not have the capacity to understand and make decisions and had an abdominal GT in place. 5. During a review of Resident 23's admission Record, the admission record indicated Resident 23 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), AFTT, and type 2 diabetes mellitus (DM2 - a chronic metabolic disease that occurs when the body doesn't produce enough insulin or cannot use it properly). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 was severely impaired with cognitive skills for daily decision making. Resident 23 was dependent with toileting and bathing. The MDS also indicated Resident 23 had a feeding tube. During a review of Resident 23's H&P, dated 8/6/2024, the H&P indicated Resident 23 does not have the capacity to understand and make decisions and had an abdominal GT. 6. During a review of Resident 42's admission Record, the admission record indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, DM2, and dementia. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was severely impaired with cognitive skills for daily decision making. Resident 42 was dependent with toileting, lower body dressing and bathing and substantial/maximal assistance with oral and personal hygiene. The MDS also indicated Resident 42 had a feeding tube. 555119 Page 32 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 42's H&P, dated 6/6/2024, the H&P indicated Resident 42 does not have the capacity to understand and make decisions. 7. During a review of Resident 69's admission Record, the admission record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in any part of the urinary system), obstructive uropathy (occurs when urine cannot drain or flows backwards through a ureter [a tube that carries urine from the kidneys to the bladder]) and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin to carry oxygen all through the body). During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 was severely impaired with cognitive skills for daily decision making. Resident 69 required substantial/maximal assistance with eating and oral hygiene and dependent with toileting, bathing, and lower body dressing. The MDS also indicated Resident 69 with an indwelling catheter. During a review of Resident 69's H&P, dated 9/25/2024, the H&P indicated Resident 69 had a fluctuating (changing) capacity to understand and make decisions. 8. During a review of Resident 225's admission Record, the admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included muscle wasting (deterioration of muscle tissue), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and atrophy (deterioration of a part of the body). During a review of Resident 225's MDS, dated [DATE], the MDS indicated Resident 225 was moderately impaired with cognitive skills for daily decision making. Resident 225 required substantial/maximal assistance with eating, oral and personal hygiene and dependent with toileting. The MDS also indicated Resident 225 had an indwelling catheter. During a review of Resident 225's H&P, dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During an observation on 10/16/2024 at 8:30 AM, there were no facility rooms observed to have EBP signage on the door or walls. There were also no PPE carts outside the rooms. During an interview on 10/16/2024 at 8:59 AM with IPN, IPN stated there were no rooms with EBP in the facility. IPN stated EBP was not implemented because the EBP only needed to be implemented with residents who have wounds, GTs, and indwelling catheters in addition to an MDRO. During an interview on 10/18/2024 at 10:56 AM with IPN, IPN stated per the facility policy, EBP should have been implemented and followed throughout the facility for residents with wounds, indwelling catheters and/or feeding tubes regardless of their MDRO status or history to prevent the spread of infections within the facility to everyone [residents, staff, and visitors]. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated: a. EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. b. EBPs employ targeted gown and glove use during high contact resident care activities when 555119 Page 33 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0880 contact precautions do not otherwise apply. Level of Harm - Minimal harm or potential for actual harm c. Gloves and gown are applied prior to performing the high contact care activity. Residents Affected - Some d. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (urinary catheter, feeding tube, etc.) and wound care. e. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. f. Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE required. g. PPE is available outside of the resident rooms. 555119 Page 34 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, the facility failed to offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae) for one of five sampled residents (Resident 2) upon readmission on [DATE] as indicated in the facility's policy. Residents Affected - Few This failure placed Resident 2 at a higher risk of acquiring preventable infections such as pneumonia (PNAan infection in your lungs), bacteremia (infection of the blood), or meningitis (infection of the tissue covering the brain and spinal cord) and increased the risk of transmission to other residents in the facility. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat too fast), Parkinson's Disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool) dated 10/4/2024, the MDS indicated Resident 2 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort needed to complete the activity) with toileting, bathing, and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene. During a review of Resident 2's Immunization Record, the Immunization Record indicated Resident 2 refused the pneumococcal vaccine on 4/14/2022. The record did not indicate any pneumococcal vaccination administration or declinations from Resident 2 upon facility admission on [DATE]. During an interview on 10/18/2024 at 12:42 PM with Director of Nursing (DON), the DON stated per facility protocol, staff are supposed to offer the pneumococcal vaccine during all admission and readmissions. The DON stated staff are supposed to check if vaccine was indicated and should offer to the resident, then document administration or declination and education provided in the resident's medical record. During a concurrent interview and record review of Resident 2's medical chart on 10/18/2024 at 12:57 PM with Infection Preventionist Nurse (IPN), IPN stated the chart indicated Resident 2 declined the pneumococcal vaccination when offered on 4/14/2022. The IPN stated there was no documentation to indicate any education and offering of the pneumococcal vaccine to Resident 2 during Resident 2's admission on [DATE]. IPN stated the facility did not offer Resident 2 the pneumococcal vaccine during current admission on [DATE]. IPN stated the facility should have offered Resident 2 the pneumococcal vaccine once admitted to the facility. IPN stated it was important to offer the vaccinations to the residents to prevent the resident from developing illnesses like PNA because PNA is very common in the elderly population. IPN stated the risks for residents, if not reoffered the pneumococcal vaccine is potentially getting a preventable illness. 