Other·May 31, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification survey. Representing the Department of Public Health: Surveyor ID#: 36290 Surveyor ID#: 30258 Surveyor ID#: 36417 Surveyor ID#: 07598 Total Resident Census: 55 Total Resident Sample: 15 Highest Scope and Severity: E

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 05/15/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 1 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 2 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and record review, the facility to develop a care plan for 1 of 15 sampled residents (Resident 1). Resident 1 had a history of refusing the nasal cannula (NC, tubing used for oxygen delivery) padding behind her ears. This deficiency resulted with Resident 1 not receiving appropriate interventions to prevent skin breakdown. Findings: A review of the face sheet indicated Resident 1 was admitted to the facility on 11/16/15 with diagnoses that included: pneumonia (infection that inflames the air sacks in the lungs), atrial fibrillation (two upper chambers of the heart beat chaotic and irregular), hypertension, anxiety disorder, and major depressive disorder. On 4/27/17 at 9:40 p.m., an interview was conducted with Resident 1's Responsible Party (RP). She stated that the staff had a difficult time with Resident 1 because she refused the NC padding behind her ears. RP stated that the staff tried placing gauze behind the ears and Resident 1 refused. On 4/28/17 at 7:52 a.m., an interview was conducted with Director of Nursing (DON). DON was asked about if a care plan was developed for Resident 1's behavior of refusing the NC padding. She stated, "I guess I trusted the staff and their judgement." DON stated that this behavior should have been care planned by the staff because the resident was refusing care and no interventions were developed, this could result with a poor patient outcome. DON stated that even when a resident refuses care, the facility had to provide care and was responsible for the well-being of the residents. A review of the Goals and Objectives, Care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 3 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Plans policy and procedure with a revision date of April 2009, indicated "Care Plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independent. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved."

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 05/15/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 4 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to ensure a post dialysis assessment was done for one of 14 sampled residents (Resident 4). This failure had the potential for the resident to have complications that may go untreated such as bleeding and swelling. Findings: An assessment face sheet indicated resident 4 was admitted to the facility on 10/30/16. The resident's diagnoses included end stage renal failure (kidney failure) requiring dialysis (a method of filtering waste from the blood when the kidneys are no longer functioning appropriately. A Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 2/6/17, indicated Resident 4 was dependent on staff for activities of daily living. Physician's orders dated 10/30/16, indicated Dialysis every Monday, Wednesday, and Friday, monitor vital signs every shift and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 5 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE monitor for signs and symptoms of edema (swelling) every shift. Another physicians order dated 11/4/16, indicated to monitor intake and output every shift. In addition the resident was on fluid restriction of 1000 milliliters per day starting 11/4/16. Review of the 4/17, Treatment Administration Records (TAR) indicated a dressing change to be made by dialysis nurse as needed started 10/30/16. Review of a Dialysis Communication and Follow- Up , dated 4/28/17, indicated the post assessment (assessment done upon return from dialysis) was not completed. The section was left blank. Nursing notes for 4/28/17, failed to indicate any documentation or vitals related to post dialysis assessment. During an interview on 4/28/17, at 8:05 p.m., licensed vocational nurse (LVN 6) stated upon return from dialysis a head to toe assessment is done. Included in the head to assessment is mental status, vitals, and assessment of the pressure bandage. During an observation on 4/28/17, at 7:30 p.m., Resident 4 was observed in her room sitting in a wheelchair the left arm was bandaged with a white gauze, and the skin to the arm was pink and shiny. According to Resident 4 she had returned from dialysis at around 12:30 p.m., earlier that day. On 4/28/17, at 8:20 a.m, during an interview, the treatment nurse stated the dialysis site should be assessed post dialysis. Most residents have the dressing removed within four hours following the return from dialysis however