Health inspection·January 31, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document and perform a wound care treatment for one of two sampled residents (Resident 1). Residents Affected - Few This failure had the potential to result in Resident 1's wounds getting worse in condition. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's History and Physical Examination (H&P), dated 11/10/23, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/15/23, MDS indicated the resident was moderately impaired with cognition (ability to think, remember, and reason), but needed partial/moderate assistance (helper does less than half the effort) with transfers (how a resident moves to and from bed, chair, wheelchair, standing position), was dependent with dressing (how a resident puts on, fastens and takes off all items of clothing), toileting hygiene and needed setup or clean-up assistance with eating and personal hygiene. During a review of Resident 1's Physician Order Sheet dated 1/19/24 at 10:45 AM, the Physician Order Sheet indicated: 1. Cleanse left dorsal (referring to the back) foot status post (s/p; referring to a state after an intervention, usually surgical) surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) with Normal Saline (NS; a mixture of sodium chloride [salt] and water) gently pack with Medihoney (a type of wound treatment gel), collagen powder (wound filler dressing [a pad applied to a wound to promote healing and protect the wound from further harm]) and calcium alginate (Ca Alg; a wound dressing), apply nonadherent (nonstick) dressing and roll gauze (a loosely woven, almost translucent fabric used to bandage wounds) every day (QD) and as needed (PRN) until further orders. 2. Page 1 of 6 555429 555429 01/31/2024 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0684 Level of Harm - Minimal harm or potential for actual harm Cleanse right medial (middle) malleolus (a bony projection with a shape likened to a hammer head especially each of those on either side of the ankle) s/p surgical wound with NS, pat dry, gently pack with Medihoney, collagen powder and Ca Alg, apply nonadherent pad and roll gauze QD and PRN until further orders. Residents Affected - Few 3. Cleanse coccyx (a small triangular bone at the base of the spine) stage 3 pressure injury (second to last stage of pressure sore progression where the sore has gone through all layers of skin into the fat tissue) with NS, pat dry, apply Medihoney and collagen powder, skin barrier cream (a product applied directly to the skin surface to help maintain the skin's physical barrier and providing protection from irritants and drying out) to periwound (tissue surrounding a wound), cover with dry dressing QD and PRN until further orders. 4. Apply betadine (used on the skin to treat or prevent skin infection in minor cuts, scrapes or burns) to left anterior (front) lower leg laceration (a wound that is produced by the tearing of soft body tissue), cover with nonadherent and roll gauze QD and PRN until further orders. 5. Cleanse right forearm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. 6. Cleanse right upper arm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. 7. Cleanse left upper arm skin tear with NS, pat dry, apply collagen powder, nonadherent pad and roll gauze QD and PRN until further orders. During a concurrent interview and record review on 1/31/24 at 2:40 PM with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR) for January 2024 was reviewed. The TAR indicated that no wound treatment was provided for Resident 1's left dorsal foot s/p surgical wound, right medial malleolus s/p surgical wound, coccyx, left anterior lower leg laceration, right posterior forearm skin tear, left upper arm skin tear, left posterior forearm skin tear, and right upper arm skin tear on 1/22/24. DON stated that the treatment nurse who was working that day did the resident's treatment for everything except for the areas that needed medical honey ointment which included both her feet because they ran out of the ointment that day. The DON stated she told the family that she, herself would provide the treatment for the areas that needed medical honey ointment once it arrived but stated that it arrived at that facility late in the evening from the pharmacy and she had already gone home. The DON also stated the daytime treatment nurse should have signed off on the treatments performed that day. The DON further stated if the nurse did not document treatment being performed, then it would be considered not being done. 555429 Page 2 of 6 555429 01/31/2024 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/31/24 at 3:19 PM with Treatment Nurse 1 (TXN 1), TXN 1 stated on 1/22/24 he provided wound care treatment to Resident 1's upper arms but did not provide treatment for any of the areas that required medical honey ointment since they were out of the medication (Medihoney). TXN 1 stated he did not sign the TAR on 1/22/24 for the areas her performed treatment on because he forgot. During an interview on 1/31/24 at 3:45 PM with the DON, the DON stated the facility was not policy driven and that they have no specific policy regarding providing treatment as ordered by the physician. During a review of the facility's policy and procedure (P&P) titled, Charting Guidelines, revised November 2019, the P&P indicated charting should be done as soon as possible after a given event. 555429 Page 3 of 6 555429 01/31/2024 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from accident hazards by failing to secure a keyboard that was placed on top of a music equipment cart on 12/31/23 at 3:30 PM while an entertainer (a person such as a singer, musician, [NAME], or comedian whose job is to entertain others) was setting up their equipment for a performance. This failure resulted in the keyboard slipping off the cart and falling onto Resident 1's feet and caused her to sustain blood blisters that needed surgical intervention. