Health inspection·August 27, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions, and resident's response. During a review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) communication form and progress note, dated 8/14/2025, timed at 5:54 PM, the change of condition indicated Resident 1 has swelling and multiple skin discoloration on the left hand and arm, with open ecchymosis (refers to a discoloration of the skin caused by the leakage of blood) on left forearm and left dorsal hand (back of the hand) related to long term anticoagulant use. The SBAR indicated the condition, symptom or sign has not occurred before. The nursing notes part of SBAR indicated Resident 1 is unable to tell what happened, but claimed there is pain. During a review of Resident 1's skin evaluation dated 8/14/2025, timed at 5:59 PM, it indicated Resident 1 has left forearm skin discoloration with open ecchymosis, measured 0.5 centimeters (cm, unit of measurement) in length, 0.5 cm in width, and 0.1 cm in depth. The skin evaluation indicated Resident 1 left dorsal hand skin discoloration with open ecchymosis, measured 0.5 cm in length, 0.5 cm in width, and 0.1 cm in depth. The skin evaluation also indicated Resident 1 has left arm multiple skin discoloration. During a review of Resident 1's order summary report dated 8/26/2025, it indicated the following orders: Treatment: Left dorsal hand skin discoloration with open ecchymosis. Cleanse with normal saline (solution used to clean wounds), pat dry, apply xeroform (a non-stick wound dressing) and cover with dry dressing every day, for 14 days, with order date of 8/14/2025. Treatment: Left forearm skin discoloration with open ecchymosis. Cleanse with normal saline (solution used to clean wounds), pat dry, apply xeroform (a non-stick wound dressing) and cover with dry dressing every day, for 14 days, with order date of 8/14/2025. Treatment: Left arm multiple skin discoloration. Monitor for skin breakdown, adverse changes (harmful), pain, significant complications. Notify Doctor immediately if noted every day per shift for 14 days, with order date of 8/14/2025. During a concurrent observation and interview on 8/26/2025 at 2:45 PM with Certified Nurse Assistant 1 (CNA 1), Resident 1 was observed in the activity room with other residents. Resident 1 was observed wearing a long sleeves top shirt, and dressing was observed on Resident 1's left dorsal hand. CNA 1 stated he is assigned to Resident 1 today, and Resident 1's dressings on his left hand and arm were new to him because Resident 1 did not have any skin issues when he was last assigned to him 2 weeks ago. CNA 1 stated he was informed today that Resident 1 was receiving treatment for skin problems on Resident 1's left hand and arm. During a concurrent record review and interview on 8/26/2025 at 3:05 with MDS nurse (MDSN), Resident 1's medical records were reviewed. MDSN stated Resident 1 was not on anticoagulant. MDSN stated Resident 1's SBAR dated 8/14/2025 indicated Resident 1 was on anticoagulant. MDSN stated Resident 1's swelling, skin discoloration and bruises should have been investigated, and the use of anticoagulant should not have been used in the documentation as the reason for having those injuries. During an interview on 8/26/2025 at 3:17 PM with Infection Preventionist Nurse (IPN), IPN stated the local law enforcement visited Resident 1 on the afternoon of 8/15/2025. The IPN recalled that the reason for the local law enforcement's visit was because Resident 1's family reported an alleged abuse. During an interview on 8/26/2025 at 3:25 PM with the treatment nurse (TN), the TN stated that on the evening shift (3 PM - 11 PM) of 8/14/2025, Registered Nurse 1 (RN 1) informed him of Resident 1's left upper extremity skin issues that needs to be assessed. TN stated it was the first time that a staff member reported a skin issue for Resident 1. During a concurrent record review and interview on 8/26/2025 at 4:13 PM with Social Service staff, Resident 1's IDT dated 8/15/2025 were reviewed. Social service staff stated IDT was conducted on the afternoon of 8/15/2025 because local law enforcement (PD, Police Department) visited Resident 1, due to Resident 1's family reported to PD that Resident 1 has bruising, and they believed that something might have happened to him to cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555908 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Pasadena Care Center 904 Mission St South Pasadena, CA 91030 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete those bruises. Social service staff stated during the IDT, it was discussed that the bruising might have been from Resident 1's last blood test on 8/12/2025 and Resident 1's using aspirin. During a concurrent record review and interview on 8/26/2025 at 4:30 PM with RN 1, Resident 1's medical records were reviewed. RN 1 stated that on 8/14/2025, Resident 1's family reported to her the skin issues on Resident 1's left upper extremity. RN 1 stated she did not know how it happened, and there was no endorsement from previous shift regarding Resident 1's skin discoloration and swelling of left upper extremity. RN 1 stated Resident 1 was unable to give them information on how he sustained his left-hand swelling and left arm discolorations. RN 1 stated maybe it's from long term use of aspirin. RN 1 stated Resident 1's change of condition of sustaining left hand swelling and skin discolorations were reported to the DON and the DON initiated Resident 1's care plan for skin discoloration, swelling and pain to left hand and arm of unknown origin. RN 1 stated the DON should have reported it to CDPH, local law enforcement and ombudsman because we did not know how Resident 1 sustained those injuries. RN 1 verified Resident 1 had a blood test on 8/12/2025, but there was no documented evidence that Resident 1 sustained skin discolorations, bruising and swelling due to the blood draw that was performed on 8/12/2025. During a concurrent record review and interview on 8/26/2025 at 6 PM with IPN, Resident 1's medical records were reviewed. IPN stated Resident 1's SBAR for left hand swelling and left arm discoloration were initiated on 8/14/2025, and Resident 1's Doctor was notified, and X-ray order was obtained because RN 1 did not know how Resident 1 sustained the skin discoloration, swelling and pain to left hand and arm. IPN verified Resident 1's care plan was initiated on 8/14/2025 by DON, and it indicated Resident's 1 skin discoloration, swelling and pain to left hand and arm was of unknown origin. IPN verified facility did not report Resident 1's left arm injuries to local law enforcement, CDPH and ombudsman. IPN stated since the DON did not know how Resident 1 sustained the left upper extremity injuries, the incident should have been reported to local law enforcement, CDPH and ombudsman for thorough investigation, to know how Resident 1 sustained the injuries, and to develop a care plan for Resident 1 to prevent these injuries from happening again. During a review of facility's Policy and Procedures (P&P), titled Investigating Resident Injuries, dated January 2025, the P&P indicated all resident injuries are investigated. The P&P also indicated Injury of unknown source is defined as an injury that meets both of the following conditions:a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; andb. The injury is suspicious because of:(1) the extent of the injury; or(2) the location of the injury(3) the number of injuries observed at one particular point in time. During a review of facility's Policy and Procedures (P&P), titled Abuse Investigation and Reporting, revised on March 2024, the P&P indicated, all reports of mistreatment and/or injuries of unknown source shall be promptly reported to agencies as defined by current regulations and thoroughly investigated by facility management. The P&P also indicated all other instances of mistreatment and/or injuries of unknown source will be reported by the facility Administrator, or designee, to the following agencies immediately or as soon as practicable, but not later than two hours after the incident occurred: Ombudsman Law enforcement officials The State licensing/certification agency responsible for surveying/licensing the facility. Event ID: Facility ID: 555908 If continuation sheet Page 3 of 3