some residents have a specific time at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 6 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which they remove the dressing. The physician determines if it is at a specific time otherwise it is removed approximately four hours after returning from the dialysis. The bruit and thrill should be assessed when looking at the site. Vitals and weights are also taken. On 4/29/17, at 6:36 a.m., Resident 4 was observed lying in bed. The resident's left arm and hand was swollen. Resident 4 stated her dressing (from dialysis the previous day) had been removed by the nurse earlier that morning, Resident 4 stated "About an hour ago." During an interview with the treatment nurse on 4/29/17, at 8:20 a.m, the treatment nurse stated vitals, level of consciousness and the bruit and thrill are to be assessed upon return from dialysis. When asked if Resident 4 had been assessed upon returning from dialysis the previous day the treatment nurse stated "I'm not sure." When asked who was responsible for assessing and removing the dressing upon return from dialysis the treatment nurse stated "Any licensed nurse.": In an interview on 4/29/17, the director of nursing (DON) acknowledged the Dialysis Post Assessment had not been completed. The DON stated upon return from dialysis the vital signs, blood sugar, dialysis dressing and site, should be assessed. The dressing to the site should be removed approximately four hours after returning from dialysis if there are no complications. The DON stated the facility staff was aware of the swelling to Resident 4's arm and hand and were actively treating it. Review of the policy Hemodialyisis Access Care, revised September 2010, indicated documentation: the general medical nurse should document in the resident's medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 7 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record every shift as follows: Location of Catheter, Condition of dressing , If dialysis was done during shift, any part of report from dialysis nurse post dialysis being given, and observations post dialysis.

F314 SS=D TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 05/15/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure sore development [localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction (objects rubbing against each other)] for one of two residents (Resident 1) at high risk for pressure sore in a total sample of 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 8 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents. For Resident 1, the facility failed to: a. Implement the physician's order to place the nasal cannula (NC, tubing used to deliver oxygen via nostrils) paddings to the back of Resident 1's ears to provide pressure relief to the area. b. Develop a care plan for when Resident 1 refuses to wear the NC padding and provide alternative interventions to provide pressure relief to the ear. c. Document skin integrity checks to the back of the ears on a daily basis to identify any skin damage to be addressed. d. Accurately assess a wound as a pressure sore by the Licensed Vocational Nurse 1 (LVN 1), Registered Nurse 1 (RN 1), and Treatment Nurse (TN 1) to provide treatment and services. e. Notification to Resident 1's physician of the development of a pressure sore. These deficient practices resulted with Resident 1 developing a pressure sore to the back of the right ear. In addition 3 of 15 sampled residents (Residents 2, 6 and 7) were not wearing NC paddings behind the ears as ordered by the physician. There was a potential for Residents 2, 6, and 7 to develop pressure sores to the back of the ears. Findings: a. A review of the face sheet (document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 9 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility on 11/16/15, with diagnoses of pneumonia (infection that inflames the lungs), atrial fibrillation (two upper chambers of the heart beat irregular), hypertension (high blood pressure), anxiety disorder (have intense, excessive and persistent worry and fear about everyday situations), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 2/21/17, indicated Resident 1 was at risk for developing pressure ulcers. A review of the Braden Scale (scale used for predicting Pressure Sore Risk assessment tool) dated 2/20/17, indicated Resident 1 was at high risk for developing pressure sores. Resident 1 score was a 10, (total score of 12 or less represents high risk). A physician's order dated 6/2/16, indicated Resident 1 required three liters of oxygen via a nasal cannula (NC, tubing used to deliver oxygen) for shortness of breath with padding to the back of the ear tubing. On 4/27/17, at 9:39 p.m., during an observation Resident 1 was lying in bed with a NC in place. Resident 1's head was turned toward the right side, lying on her right ear. There was no padding in place