Health inspection·August 27, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an injuries of unknown source for one (1) of two sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB, advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement on 8/14/2025. This deficient practice resulted in a delay of onsite inspection by the Department of Public Health and had the potential to result in inadequate care to residents, unidentified abuse/neglect and continuation of abuse/neglect to the residents in the facility. During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of but not limited to dementia (a progressive state of decline in mental abilities), atrial fibrillation (an irregular and often rapid heartbeat) and anemia (a condition where the body does not have enough healthy red blood cells), Type II diabetes (body cannot use insulin effectively or does not produce enough insulin to regulate blood sugar level) and repeated falls. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/27/2025, indicated Resident 1's cognitive (ability to think, reason and problem solving) skills for daily decision making were modified independence (some difficulty in situations only). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 is not taking anticoagulant (medicines that prevent blood clots [a clump of blood that has thickened from a liquid to a solid gel] from forming in the bloodstream). During a review of Resident 1's care plan, initiated on 8/14/2025 by the Director of Nursing, the care plan indicated that Resident 1's has skin discoloration, swelling, and pain to left hand and arm of unknown origin. Resident 1 is on aspirin (medication used to relieve pain, reduce fever, and decrease inflammation), which may contribute to bruising. The care plan interventions included the following: Monitor left arm and hand for changes in color, swelling, pain, and skin integrity every shift and PRN. Elevate affected extremity as tolerated to help reduce swelling. Administer pain medication as ordered and monitor effectiveness. Follow Doctor's order for STAT (immediately) X-ray (a diagnostic imaging procedure that uses high-energy radiation to create black-and-white pictures of the inside of the body) and implement subsequent treatment plan. Avoid unnecessary handling or pressure to affected extremity. Document all findings, Page 1 of 3 555908 555908 08/27/2025 South Pasadena Care Center 904 Mission St South Pasadena, CA 91030

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 555908 Page 2 of 3 555908 08/27/2025 South Pasadena Care Center 904 Mission St South Pasadena, CA 91030

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 555908 Page 3 of 3