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's History and Physical Examination (H&P), dated 11/10/23, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1'S Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/15/23, MDS indicated the resident was moderately impaired with cognition (ability to think, remember, and reason), but needed partial/moderate assistance (helper does less than half the effort) with transfers (how a resident moves to and from bed, chair, wheelchair, standing position), was dependent with dressing (how a resident puts on, fastens and takes off all items of clothing), toileting hygiene and needed setup or clean-up assistance with eating and personal hygiene. During a concurrent observation and interview on 1/31/24 at 10:47 AM with Resident 1's Family Member in Resident 1's room, Resident 1 was observed lying down in bed with both of her feet wrapped in gauze (a loosely woven, almost translucent fabric that is used to bandage wounds). Resident 1's Family Member stated that on 12/31/23 a keyboard fell on both of Resident 1's feet and now has two surgical wounds (a cut or incision in the skin that is usually made by a scalpel during surgery and can vary greatly in size. They are usually closed with sutures but are sometimes left open to heal) on her feet. During an interview on 1/31/24 at 3:30 PM with Activities Specialist (AS), AS stated on 12/31/23 at 3:30 PM an entertainer was setting up their music equipment in the activities room and the music equipment cart was placed in front of Resident 1's wheelchair. AS stated, she was repositioning the resident's wheelchair and locked the wheelchair brake. AS then stated, the keyboard that was placed on top of the equipment cart slid off the cart and fell onto both of Resident 1's feet. During a review of Resident 1's Complete Interdisciplinary Note dated 12/31/23 at 5:30 PM, the Completed Interdisciplinary Note indicated Resident 1 was involved in an incident where a piano keyboard fell onto her feet while an entertainer was trying to set up their instruments in the activities room. Resident 1 complained of pain in both her feet with the right inner ankle swollen and discolored. Resident 1's doctor (MD) was notified and a STAT (immediately) order for both lower extremities 555429 Page 4 of 6 555429 01/31/2024 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few x-ray (use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) was obtained as well as an order to medicate the resident with pain medication when needed. During a review of Resident 1's Radiology Report dated 12/31/23 at 8:47 PM, the Radiology Report indicated that both the right and left ankle were found to be intact with soft tissue swelling but no fracture. During a review of Resident 1's Complete Interdisciplinary Note dated 1/1/24 at 3:58 AM, the Complete Interdisciplinary Note indicated that Resident 1's right foot was swollen and discolored purplish, and no heavy linens were to be placed on top of the right foot. During a review of Resident 1's Complete Interdisciplinary Note dated 1/1/24 at 10:49 PM, the Complete Interdisciplinary Note indicated Resident 1's right foot near her ankle was noted with a bump and discoloration while her left foot was noted to have a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) on the top of it. During a review of Resident 1's Complete Interdisciplinary Note dated 1/8/24 at 12:20 PM, the Complete Interdisciplinary Note indicated Resident 1, incurred hematoma on both lower extremities during the weekend due to incident. The form also indicated, Resident 1's left dorsal (relating to the back of a structure) foot blood blister (a bump on the skin filled with blood) and right medial (middle) aspect of malleolus (a bony projection with a shape likened to a hammer head especially each of those on either sided the ankle) had blood blister, intact. During a review of Resident 1's Complete Interdisciplinary Note dated 1/11/24 at 10:30 AM, the Complete Interdisciplinary Note indicated that Resident 1 was seen by the wound care MD. Per MD, the left dorsal foot blood blister was 2.5 centimeters (cm) by 3 cm by unstageable (pressure ulcer stage is not clear) with 100% eschar (dead tissue that forms over healthy skin and then over time, falls off or sheds) noted with redness around area and treatment with betadine (an antiseptic used for skin disinfection) to be continued. The right medial malleolus blood blister measuring 3.5 cm by 3 cm by unstageable with 100% eschar with redness around area was to continue with betadine treatment until further orders. During a review of Resident 1's Complete Interdisciplinary Note dated 1/12/24 at 11:18 PM, the Complete Interdisciplinary Note indicated that Resident 1 was transferred to General Acute Care Hospital (GACH) accompanied by her family and MD was notified. The GACH H&P indicated skin assessment showed bilateral lower circumferential erythema (a skin lesion presenting redness in a ring form that spreads from the center) of both feet with exquisite thrombotic thrombocytopenic purpura (TTP; a blood disorder in which platelet [a small colorless cell fragment in our blood that form clots and stop or prevent bleeding] clumps form in small blood vessels and leads to a low platelet count), eschar on the left ankle without purulence (the condition of containing or forming pus) appreciated (not found on exam). The GACH H&P also indicated, plan included a vascular (relating to blood vessels) surgery consult and for Resident 1 to start on a blood thinning medication for prophylaxis (ppx; action taken to prevent disease). During a review of Resident 1's GACH Consultation Note dated 1/16/24 at 7:55 PM, the GACH Consultation Note indicated Resident 1's right ankle and left foot were found to have acute signs of localized infection of hematoma which required the sites to undergo an incision and drainage (I&D) for the 555429 Page 5 of 6 555429 01/31/2024 Villa Gardens Health Care Unit 842 East Villa Street Pasadena, CA 91101

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evacuation of the hematoma. After the I&D of both the infected hematomas, undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) approximately three centimeters circumferentially were noted. During a review of the facility's policy and procedure titled, Resident Safety Plan, revised 07/2010, the Resident Safety Plan indicated its purpose, to improve the health and safety of residents and reduce preventable safety occurrences. 555429 Page 6 of 6