to the part of the NC in the back of the ear. On 4/27/17, at 9:40 p.m., an interview was conducted with Resident 1's Responsible Party (RP). RP stated Resident 1 had refused placement of the NC padding and that Resident 1 preferred to lie down on her right side. There was no care plan developed for this behavior (refusal of padding) found in Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 10 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medical record. On 4/27/17, at 9:43 p.m., an observation was conducted of Resident 1's right ear with the NC in place. The skin alongside the NC was red and swollen, there was crust (thick yellowish liquid that gets dried up) touching the skin and over the tubing with mild weeping (slow discharge from a wound) fluid. The back of both ears were compared and the back of the right ear was bigger than the left. In addition, the NC tubbing under Resident 1's chin was pulling toward the left and pulling the portion located behind the right ear. There was no documented evidence the staff assessed the skin underneath the NC device behind the ears. On 4/27/17, at 9:43 p.m., Resident 1 stated her right ear hurt whenever someone pulled the NC tubing. On 4/27/17, at 10:02 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 was caring for Resident 1 and stated another of her residents had a pressure ulcer. During a subsequent observation of Resident 1, on 4/27/17, at 11:09 p.m., the NC had padding. The function of the padding is to help prevent local skin damage cause by the pressure of the tubing. On 4/27/17, at 11:10 p.m., LVN 1 was asked if she had placed the padding of Resident 1's NC behind the ears and stated, "Yes." LVN 1 was asked if she assessed the back of the right ear and she stated "Yes, it's just red." LVN 1 stated Resident 1 always refused placement of the NC padding to the back of her ears and staff had tried to wrap the tubing with gauze a few times. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 11 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 4/27/17, at 11:15 p.m., a second observation was conducted of Resident 1's right ear; LVN 1, RN 1, and Surveyor 2 were present. Resident 1 was completely turned toward the left side and a flashlight was used during the assessment. Resident 1's NC was removed and the back of her ear had an open wound (the length correlated with the location of the NC), redness around the wound and redness directly behind the ear with a mild amount of purulent (light yellow) drainage present, and swelling to the back of the ear. During an interview on 4/27/17, at 11:16 p.m., RN 1 stated Resident 1's back of the ear had yellow drainage, redness, swelling, and the skin was open. A review of the physician's order dated 4/27/17, at 11:40 p.m., indicated to observe the back of the right ear on a daily basis and cleansed with normal saline (sterile water) or wound cleaner with the application of hydrogen gel (gel used for wounds). A review of LVN 1's notes dated 4/28/17, at 12:40 a.m., indicated "resident complained of pain in right ear noted with redness." There was no documentation of the drainage and open wound. On 4/28/17, at 7:52 a.m., an interview was conducted with the director of nursing (DON). The DON stated the Resident 1 had refused to wear the NC paddings and this behavior was not care planned. The DON stated the staff should develop a care plan for when a resident resist care because if no interventions are developed it can result in a poor resident outcome. On 4/28/17, at 8:16 a.m., an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 12 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with RN 2. RN 2 stated on 4/27/17, after the survey team had left after midnight, she was asked by the facility to perform a second assessment to the back of Resident 1's ear, "I didn't see anything." RNS 2 stated she put A & D ointment (topical skin protectant) to the back of the ear. A review of RN 2's notes dated 4/28/17, at 8:41 a.m., indicated a late entry for 4/27/17, at 10:00 p.m. The documentation indicated the back of the right ear had "mild pinkness, dry, [and] no breakdown noted." The documentation was done after the interview and the information was not consistent. There was no prior documentation on the condition of the ear prior to this late entry. On 4/28/17, at 8:23 a.m., a third observation to the back of Resident 1's ear was conducted with RN 2, DON (director of nursing), and TN 1 present. The back of Resident 1's ear had an open wound; the skin was pink, and swollen. A review of RN 2's notes dated 4/28/17, at 9:00 a.m., indicated "follow up assessment of behind right ear. Behind right ear redness and pinpoint size ulcer note without drainage." On 4/28/17, at 8:25 a.m., an interview was conducted with the DON, she stated the back of Resident 1's ear had open skin, was pink, and the ridge was bigger than the left ear. On 4/28/17, at 8:32 a.m., TN 1 cleaned the wound with normal saline and then measured Resident 1's wound with a cotton swab. As TN 1 was measuring the wound, he verbalized the following: length 1 centimeter (cm), width 0.2 cm, and depth 0.3 cm. TN 1 stated Resident 1's skin to the back of the ear was open and pink. TN 1 further stated the tubing of the NC could cause pressure to the back of the ears. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 13 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of TN 1's notes dated 4/28/17, indicated the back of the ear was red measuring 1 cm in length, 0.2 cm in width, and 0.3 cm in depth. The skin issue type was documented as an "Abrasion/irritation-minor (an injury caused by something that rubs or scrapes against the skin; a superficial damage to the skin)." According to the National Pressure Ulcer Advisory Panel (NPUAP) dated 2/23/15, indicated that Medically Related Pressure Ulcers are "pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device." The number one locations where these pressure ulcers occur are: head, neck, face, and ears. Oxygen delivery via nasal cannula is pressure ulcers waiting to happen. The recommendations for assessment of skin and medical devices "Inspect skin and under medical device at least twice daily ideally more frequently." The general preventive care "View skin under devices each shift, lift the device and reposition, use skin protectant. The strategies for pressure ulcer prevention for the use of oxygen tubing "watch ears, move hair [and] use tubing protectors." http://www.npuap.org/resources/educationaland-clinical-resources/npuap-pressure-injurystages/ A review of DON's notes dated 4/28/16, at 8:44 a.m., indicated "On assessment with treatment nurse, area behind right ear noted. Small area with a small, narrow, broken area, clean, dry, no exudate, and pink in color...Ear shape has a protuberance (usually rounded part that sticks out from a surface) on that side somewhat more than the left side." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 14 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 4/29/17, at 6:10 a.m., an interview was conducted with RN 1. RN 1 stated LVN 1 notified the physician of Resident 1's condition and obtained an order for the treatment without providing the physician the actual condition of Resident 1. The actual condition of Resident 1 was not provided to the physician due to RN 1 not endorsing or documenting her assessment of Resident 1's ear. RN 1 further stated the yellow drainage observed on Resident 1's ear was A & D ointment placed by RN 2. The information provided by RN 1 about the A & D ointment application was not consistent with the time provided by RN 2 of when she applied the A&D ointment. On 4/29/17, at 6:58 a.m., an interview was conducted with LVN 2. LVN 2 stated the facility practice was when residents require the use of a NC for oxygen delivery a gray pad is place to the tubbing behind the ears. The purpose of the padding to the back of the ears is to prevent redness and sores. LVN 2 stated that the NC could cut the skin and cause pressure sores. The refusal of NC padding by a resident, places them at greater risk for pressure sores, they are to receive education and a care plan should be develop. LVN 2 stated residents who refuse the paddings to the back of the ears should be checked every day. b. A review of the face sheet indicated Resident 2 was admitted on 4/10/17 with diagnoses that included: artificial hip joint, difficulty walking, and cardiac arrhythmia (abnormal heart beat). A review of the physician's order dated 4/10/17 for Resident 2, indicated oxygen to be administered at 2 liters by nasal cannula at a continuous rate for shortness of breath. In FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 15 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE addition, the application of padding to the oxygen tubing for both earlobes was ordered. On 4/27/17 at 10:56 p.m., an observation was conducted. Resident 2 was asleep and lying on his bed with a nasal cannula in place and there was no padding to the right earlobe (back of the ear). Certified Nursing Assistant 1 (CNA 1) confirmed the observation. c. During an observation on 3/27/17 at 10:57 PM in the presence of Certified Nursing Assistant (CNA) 3, Resident 6 had a nasal cannula (the equipment used to administer oxygen; a mall tube that goes from the oxygen tube and attached to a person's head. The tube's securement begins under the chin, the splits to go behind the ears, across the cheeks, and then meet under the nose where two small tubes branch to the opening of each nostril to allow for the flow of oxygen to enter the nose) attached to her head without padding on the tubing behind her ears. According to the physician orders for Resident 6, there was an order for oxygen to be given at 3 liters per minute (the prescribed flow rate of the oxygen) via nasal cannula