Other·May 2, 2018

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#: 35893 Surveyor ID#: 27785 Surveyor ID#: 36535 Surveyor ID#: 36205 Surveyor ID#: 38864 Total Resident Census: 125 Total Resident Sample: 27 Highest Scope and Severity: E

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 04/15/2017 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide dignity during breakfast for one out of 27 sampled residents (Resident 77). Certified Nurse Assistant 5 (CNA 5) did not provide clothe protector for Resident 77 during breakfast to cover the resident's chest and to catch food particles. This deficient practice resulted in 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: WGOL11 Facility ID: CA970000075 If continuation sheet 1 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Resident 77 experiencing negative feelings and a loss of dignity. Findings: During an observation on 3/16/18, at 8:01 a.m., Resident 77 was observed in bed, alert, sitting up, and eating breakfast. Resident 77 was leaning to the left side, her gown was halfway down her chest area, exposing the upper half of her chest, and there were food particles noted on the bare skin of her upper chest area. During an interview on 3/16/18, at 8:06 a.m., Licensed Vocational Nurse 10 (LVN 10) confirmed that during breakfast time, Resident 77 had no towel bib to catch falling food, her gown was halfway down her chest, and food was on her skin. LVN 10 stated Resident 77's Certified Nursing Assistant (CNA) did not place a towel bib for her, and Resident 77 should have had a clothe protector place over the resident's chest. During an interview on 3/16/18, at 8:10 a.m., Resident 77 stated she preferred to have clothe protector during meals. Resident 77 stated it "feels no good" to have her chest area half exposed and food pieces on her. During an interview on 3/16/18, at 8:13 a.m., CNA 5 stated she was Resident 77's CNA that morning. CNA 5 stated she would normally get Resident 77 ready for breakfast by positioning Resident 77 upright, and placing a towel bib over her chest, but today she did not place the clothe protector. CNA 5 stated Resident 77 needed the towel bib to catch food because food would fall on her due to her hands lacking coordination. She stated she should have gotten the clothe protector. A review of Resident 77's face sheet, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 2 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Resident 77 was admitted to the facility on 3/24/17, with diagnoses of chronic obstructive pulmonary disease (a lung disease characterized by long term poor airflow), osteoarthritis (a joint disease that mostly affects the cartilage [the slippery tissue that covers the ends of bones]), muscle weakness, left-sided hemiplegia (paralysis of one side of the body), and hemiparesis (muscle weakness or partial paralysis of one side of the body). A review of Resident 77's Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool), dated 2/5/18, indicated that Resident 77 had moderate impairment in cognition (refers to mental abilities or processes), and required extensive assistance from staff with activities of daily living (ADLs), which included eating, toileting, dressing, and personal hygiene. A review of Resident 77's care plan, revised on 2/16/18, indicated that Resident 77 had selfcare deficits with the goal that Resident 77 will be clean, dry, and well groomed. The care plan indicated that the goal was for staff to assist Resident 77 with ADLs as needed and maintain the resident's privacy. A review of the facility's policy and procedure, titled "Assisting the Resident with In-room Meals," revised on 12/2013, indicated that the facility was to provide for any special needs of the residents who eat in their room and assemble needed equipment and supplies, which included wash cloth and towel.