555119 Page 35 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/18/2024 at 4:47 PM with Resident 2, Resident 2 stated he cannot recall being offered the pneumococcal vaccine by the facility during current admission, and that he would be interested in getting the pneumococcal vaccine because he has had PNA twice in the past. During a review of the Centers for Disease Control and Prevention, Vaccine Information Statement: Pneumococcal Conjugate Vaccine: What You Need to Know, revised 5/12/2023, the statement indicated the pneumococcal conjugate vaccine can prevent pneumococcal disease, which refers to any illness cause by the pneumococcal bacteria including PNA, meningitis and bacteremia. The statement also indicated adults 65 years or older are at higher risk to get pneumococcal disease, which can result in long-term problems like brain damage or hearing loss or meningitis, bacteremia or PNA which can be fatal (cause death). During a review of the facility's Policy and Procedure (P&P) titled, Pneumococcal Vaccine, revised 10/2019, the P&P indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The P&P also indicated prior to, upon admission, or within five (5) working days, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, offered the vaccine series within 30 days of admission to the facility. The P&P indicated if a resident refuses, appropriate entries will be documented in the resident's medical record and if administered, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 555119 Page 36 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to provide the minimum of 80 square feet (sq.ft.) per resident bed in 25 of 27 residents' rooms in the facility. Residents Affected - Some This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents. Findings: During an observation of the resident's rooms one (1) to nine (9) and 11 to 26 on 10/15/2024, at 8:36AM, 25 of 27 resident's rooms did not meet the minimum 80 sq. ft. per resident in each room. The residents did not complaint regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. Residents that were wheelchair bound were able to move in and out of the room without difficulty. During a concurrent observation and interview with Resident 45 on 10/18/2024, at 12:07 PM, Resident 45 was observed coming out of the bathroom on her wheelchair. Resident 45 propelled herself to the left side of bed, where the TV and bedside table were located. Resident 45 stated her room was fine, and she has no complaints with the room size. Resident 45 stated she has no issues with getting in and out and the size of the room was fine. Resident 45 stated the staff helps her with no problems. During a concurrent observation inside Resident 52's room and interview with Certified Nursing Assistant 3 (CNA 3) on 10/18/2024, at 9:06 AM, CNA 3 was observed transferring Resident 52 from bed to the wheelchair. CNA 3 stated, the room was spacious enough to care for the residents. CNA 3 was able to maneuver Resident 52's wheelchair without issues. During a review of the room waiver indicated the following: Room Beds Total sq. ft. Sq. ft. per Resident 1 3 218 72.67 2 2 555119 Page 37 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 147 Level of Harm - Potential for minimal harm 73.50 3 Residents Affected - Some 3 218 72.67 4 2 147 73.50 5 3 218 72.67 6 3 218 72.67 7 3 218 72.67 8 3 218 555119 Page 38 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 72.67 Level of Harm - Potential for minimal harm 9 3 Residents Affected - Some 218 72.67 11 3 218 72.67 12 3 218 72.67 13 5 358 71.60 14 5 361 72.20 15 3 218 72.67 555119 Page 39 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 16 Level of Harm - Potential for minimal harm 2 147 Residents Affected - Some 73.50 17 3 218 72.67 18 3 218 72.67 19 2 147 73.50 20 2 150 75.00 21 3 220 73.33 22 555119 Page 40 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 3 Level of Harm - Potential for minimal harm 220 73.33 Residents Affected - Some 23 3 220 73.33 24 3 220 73.33 25 3 220 73.33 26 3 220 73.33 During a review of the Room Waiver dated 10/15/2024, the Room Waiver indicated, Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 measured less than the minimum requirement for room size. The Request Waiver indicated a request for the continued waiver for square footage per resident. Room Beds Total sq. ft. 555119 Page 41 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 1 Level of Harm - Potential for minimal harm 3 218 Residents Affected - Some 2 2 147 3 3 218 4 2 147 5 3 218 6 3 218 7 3 218 8 3 218 9 555119 Page 42 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 3 Level of Harm - Potential for minimal harm 218 11 Residents Affected - Some 3 218 12 3 218 13 5 358 14 5 361 15 3 218 16 2 147 17 3 218 18 3 555119 Page 43 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 218 Level of Harm - Potential for minimal harm 19 2 Residents Affected - Some 147 20 2 150 21 3 220 22 3 220 23 3 220 24 3 220 25 3 220 26 3 220 555119 Page 44 of 45 555119 10/18/2024 Saint Vincent Healthcare 1810 N. Fair Oaks Ave Pasadena, CA 91103

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some During the re-certification survey from 10/15/2024 to 10/18/2024, the above listed rooms had sufficient space for the residents' freedom of movement. The rooms had adequate space to provide nursing care, privacy during care, and the ability to maneuver resident care equipment with the room. The room size did not present any adverse effect on the residents' personal space, nursing care, and comfort. The Department would be recommending the room waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19,20,21,22,23,24, 25, and 26. 555119 Page 45 of 45