to be administered continuously for shortness of breath. The order indicated to "apply padding to O2 (oxygen) to tubing bilateral earlobe." The order was written on 1/26/17. d. During an observation on 3/27/17 at 10:58 PM in the presence of CNA 3, Resident 7 had a nasal cannula attached to his head without padding on the tubing behind his ears. According to the physician orders for Resident 7, there was an order for oxygen to be given at 3 liters per minute (the prescribed flow rate of the oxygen) via nasal cannula to be administered continuously for shortness of breath. The order indicated to "apply padding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 16 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to O2 (oxygen) to tubing bilateral earlobe." The order was written on 4/11/17. During an interview with the DON on 4/29/17, the DON confirmed that nursing staff should ensure that padding should be placed on the oxygen tubing if the physician ordered it.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 05/15/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 17 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that oxygen was flowing at the prescribed rate for two out of 14 sampled residents (Resident 6 and Resident 7). For Resident 6, a resident was receiving oxygen therapy that was flowing at a rate lower than the prescribed rate. For Resident 7, there was not "oxygen in use" sign above the door. This had the potential for the residents to have inadequate oxygen administration and monitoring. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 18 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a. During the initial tour on 4/27/17 at 8:13 PM in the presence of LVN 3, it was observed that the flow rate of Resident 6's oxygen was flowing at a rate between 2 and 2.5 liters as indicated by the meter. LVN 3 confirmed that the oxygen rate was flowing between 2 and 2.5 liters. LVN 3 stated that Resident 6 should receive oxygen at 3 liters in accordance with the physician orders. LVN 3 was observed changing the flow rate to 3 liters at this time. During a review of Resident 6's physician orders, the order for oxygen indicated that the flow rate should be at 3 liters. The order was active as of 1/26/17. During an interview with the DON on 3/29/17 at 3:37 PM, the DON confirmed that that nursing staff are supposed to follow the physician orders and that the flow rate should have been set at 3 liters for Resident 6. b. During an observation in the presence of CNA 3 on 3/27/17 at 10:58 PM, it was observed that there was not an oxygen sign on the door for the room of Resident 7. CNA 3 confirmed that there was not a sign on Resident 7's door and stated that there should have been a sign on the door. According to the facility's policy and procedure titled "Oxygen Administration," the policy indicates "place an oxygen in use sign on the outside of the room entrance door." The policy further indicates "unless otherwise noted, start the flow of oxygen at the rate of 2 to 3 liters per minute."

F332 SS=D FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F332 Event ID: 5PU211 05/15/2017 Facility ID: CA970000066 If continuation sheet 19 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (f) Medication Errors. The facility must ensure that its(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility staff failed to ensure medications were adminstered as ordered for one randomly sampled resident (RSR 15). Findings: a. An admission assessment indicated Randomly Sampled Resident (RSR 15) was admitted to the facility on 1/31/17. A physician's order dated 3/31/17, indicated to administer Med Pass 60 cc by mouth three times a day. For decrease in weight. During observation of a medication pass the charge nurse failed to administer the supplement Med Pass 2.0. During an interview on 4/29/17, licensed vocational nurse (LVN 7) stated she forgot to administer the Med Pass 2.0 supplement to RSR 15. b. During observation of a medication pass on 4/29/17, starting at 10:25 a.m. medications were not adminsitered until 10:40 a.m., The medicaitons were ordered to being given at 9 a.m. Duirng an interview on 4/29/17, at 10:40 a.m., licensed vocational nurse (LVN 7) stated she was late because she fell behind with another resident. When asked if she had any more residents to pass medications, LVN 7 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 20 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she had one more resident that she needed to give medications before she is finished with the morning medication pass. LVN 7 stated she was allowed to give medicaitons one hour before and one hour after, LVN 7 stated "I know I was late". Review of the Guidelines for Medication Administration indicated the five rights for the administration of medication. The right resident, the right drug, the right dose, the right time, and the right route.