F609 Reporting of Alleged Violations FORM CMS-2567(02-99) Previous Versions Obsolete

F609 Event ID: WGOL11 04/15/2018 Facility ID: CA970000075 If continuation sheet 3 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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) SS=D CFR(s): 483.12(c)(1)(4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to thoroughly investigate and report an allegation of staff to resident abuse for one of 27 sampled residents (Resident 324) in a timely manner. This deficient practice had the potential to put the residents' safety at risk. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 4 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 facility reported incident regarding staff to resident abuse was investigated during the facility's recertification survey. A review of the clinical record indicated Resident 324 was admitted to the facility on 12/15/17 with diagnoses that included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis, dependence on renal dialysis [procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances]), quadriplegia (paralysis of all four limbs), and spinal cord compression ( caused by any condition that puts pressure on the spinal cord). A review of the admission Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 12/22/17 indicated Resident 324's cognition was moderately impaired. Resident 324 required total dependence (full staff performance every time) in performing activities of daily living such as bed mobility, dressing, toilet use and personal hygiene with one person physical assist. On 3/12/18 at 3:15 p.m., during an initial tour of the facility, Resident 324 complained he was "roughly handled by a staff" and felt "inhumanely treated". Resident 324 stated a female Certified Nursing Assistant (CNA 1 that works from 11 p.m. - 7 a.m. shift) did not like him since admission. Resident 324 stated "She handled me very rough. She used vulgar words and she would make comments if I have a bowel movement like 'Oh my God, look at this'. She made me feel inhuman, I even told her try being quadriplegic yourself". Resident 324 stated CNA 1 would let him sat on his own feces and she will clean him last. Resident 324 added that CNA 1 will look at him angry if he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 5 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 had a bowel movement. Resident claimed at one incident CNA 1 grabbed a friend and stated "come see this guy" and resident said he did not like what she did. Resident 324 stated "She scrubbed me hard, I had abrasive scars from her strong scrubbing. She uses a solution I don't know what, she never told me what the solution was but when she poured it on me, it burned me. I felt scared every time I heard her voice." Resident 324 stated he had enough of the CNA's behavior so he reported to the charge nurse and facility staff approximately three weeks ago. On 3/13/18, at 9:35 a.m., an interview was conducted with the facility's administrator who stated the facility received a grievance from Resident 324 that he felt CNA 1 was "too short with him" and "he was upset". The Administrator indicated the resident felt CNA 1 was rough with him. The Administrator stated he did not report the incident to the licensing department since there was no indication for him to believe there was an abuse that happened. The Administrator confirmed the resident made a complaint that CNA 1 was rough with him. The Administrator indicated a grievance can be a complaint and he should have reported the incident to the licensing department to be investigated. On 3/13/18, at 10:10 am, an interview was conducted with the facility's director of staff development (DSD) assistant who stated," Maybe 2 months ago, one day I noticed the resident was quiet and he was different that day. I asked him what was wrong and he told me the 11 p.m.-7 a.m. female nurse did not treat him professionally. He told me the female nurse was unprofessional, making jokes on the consistency of his diarrhea. He stated to me he did not enjoy the care and the nurse was too rough. He stated he would appreciate if another FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 6 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 nurse would take care of him. I immediately told my charge nurse that my patient was uncomfortable and that a female nurse did not treat him right". On 3/13/18 at 2:40 p.m., an interview was conducted with the facility's Registered Nurse (RN 1) who stated she did not know the specific incident and all she remembered was that Resident 324 made a complaint about the 11 p.m.