Health inspection·August 24, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, resident and staff interviews, the facility failed to follow the facility's menu for thirtyone (31) of thirty-four (34) residents in accordance with the facility's policy and procedure by: Residents Affected - Some 1. 31 residents who are on a regular (diet with no restrictions) and therapeutic diets (diet that controls the intake of certain foods or nutrients) received unportioned Haricot Verts (French [NAME] beans) 2. Seven (7) residents received unportioned steak fajitas. These deficient practices placed facility residents on regular and therapeutic diets at risk of potential increased or decreased nutrient intake causing unplanned weight gain or unintentional weight loss (weight loss without trying). Findings: A review of the facility's menu spread sheets dated 8/23/2023, indicated the following items will be served on Regular Diet and Therapeutic Diets based: a. For Option One (1) - Half cup of Haricot Verts b. Option two (2) - Three (3) oz Steak Fajita During tray line (area used to plate food of the residents) observation in the dining room on 8/24/2023 at 12:42 p.m., Food Service Worker 1 (FSW1) was using tongs in dishing out (preparing the plate) Steak Fajitas for 7 residents. FSW 1 used tongs in dishing out Haricot Verts for all the residents on Regular and Therapeutic Diets. During a concurrent interview with FSW1 on 8/24/2023 at 12:42 p.m. at 12:42 p.m., FSW 1 stated, using a scoop or spoodle (a type of utensil used for measuring and serving food) were appropriate for portion accuracy when dishing out or preparing plate for the residents. FSW 1 stated, I used the tong because I could not find anything other than the tong. Page 1 of 6 555429 555429 08/24/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Executive Chef (EC) on 8/24/2023 at 1:15 p.m., EC stated, Fajita was 3 oz portion per serving. EC stated that spoodles and scoops were the appropriate kitchen utensils to use, particularly the color green scoop for Fajitas which was 3 oz portion and ½ cup spoodle for green beans. EC stated, staff used eyeballing method (to look over carefully) using a tong to portion the fajitas and green beans however, eyeballing was not an accurate method of portioning food. EC stated, there was a possibility of getting too much or too little food to the residents using a tong compared to a scoop. During an interview with the Director of Dining Services (DSS) on 8/24/2023 at 1:28 p.m., DSS stated, serving inaccurate portions to residents has a potential for residents not to receive their required amount of calorie and protein. DSS stated, we should be utilizing the scoops to portion food. DSS stated, serving inaccurate portions to resident could cause potential harm of weight gain, weight loss, and increase or decrease blood sugars. During an interview with the Registered Dietitian (RD) on 8/24/2023 at 3:28 p.m., RD stated, #12 scoop, green in color was the scoop size for Steak Fajita and #8 scoop was the scoop size for green beans. RD stated that using tongs in portioning food was incorrect because it was not a controlled portion. RD stated, inaccurate portion sizes can have a potential outcome of unintended weight gain or unintentional weight loss to the residents. A review of the facilities' policy and procedure titled Food Portion Control dated 8/1/2007, indicated (1) Know the standard serving portion for each item on the menu for both regular and therapeutic diets. (3) Use the appropriate scoops, measuring cup or ladle when serving portions. Do not estimate portion size. (6) Always weigh or measure portions before serving. Based on observations, resident and staff interviews, the facility failed to follow the facility's menu for thirtyone (31) of thirty-four (34) residents in accordance with the facility's policy and procedure by: 1. 31 residents who are on a regular (diet with no restrictions) and therapeutic diets (diet that controls the intake of certain foods or nutrients) received unportioned Haricot Verts (French [NAME] beans) 2. Seven (7) residents received unportioned steak fajitas. These deficient practices placed facility residents on regular and therapeutic diets at risk of potential increased or decreased nutrient intake causing unplanned weight gain or unintentional weight loss (weight loss without trying). Findings: A review of the facility's menu spread sheets dated 8/23/2023, indicated the following items will be served on Regular Diet and Therapeutic Diets based: a. For Option One (1) - Half cup of Haricot Verts b. Option two (2) – Three (3) oz Steak Fajita During tray line (area used to plate food of the residents) observation in the dining room on 555429 Page 2 of 6 555429 08/24/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8/24/2023 at 12:42 p.m., Food Service Worker 1 (FSW1) was using tongs in dishing out (preparing the plate) Steak Fajitas for 7 residents. FSW 1 used tongs in dishing out Haricot Verts for all the residents on Regular and Therapeutic Diets. During a concurrent interview with FSW1 on 8/24/2023 at 12:42 p.m. at 12:42 p.m., FSW 1 stated, using a scoop or spoodle (a type of utensil used for