F371 SS=D FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 05/15/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 21 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility staff failed to store and protect food under sanitary conditions,two kitchen spices were not labeled with appropriate open dates, the third door on the refrigeration unit did not have a working light. This improper food safety practice could lead to possible food borne illness and or food/contamination. As well as the kitchen equipment was maintained in good health. Findings: During initial tour on 4/27/17, at 7:45 p.m., two spices in 16 ounce containers located above the two compartment sink were observed with no open date nor did the containers have an expiration date. The first was a lemon pepper and the second a ground cumin. During an interview on 4/27/17, at 7:45 p.m, dietary staff stated the spices should have been dated with an open date. According to the dietary staff he was unsure of the reason why they were not dated. The dietary staff also stated the spices should have an expiration date however he was unable to find one on either of the spices. On 4/28/17, at 6:40 p.m., the dietary supervisor stated the spices or any food should always be labeled with an open date. b. During an inspection of the kitchen on 4/28/17, at 6:50 a.m., and in the presence of the dietary supervisor, the refrigeration unit did not have a working light when the 3rd door was opened. The dietary supervisor was asked if it was supposed to have a light. The dietary supervisor stated "Yes". The dietary supervisor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 22 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE closed the door and reopened and once again the light did not turn on.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 05/15/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 23 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that medications were properly secured for a medication cart in one out of two nursing units (Unit 1). For Unit 1, a nurse left a medication cart unlocked and unattended after use. This failure had the potential for unauthorized persons to have access to resident medications. In addition, the facility failed to ensure the medication refrigerator was between 26 and 46 degrees Fahrenheit. This failure had the potential for medications to go bad or not work as indicated. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 24 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a. During an observation on 4/28/17 at 9:30 PM, it was observed that Registered Nurse Supervisor (RNS 3) left a medication cart unlocked and unattended. The medication cart was stored against the wall between rooms 2 and 3. This location is not in view of the nursing station. The medication cart was observed having the lock pushed out and the top draw open and pushed outward. At 9:38 PM, RNS 3 returned to the medication cart and was asked if the cart was locked. RNS 3 confirmed that the cart was not unlocked. RNS 3 confirmed that she is supposed to keep the medication cart locked before she leaves it. RNS 3 pushed in the top drawer and pushed the lock in at this time. RNS 3 verbalized that someone, including a resident, could have access to the medication cart from failure to keep it locked. During an interview with the Director of Nursing (DON) on 4/29/17 at 3:57 PM, the DON confirmed that medication carts are supposed to be locked before nurses leave them unattended. According to the facility's policy titled "Medication Storage and Labeling" indicates under the "reference" section "Drugs shall be accessible only to personnel designated in writing by the licensee." b. During initial tour on 4/27/17, at 7:44 p.m., the temperature on the medication refrigerator was 52 degrees Fahrenheit. The refrigerator contained eye drops, and various vaccines. During the same time of the observation on 4/28/17, registered nurse (RN 1) was interviewed about the required temperature for the refrigerator and stated the temperature of the refrigerator should be "40 degrees" Fahrenheit. Review of the temperatures on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 25 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE refrigerator log indicated the temperature for the 3-11 shift was 40 degrees Fahrenheit. On 4/28/17 at 7 p.m., the director of nursing (DON) stated a second thermometer was added to the refrigerator the day the observation was made (4/27/17) in order to determine if the temperature reading of 52 degrees Fahrenheit was correct. The DON acknowledged the temperature had been too high.

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 05/15/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 26 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 27 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facilty failed to ensure new employees were tested and immunized within 30 days. This failure had the potential for the staff to develop and spead infecftions disease. Findings: A review of new hired employee files indicated one out of 5 employee files did not have a tuberculosis test that was no more than 90 days old. Staff 1 was hired on 3/13/17 and a chest xray was done on 11/18/16. During an interview on 4/29/17 at 3 p.m., the director of staff development (DSD) stated the employee had last received a chest x-ray at a general acute care facility (GACH). The DSD acknowledged the employee did not have the tuberculin test that was not older than 90 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 28 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F468 CORRIDORS HAVE FIRMLY SECURED HANDRAILS CFR(s): 483.90(i)(3)

F468 05/15/2017

F518 05/15/2017 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i)(3) Equip corridors with firmly secured handrails on each side; and This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that corridor handrails were firmly secured to the walls. Five handrails were moveable and unsteady. Findings: On 3/29/17 at 10:00 AM, a facility handrail observation was conducted in the presence of Maintenance Staff 1. Five different handrails throughout the facility's corridors were not adequately secured to the wall; the end portions were attached to the wall, were shaky, and able to move the handrails up and down. On 3/29/17 at 10:10, am interview was conducted with Maintenance Staff 1. Maintenance Staff 1 stated at one of the loose handrails across from the shower room near Room 17 "The bolts is loose." Maintenance Staff 1 confirmed that the handrails are supposed to be secured to the wall. According to the facility's policy provided by the Administrator on 3/29/17, titled "Administrative Policy: Environmental Services Ch. 408" the policy indicates "Licensee shall maintain handrails in safe and secure working conditions at all times. Areas of concern/need of repair shall be reported to the Plant/Maintenance Department for immediate correction."