-a.m. shift CNA and that he did not want the same CNA to be assigned to him. On 3/13/18, at 3:10 p.m. an interview was conducted with the facility's Director of Nursing (DON) who stated the charge nurse reported to her that Resident 324 complained that CNA 1 went to his room and called another nurse and the 2 staff made a comment that he was soiled. DON stated the resident claimed the nurse was laughing about his stool. The DON confirmed the resident's grievance was not reported to the licensing department based on the administrator's conclusion that the incident is not something that the staff had intent or will to do harm to the resident as it was a miscommunication. The DON indicated a grievance and a complaint are the same and all allegations of abuse had to be reported to the licensing department for investigation. On 3/13/18 at 3:30 p.m., an interview was conducted with the facility's Director of Staff Development (DSD) who stated the incident was reported to her by her DSD assistant who stated Resident 324 was uncomfortable with brief change from the female CNA as she was "kind of rough to the resident". DSD stated "I interviewed the resident and he did say he was uncomfortable that the staff left him after checking his soiled diaper". DSD stated the CNA wanted to show to the charge nurse that the previous shift did not change the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 7 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 soiled diaper. DSD indicated all allegations of abuse had to be reported to the licensing department for investigation. A review of the facility's Verification of Incident Investigation/Administrative Summary indicated the date of incident was on 2/11/18 night shift. Brief description of the incident indicated on 2/11/18 resident complained that when his nurse assistant came into his room to change him and saw his soiled brief, she turned away disgusted and commented to another nurse. Resident did not hear what she said and thought she may have been commenting about how gross he was due to his being soiled. He also stated that he felt she could have been more gentle while cleaning him up. On 2/14/18 the investigation was concluded. A review of the facility's undated policy and procedure titled" Abuse Allegation Reporting" indicated the administrator/abuse coordinator will report all alleged violations to the DHS within 24 hours and the Ombudsman within 48 hours utilizing the SOC 341. This initial reporting may include the allegation, suspension and continuing investigation. The results of all abuse allegations will be reported to the DHS and Ombudsman within five (5) working days and if the violation is substantiated, the appropriate corrective actions was taken, including the notification of the appropriate licensing /certification board of the alleged perpetrator.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 04/15/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 8 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to implement their abuse policy and procedure to protect and prevent further potential abuse for 1 of 27 sampled residents (Resident 324). The facility allowed an alleged perpetrator to work and provide care to residents while abuse investigation was ongoing for Resident 324. This deficient practice had the potential to result in further abuse. Findings: A facility reported incident regarding staff to resident abuse was investigated during the facility's recertification survey. A review of the clinical record indicated Resident 324 was admitted to the facility on 12/15/17 with diagnoses that included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis, dependence on renal dialysis [procedure to remove wastes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 9 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 or toxins from the blood and adjust fluid and electrolyte imbalances]), quadriplegia (paralysis of all four limbs), and spinal cord compression ( caused by any condition that puts pressure on the spinal cord). A review of the admission Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 12/22/17 indicated Resident 324's cognition was moderately impaired. Resident 324 required total dependence (full staff performance every time) in performing activities of daily living such as bed mobility, dressing, toilet use and personal hygiene with one person physical assist. On 3/12/18 at 3:15 p.m., during an initial tour of the facility, Resident 324 complained he was "roughly handled by a staff" and felt "inhumanely treated". Resident 324 stated a female Certified Nursing Assistant (CNA 1 that works from 11 p.m. - 7 a.m. shift) did not like him since admission. Resident 324 stated "She handled me very rough. She used vulgar words and she would make comments if I have a bowel movement like 'Oh my God, look at this'. She made me feel inhuman, I even told her try being quadriplegic yourself". Resident 324 stated CNA 1 would let him sat on his own feces and she will clean him last. Resident 324 added that CNA 1 will look at him angry if he had a bowel movement. Resident claimed at one incident CNA 1 grabbed a friend and stated "come see this guy" and resident said he did not like what she did. Resident 324 stated "She scrubbed me hard, I had abrasive scars from her strong scrubbing. She uses a solution I don't know what, she never told me what the solution was but when she poured it on me, it burned me. I felt scared every time I heard her voice." Resident 324 stated he had enough of the CNA's behavior so he reported to the charge nurse and facility staff approximately FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 10 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 three weeks ago. On 3/13/18, at 9:35 a.m., an interview was conducted with the facility's administrator who stated the facility received a grievance from Resident 324 that he felt CNA 1 was "too short with him" and "he was upset". The Administrator indicated the resident felt CNA 1 was rough with him. The Administrator stated he did not report the incident to the licensing department since there was no indication for him to believe there was an abuse that happened. The Administrator confirmed the resident made a complaint that CNA 1 was rough with him. The Administrator indicated a grievance can be a complaint and he should have reported the incident to the licensing department to be investigated. On 3/13/18, at 10:10 am, an interview was conducted with the facility's director of staff development (DSD) assistant who stated," Maybe 2 months ago, one day I noticed the resident was quiet and he was different that day. I asked him what was wrong and he told me the 11 p.m.