measuring and serving food) were appropriate for portion accuracy when dishing out or preparing plate for the residents. FSW 1 stated, I used the tong because I could not find anything other than the tong. During an interview with the Executive Chef (EC) on 8/24/2023 at 1:15 p.m., EC stated, Fajita was 3 oz portion per serving. EC stated that spoodles and scoops were the appropriate kitchen utensils to use, particularly the color green scoop for Fajitas which was 3 oz portion and ½ cup spoodle for green beans. EC stated, staff used eyeballing method (to look over carefully) using a tong to portion the fajitas and green beans however, eyeballing was not an accurate method of portioning food. EC stated, there was a possibility of getting too much or too little food to the residents using a tong compared to a scoop. During an interview with the Director of Dining Services (DSS) on 8/24/2023 at 1:28 p.m., DSS stated, serving inaccurate portions to residents has a potential for residents not to receive their required amount of calorie and protein. DSS stated, we should be utilizing the scoops to portion food. DSS stated, serving inaccurate portions to resident could cause potential harm of weight gain, weight loss, and increase or decrease blood sugars. During an interview with the Registered Dietitian (RD) on 8/24/2023 at 3:28 p.m., RD stated, #12 scoop, green in color was the scoop size for Steak Fajita and #8 scoop was the scoop size for green beans. RD stated that using tongs in portioning food was incorrect because it was not a controlled portion. RD stated, inaccurate portion sizes can have a potential outcome of unintended weight gain or unintentional weight loss to the residents. A review of the facilities' policy and procedure titled Food Portion Control dated 8/1/2007, indicated (1) Know the standard serving portion for each item on the menu for both regular and therapeutic diets. (3) Use the appropriate scoops, measuring cup or ladle when serving portions. Do not estimate portion size. (6) Always weigh or measure portions before serving. 555429 Page 3 of 6 555429 08/24/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to always maintain the facility's roof in good repair. Residents Affected - Some This deficient practice had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors. Findings: During a concurrent observation in the facility's satellite kitchen and interview on 8/23/2023 at 11:24 a.m., with the Administrator (ADM), Registered Dietician (RD), Maintenance Coordinator (MC), and Maintenance 1 (M1), there was a large hole on the ceiling near the hand washing sink and entrance exposing the pipes, ducts, and electricals. The ADM stated, there was water leaking from the roof due to the rain on 8/20/2023, that affected the area. The ADM also stated, the next day (8/21/2023), the facility decided to close the satellite kitchen to assess the damage and clean the area and when the staff came here to work and clean, the ceiling fell down because the rainwater had soaked into the ceiling. M1 measured 14 feet (ft) by 5 ft hole on the kitchen ceiling. During a concurrent observation at the facility's dining room near the satellite kitchen and interview on 8/23/2023 at 11:32 a.m., with the ADM and MC, there was a large opening on the ceiling exposing pipes, ducts, and electricals. The ADM stated the moisture from the rainwater leak in the satellite kitchen ceiling and traveled to the dining area ceiling. The ADM stated, the maintenance personnel removed the ceiling tiles because the ceiling was damped. The MC stated the opening on the ceiling at the dining room was 8 ft by 9 ft in size. During an interview on 8/23/2023 at 11:41 a.m., Dietary Aide 1 (DA1) stated she had noticed water leaking from the ceiling in the SNF satellite kitchen before but does not remember exactly when. During an interview on 8/23/2023 at 12:01 p.m., the Maintenance Supervisor (MS) stated, on Sunday, 8/20/2023, he was notified that rainwater was leaking into the SNF satellite kitchen and it was after 10 p.m. when it got worse. MS also stated, it was after breakfast on Monday (8/21/2023) morning when the SNF satellite kitchen was closed. MS added, last year (unable to recall exact month) rainwater had also leaked in the kitchen and the maintenance had fixed and patched the affected areas. MS also stated, there was a small leak in the activity room that he discovered on Monday (8/21/2023). During a concurrent observation in the facility's activity room and interview on 8/23/2023 at 11:32 a.m., with MS, there was a small hole on the ceiling and evidence of water damage including bubbling paint (indicates water leak). The MS stated they put a hole on the ceiling to open it up so that the rainwater would not travel. The MS stated the water damage on the ceiling was 4 ft by 6 ft in size. During a concurrent observation on the roof located above the SNF satellite kitchen and interview on 8/23/2023 at 12:30 p.m., with the MS, there were cracks on the roof. MS stated that the cause of rainwater leak could be from the cracks here in the roof. The MS explained, water travels so it could go from any place or ceiling in the facility. During an interview on 8/23/2023 at 4:46 p.m., the ADM explained the importance of maintaining the 555429 Page 4 of 6 555429 08/24/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0921 facility/building in good repair is to ensure the safety of the residents. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Maintenance Work Order Request Log, dated 2/24/2023, the log indicated, ceiling is leaking in the kitchen. Residents Affected - Some During a review of the facility's Maintenance Work Order Request Log, dated 2/25/2023, the log indicated, leaky ceiling in the kitchen. During a review of the facility's policy and procedure (P&P) titled, Maintenance, dated August 2023, the P&P indicated, it is the facility's policy to have an outline of the methods for the preventative maintenance, testing and inspection, scheduled maintenance and unscheduled maintenance of all equipment . and physical plant. The purpose of this policy is to ensure that all equipment and the physical plant is maintained in an approved fashion for the safety of the residents, physicians, visitors, and staff. Based on observation, interview, and record review, the facility failed to always maintain the facility's roof in good repair. This deficient practice had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors. Findings: During a concurrent observation in the facility's satellite kitchen and interview on 8/23/2023 at 11:24 a.m., with the Administrator (ADM), Registered Dietician (RD), Maintenance Coordinator (MC), and Maintenance 1 (M1), there was a large hole on the ceiling near the hand washing sink and entrance exposing the pipes, ducts, and electricals. The ADM stated, there was water leaking from the roof due to the rain on 8/20/2023, that affected the area. The ADM also stated, the next day (8/21/2023), the facility decided to close the satellite kitchen to assess the damage and clean the area and when the staff came here to work and clean, the ceiling fell down because the rainwater had soaked into the ceiling. M1 measured 14 feet (ft) by 5 ft hole on the kitchen ceiling. During a concurrent observation at the facility's dining room near the satellite kitchen and interview on 8/23/2023 at 11:32 a.m., with the ADM and MC, there was a large opening on the ceiling exposing pipes, ducts, and electricals. The ADM stated the moisture from the rainwater leak in the satellite kitchen ceiling and traveled to the dining area ceiling. The ADM stated, the maintenance personnel removed the ceiling tiles because the ceiling was damped. The MC stated the opening on the ceiling at the dining room was 8 ft by 9 ft in size. During an interview on 8/23/2023 at 11:41 a.m., Dietary Aide 1 (DA1) stated she had noticed water leaking from the ceiling in the SNF satellite kitchen before but does not remember exactly when. During an interview on 8/23/2023 at 12:01 p.m., the Maintenance Supervisor (MS) stated, on Sunday, 8/20/2023, he was notified that rainwater was leaking into the SNF satellite kitchen and it was after 10 p.m. when it got worse. MS also stated, it was after breakfast on Monday (8/21/2023) morning when the SNF satellite kitchen was closed. MS added, last year (unable to recall exact month) rainwater had also leaked in the kitchen and the maintenance had fixed and patched the affected areas. MS also stated, there was a small leak in the activity room that he discovered on Monday (8/21/2023). 555429 Page 5 of 6 555429 08/24/2023 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation in the facility's activity room and interview on 8/23/2023 at 11:32 a.m., with MS, there was a small hole on the ceiling and evidence of water damage including bubbling paint (indicates water leak). The MS stated they put a hole on the ceiling to open it up so that the rainwater would not travel. The MS stated the water damage on the ceiling was 4 ft by 6 ft in size. During a concurrent observation on the roof located above the SNF satellite kitchen and interview on 8/23/2023 at 12:30 p.m., with the MS, there were cracks on the roof. MS stated that the cause of rainwater leak could be from the cracks here in the roof. The MS explained, water travels so it could go from any place or ceiling in the facility. During an interview on 8/23/2023 at 4:46 p.m., the ADM explained the importance of maintaining the facility/building in good repair is to ensure the safety of the residents. During a review of the facility's Maintenance Work Order Request Log, dated 2/24/2023, the log indicated, ceiling is leaking in the kitchen. During a review of the facility's Maintenance Work Order Request Log, dated 2/25/2023, the log indicated, leaky ceiling in the kitchen. During a review of the facility's policy and procedure (P&P) titled, Maintenance, dated August 2023, the P&P indicated, it is the facility's policy to have an outline of the methods for the preventative maintenance, testing and inspection, scheduled maintenance and unscheduled maintenance of all equipment . and physical plant. The purpose of this policy is to ensure that all equipment and the physical plant is maintained in an approved fashion for the safety of the residents, physicians, visitors, and staff. 555429 Page 6 of 6