F518 TRAIN ALL STAFF-EMERGENCY SS=D FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 29 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PROCEDURES/DRILLS CFR(s): 483.75(m)(2) The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff did not know emergency preparedness procedures, 2 of 9 staff (Registered Nurse Supervisor 1 and 3, RNS 1 and 3). For RNS 1, staff failed to know to use red outlets in case of a power outage. In case of an emergency, this deficient practice had the potential to result in harm for the residents that require use of medical equipment. For RNS 3, staff failed to know the location of water/gas shut off valves, electrical panel location and fire emergency interventions. These failures had the potential to compromise the residents in the event of an emergency/disaster. Findings: On 4/29/17 at 6:10 a.m., an interview was conducted with RNS 1. RNS 1 was asked where the resident's medical equipment should be plugged in if the facility experienced a power outage. No answer, then she was asked if the facility had different color outlets. RNS 1 could not respond and asked if she knew what outlets were? "Yes," RNS 1 did not know to plug in resident's medical equipment in to the red outlets in case of a power outage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 30 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 4/29/17 at 7:15 a.m., an interview was conducted with the Director of Staff Development (DSD). She stated that if the facility experienced a power outage the backup generator activates and the staff is taught to check if any residents need a power source for the medical equipment. DSD stated that this power source could only come from the red outlets located throughout the facility. A review of the Fire and Disaster Guidelines indicated that the "Generator provides automatic restoration of power for Emergency circuits within TEN SECONDS after normal power failure, The following services shall be powered by the Emergency Generator: Electrical Outlets (usually colored red)." b. During an interview with Registered Nurse Supervisor (RNS) 3 on 3/28/17 at 9:00 PM, RNS 3 was asked the location of the emergency water shut off, the emergency gas shut off, and the electric panel. RNS 3 verbalized that she did not know where the emergency gas shut off was. RNS 3 did not know the actual location of the emergency water shut-off was located; RNS 3 stated the location of the emergency water shut off was next to the Director of Staff Development and Medical Records office during the interview. RNS 3 did not know the location of the electric panel. RNS 3 referred to the reference card on her badge, and stated "I do not know where exterior is." The reference card indicates "shut off valve locations: Electric: Exterior Rm #23." During the interview, RNS 3 was asked about appropriate evacuation of the residents during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 31 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055480 (X3) DATE SURVEY COMPLETED 04/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN PASADENA HEALTHCARE 120 Bellefontaine St Pasadena, CA 91105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an emergency. RNS 3 was given a scenario where Unit 1 had a fire and Unit 2 was not on fire and that all residents would need to be evacuated. RNS 3 was asked which unit she would evacuate first. RNS 3 did not know which unit to evacuate first. After this, RNS 3 was told that Residents in Unit 1 were in immediate danger in the scenario because of the fire in Unit 1, while Residents in Unit 2 were not near the fire. RNS 3 was asked which residents she should attempt to evacuate first after being provided with this information. RNS 3 stated Unit 2. RNS 3 confirmed after this statement that she would first evacuate the residents in the unit that did not have the fire on it. According to the facility's Fire and Disaster Manual, revised 11/02, reviewed and approved 1/18/17, the manual indicates that the "those in immediate danger" should first be evacuated. During an interview with the Director of Nursing (DON) on 4/29/17 at 3:57 PM, the DON confirmed that nursing staff are responsible for knowing the facility's emergency preparedness information. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5PU211 Facility ID: CA970000066 If continuation sheet 32 of 32