-7 a.m. female nurse did not treat him professionally. He told me the female nurse was unprofessional, making jokes on the consistency of his diarrhea. He stated to me he did not enjoy the care and the nurse was too rough. He stated he would appreciate if another nurse would take care of him. I immediately told my charge nurse that my patient was uncomfortable and that a female nurse did not treat him right". A review of the facility's Verification of Incident Investigation/Administrative Summary indicated the date of incident was on 2/11/18 night shift. The brief description of the incident indicated on 2/11/18 Resident 324 complained that when the nurse assistant came into his room to change him and saw his soiled brief, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 11 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 turned away disgusted and commented to another nurse. Resident 324 did not hear what the nurse assistant said and thought she may have been commenting about how gross he was due to his being soiled. Resident 324 stated that he felt the nurse assistant could have been more gentle while cleaning him up. On 2/14/18 the investigation was concluded. A review of CNA 1's Employee Time Card indicated the following: 2/11/18 (Sun) - Signed In: 11:19 PM- Signed Out: 7:46 AM 2/13/18 (Tue) - Signed In: 11:16 PM- Signed Out: 7:45 AM 2/14/18 (Wed) - Signed In: 11:18 PM- Signed Out: 7:45 AM On 3/13/18 at 3:30 p.m., an interview was conducted with the facility's Director of Staff Development (DSD) who confirmed CNA 1 was working on 2/11/18, 2/13/18 and 2/14/18 while the investigation of abuse allegation for Resident 324 was ongoing. DSD stated CNA 1 should not have been scheduled to work until a final conclusion of the investigation had been made. On 3/14/18 at 8:45 a.m., an interview was conducted with the facility's Director of Nursing (DON) who confirmed CNA 1 was working on 2/11/8, 2/13/18 and 2/14/18 while investigation of abuse allegation for Resident 324 was ongoing. The DON stated CNA 1 should not have been scheduled to work until a final conclusion of the investigation had been made. On 3/14/18 at 9:30 a.m., an interview was conducted with the facility's administrator who confirmed the investigation was concluded on 2/14/18. On 3/15/18 at 8:30 a.m., a telephone interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 12 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 was conducted with CNA 1 who confirmed she was not suspended from work and she continued to work in the facility on 2/11/18, 2/13/18 and 2/14/18. A review of the facility's undated policy and procedure titled" Abuse Allegation Reporting," indicated the director of nursing and/or administrator will suspend the employee to prevent further potential abuse while the investigation is in progress.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 04/15/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility's staff failed to accurately code the medication the residents were taking at the time of the assessment in the Minimum Data Set (MDS, a standardized resident assessment and care planning tool) for two of 27 sampled residents (Residents 7 and 19). For Residents 7 and 19, the latest quarterly MDS assessment , dated 2/15/18, and 12/1/18, indicated Residents 7 and 19 were receiving an anticoagulant (medications used to prevent the formation of blood clots) medication but Residents 7 and 19 were not on any anticoagulant medication. The inaccurate assessment on the MDS had the potential for residents to receive, or not receive, services that could cause harm on the residents' physical and emotional well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 13 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Findings: a. A review of the Admission Record for Resident 7 indicated the resident was originally admitted to the facility on 8/17/16, with diagnoses that included quadriplegia (partial or total loss of use of all limbs and torso), anemia (a medical condition in which the red blood cell count or hemoglobin is less than normal), and gastritis (inflammation, irritation, or erosion of the lining of the stomach). A review of Resident 7's latest quarterly MDS, dated 2/15/18, indicated the resident had the ability to understand others and makes self understood. The MDS indicated Resident 7 was totally dependent on staff for her activities of daily living. The Section N of the MDS, under medications receive, indicated Resident 7 received anticoagulant for the past 7 days of the assessment period, ending on 2/15/18. Further review of Resident 7's clinical record indicated the resident was not receiving any anticoagulant medication, instead, the resident was receiving 81 milligrams of aspirin (a pain and anti-inflammatory medication used to prevent stroke or heart attack by preventing the formation of blood clots) which can prevent formation of blood clots but is not an anticoagulant. A review of Resident 7's Physicians Recapitulation Orders for the month of February 2018, indicated Resident 7 had no physician's order for anticoagulant medication. b. A review of the Admission Record for Resident 19 indicated the resident was originally admitted to the facility on 2/28/16, with diagnoses that included paraplegia (inability to voluntarily move the lower parts of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 14 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 the body), anemia (a medical condition in which the red blood cell count or hemoglobin is less than normal), and hypertension (high blood pressure). A review of Resident 19's latest quarterly MDS, dated 12/1/17, indicated the resident had the ability to understand others and makes self understood. The MDS indicated Resident 19 required extensive assistance from staff for most of her activities of daily living. The section N of the MDS, under the medications receive indicated Resident 7 received anticoagulant for the past 7 days of the assessment period, ending on 12/1/17. Further review of Resident 19's clinical record indicated the resident was not receiving any anticoagulant medication, instead the resident was receiving 81 milligrams of aspirin which can also prevent formation of blood clots but is not an anticoagulant. A review of Resident 19's Physicians Recapitulation Orders for the month of December 2017, indicated the resident had no physician's order for anticoagulant medication. During an interview with the MDS Coordinator, on 3/16/18, at 8:41 AM, she stated that Aspirin is an antiplatelet (a group of medications that stop blood cells [called platelets] from sticking together and forming a blood clot) and not an anticoagulant. The MDS coordinator stated Residents 7 and 19 did not have orders for an anticoagulant and the residents were not taking anticoagulant medication. The MDS coordinator stated that the anticoagulant should not have been coded in the MDS. During an interview on 03/16/18, at 8:57 AM, the Director of Nursing (DON) stated she signed the MDS for completeness. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 15 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 stated the residents were not receiving anticoagulant and the MDS should not have been coded for anticoagulant.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 04/15/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(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, 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 16 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 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 by: Based on observation, interview, and record review, the facility failed to develop an individualized plan of care for four of 27 sampled residents (Residents 97, 13, 46, and 65). a. For Resident 97, interventions for activities of daily living (ADL) were not specific to the resident's needs. b. For Resident 13, there was no plan of care to address the resident's history of suicidal ideation. c. For Resident 46, there was no care plan initiated for restorative nurse assistant (RNA) ambulation which front wheel walker. d. For Resident 65, the care plan did not reflect individualized interventions such as the use of heel protectors for the prevention of pressure ulcers. These failures had the potential for residents not to receive adequate care and services which can affect the residents' well-being. Findings: a. A review of Resident 97's Admission Record indicated the resident was readmitted to the facility on 2/22/18. Resident 97's diagnoses included cerebral infarction (area of dead tissue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 17 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 in the brain resulting from blockage of blood supply), muscle weakness, hemiplegia (loss of muscle movement on one side of the body), hemiparesis (weakness of one side of the body), and left hand osteopenia (decreased density of the bone). A review of Resident 97's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/19/18 indicated the resident's brief interview for mental status (BIMS, screening to test cognition) score was 11 (a score of 8-12 indicated moderately impaired cognitive skills for daily decision making). Resident 97 required limited assistance with eating and extensive assistance with bed mobility, transfer, walking, locomotion, toilet use, personal hygiene, and bathing. The Care Area Assessment (CAA) Summary on the MDS indicated to proceed to care plan with activities of daily living (ADL) functional/rehabilitation. On 3/12/18, at 1:30 p.m., during and interview, Resident 97 stated he was independent prior to admission, but needed more assistance with ADLS since then. A review of the Resident 97's nursing care plan titled, "ADL Functional/Rehabilitation Potential, Resident is At Risk for Self Care Deficit," dated 2/22/18, indicated the staff interventions were to assist the resident with ADLs including grooming and trimming of fingernails, dressing, brushing hair daily, turning and repositioning. The staff interventions also including for staff to performed oral care on routine basis, ensure the call light within reach, and transfer the resident from bed/chair as recommended . On 3/16/18, at 10:37 a.m., during concurrent record review and interview with licensed vocational nurse (LVN 4), she stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 18 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Resident 97's care plan interventions for ADLs were not specific to resident needs. LVN 4 stated that the intervention did not indicate the level of staff assistance such as transfers with a one or two person assist. LVN 4 stated an individualized care plan would prevent falls and also prevent staff injury. LVN 4 stated having an individualized care plan with interventions specific to the residents' needs will enable the staff to evaluate that the goal on the care plan was being met or not. A review of the undated facility's policy and procedure titled, "Care Plans," indicated that residents are assessed upon admission and a plan of care for the key problems or possible problems identified. The care plan will be completed within seven days. the policy indicated that the goals will be measurable and after the resident assessment was completed, the care plan will be updated to include all additional information gained within seven days of completion/ any changes in the resident's status will be put on the care plan as they occur. b. a review of Resident 13's face sheet indicated the resident was admitted to the facility on 11/7/17 with the diagnoses that included chronic kidney disease and depressive disorder. a review of Resident 13's MDS, dated 2/12/18, indicated the resident had poor memory recall and required extensive assistance with one person physical assistance in transfers and toilet use. A review of Resident 13's History and Physical (H & P) from a General Acute Care Hospital (GACH) indicated the resident was taken to the a GACH due to the resident threatened staff at a clinic on 3/9/18. The H & P indicated upon Resident 13's arrival to the psychiatric emergency room, the resident exhibited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 19 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 suicidal and homicidal ideation. The H &P indicated the resident was assessed by a psychiatrist and the resident denied suicidal and homicidal ideation and he did not fit for the 5150 hold, and was transferred back to the facility on 3/9/18. During a review of Resident 13's clinical record and a concurrent interview with Licensed Vocational Nurse 9 (LVN 9), she stated there should have been a plan of care upon the resident returning for history of suicidal/homicidal ideation. LVN 9 stated care plan would include behavior monitoring to keep the resident as well as the other residents in the facility safe. During an interview, on 3/14/18, at 6:59 a.m., the Social Service Director (SSD) stated that she was the one who received the call from the clinic regarding the Resident 13's behavior for threatening staff. The SSD confirmed that she should have seen the resident when he got back into the facility and conducted frequent room visits which she did not. c. A review of Resident 46's clinical record indicated the resident was admitted to the facility on 9/6/17 and was readmitted on 1/29/18 with diagnoses that included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis, dependence on renal dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream]), difficulty in walking, and muscle weakness. A review of Resident 46's MDS, dated 9/13/17, indicated the resident was cognitively intact. Resident 46 required total dependence (full staff performance) with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 20 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Resident 46's Physician Order,dated 2/15/18, indicated for Restorative Nursing Assistant (RNA) to assist the resident with ambulation with front wheeled walker, as tolerated, every day, 5 times a week. A review of Resident 46's RNA flowsheet, dated from 3/1/18 to 3/31/18, indicated the resident tolerated RNA ambulation with front wheel walker on 3/1/18, 3/2/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/19/18, 3/12/18, 3/13/18, 3/14/18, and 3/15/18 for 15 minutes each session. A review of Resident 46's care plan indicated there was no care plan initiated for RNA ambulation with the front wheel walker, 5 times a week, as ordered. During a review of Resident 46's care plan, and a concurrent interview was conducted with Registered Nurse 1 (RN 1), on 3/14/18, at 10:00 a.m., she stated there was no care plan initiated for Resident 46 for RNA ambulation with front wheel walker, 5 times a week, as ordered. RN 1 stated the care plan identifies specific goal and approaches/interventions on how to reach the goal for the benefit of the resident. RN 1 stated the care plan will serve as a guide for all disciplines (nursing, rehab, etc.) to follow specific interventions for the resident. d. A review of Resident 65's clinical record indicated the resident was admitted to the facility on 11/29/17, and was readmitted on 12/10/17 with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain), and unspecified dementia (long term and often gradual FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 21 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 decrease in the ability to think and remember severe enough to affect a person's daily functioning) without behavioral disturbance. A review of Resident 65's Physician Order, dated 2/13/18, indicated the resident was admitted to hospice (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life) starting 12/14/17 with diagnosis of CVA (Cerebrovascular Disease includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow). A review of Resident 65's MDS, dated 12/22/17, indicated the resident's cognitive skills for daily decision making was severely impaired. Resident 65 required total dependence (full staff performance) with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. The MDS indicated the resident was at risk of developing pressure ulcers. A review of Resident 65's care plan, dated 1/3/18, indicated the resident was at risk for developing pressure sore, bruising, and other types of skin breakdown related to reduced mobility, impaired cognition, fragile skin, hemiparesis/hemiplegia and terminal illness. The approached intervention was to provide pressure relieving devices as needed. On 3/14/18, at 10:05 a.m. Resident 65 was observed sleeping in bed with heel protector on the right foot while the left foot had heel protector but not secured. The heel protector straps were unfastened and the left foot was lying directly on the mattress. On 3/14/18, at 10:10 a.m., an interview was conducted with the facility's Treatment Nurse/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 22 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Licensed Vocational Nurse (LVN 2) who confirmed Resident 65 had heel protector on the right foot while the left foot had heel protector but not secured and left foot was lying directly on the mattress. LVN 2 indicated heel protectors are applied for prevention of pressure ulcer and for skin maintenance. On 3/14/18 at 10; 15 a.m., an interview was conducted with the facility's Director of Nursing (DON) who stated the use of heel protector should be written in the care plan. The DON stated a care plan was initiated on the use of pressure relieving device but not specific to heel protector use for Resident 65 who was at risk for developing pressure injury. The DON stated the care plan should be individualized and specific to each resident and the facility needed to be specific with interventions written in the plan of care. The DON stated the use of heel protector is a nursing measure to prevent pressure injury. A review of the facility's undated policy and procedure titled," Procedure: Heel Protectors/Heel Floating Device," indicated the objective of heel protectors/heel floating device is to protect skin from pressure and irritation.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 04/15/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 23 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview, and record review , the facility failed to revise the care plan for one of 27 sampled residents (Resident 43). This failure had the potential for nursing interventions to not be implemented to improve the care for the resident. Findings: A review of Resident 43's face sheet indicated the resident was admitted to the facility on 12/20/17 with the diagnoses that included kidney disease (kidneys can no longer perform their functions to full capacity), heart failure, and cardiomegaly (heart muscle disease). A review of Resident 43's Minimum Data Set (MDS- standardized assessment and care planning tool), dated 1/2/18, indicated the resident's cognition was intact. The MDS indicated the resident required total dependence on staff with one person physical assist for transfers; For other activities of daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 24 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 living such as dressing and toilet use, the resident required extensive assistance with one person physical assist. During review of Resident 43's Physician Order, dated 3/2/18, indicated to administer oxygen at 2 liters (L/Min) via nasal cannula (oxygen administered to nares through a tube) continuously as needed. A review of Resident 43's Mediation Administration Record (MAR) for the month of March 2018 indicated the resident received 2L of oxygen, on 3/5/18, and 3/14/18. A review of Resident 43's Care Plan titled "Respiratory Care," dated 2/27/18 indicated there was no oxygen monitoring and administration as an intervention for the resident. A concurrent interview was conducted with Licensed Vocational Nurse 6 (LVN 6), on 3/14/18, at 2:20 p.m., she stated there were no parameters within the oxygen order as to when to administer the oxygen. LVN 6 stated that the physician should have been called to clarify the oxygen order. LVN 6 stated there should have been an oxygen monitoring order but there was not in the clinical record. LVN 6 stated the respiratory care plan should have been revised to reflect the resident's need for oxygen. The facility's undated policy and procedure titled " Care Plans," indicated to put any changes to the resident's status as they occur. The policy indicated the care plans were used to coordinate care of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 25 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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

F676 Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/15/2018 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 26 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 failed to ensure one of 27 sampled residents (Resident 325) was provided with care and services to prevent, maintain or improve the resident's communication abilities by failing to: 1. Ensure the call light (bedside button in a resident's room which directs a signal to indicate that the resident has a need or perceived need requiring attention from staff) was within the resident's reach. 2. Ensure the communication board was readily accessible for the resident to use. These deficient practices had the potential to result in the resident's needs not effectively conveyed to staff and that could lead to a decline in the resident's quality of life. Findings: A review of Resident 325's clinical record indicated the resident was admitted to the facility on 11/16/17 with diagnosis that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain), and epilepsy (brain disorder in which a person has repeated seizures/convulsions over time. Seizures are episodes of disturbed brain activity that cause changes in attention or behavior). a review of Resident 325's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 11/23/17 indicated the resident's cognitive skills for daily decision FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 27 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 making was impaired. Resident 325 required extensive assistance with bed mobility, transfer, locomotion off unit, dressing, eating, toilet use and personal hygiene. A review of Resident 325's care plan, dated 12/8/17, indicated the resident had cognitive and communication deficit manifested by short and long term memory problem, problems making self understood and no speech. The resident's diagnosis included aphasia, CVA (blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) right sided hemiparesis (muscular weakness of one half of the body), and dysphagia (difficulty in swallowing). The Identified approaches included: - Acknowledge and support verbal, nonverbal expressions - Keep call light within reach - Translator/communication devices as indicated On 3/12/18, at 2:25 p.m.., during an initial tour of the facility with Licensed Vocational Nurse 1 (LVN 1) Resident 325 was observed awake lying in bed, non verbal but alert. Resident 325's call light was observed dangling on the bed's side rail on the right side of the bed. The call light was not within the resident's reach, and there was no communication board accessible for the resident to use. On 3/12/18, at 2:30 p.m., an interview was conducted with LVN 1 who confirmed the call light was not within Resident 325's reach and there was no communication board available for the resident to use. LVN 1 stated Resident 325 was nonverbal, and the call light must be within resident's reach for accessibility. LVN 1 stated the call light should have been clipped to Resident 325's bedsheet. LVN 1 stated Resident 325 should have the communication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 28 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 board in the room and/or at bedside with the resident. LVN 1 stated the communication board is important for Resident 325 to use so the resident would be able to effectively communicate with staff instead of guessing what the resident wanted to convey/express. On 3/12/18, at 3:30 p.m., an interview was conducted with the facility's registered nurse (RN 1) who stated the call light should be within the resident's reach to use as written in the resident's plan of care. RN 1 stated the communication board must be with the resident at all times and should be readily accessible. A review of the facility's undated policy and procedure, titled" Call Lights," indicated the purpose of the policy is to assure that residents receive prompt assistance. Nursing staff must ensure the call light is within the resident's reach when the resident is in his/her room or when on the toilet. A review of the facility's undated policy and procedure, titled" Procedure: Care of Aphasic Residents," indicated to utilize communication board, writing instruments, magazine, cards, pictures, and money to stimulate communication and comprehension as necessary.

F684 SS=E Quality of Care CFR(s): 483.25

F684 04/15/2018 § 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 29 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary services for two of 27 sampled residents (Residents 74 and 73). a. For Resident 74, the facility failed to provide padded siderails as indicated in the resident's plan of care. b. For Resident 73, the facility failed to provide Ativan (medication to treat anxiety) as indicated. These failures had the potential for the resident to be injured in the event of a seizure for Resident 74, and the potential to affect Resident 73's improvement in behavior. Findings: a. During the initial tour on 03/12/18, at 1:40 PM, Resident 74 was in bed and the resident was not able to respond to questions. Resident 74's bilateral side rails were up with no padding. a review of Resident 74's face sheet indicated the resident was admitted to the facility on 4/26/17 with the diagnoses that included chronic kidney disease (loss of kidney function), and seizures (sudden, uncontrolled electrical disturbance in the brain that can cause changes in your behavior, movements or feelings, and in levels of consciousness). A review of Resident 74's Minimum Data Set (MDS- standardized assessment and care planning tool ), dated 2/1/18 indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 30 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 resident's cognition was not intact and the resident had poor memory recall. The MDS indicated Resident 74 required extensive assistance with one person physical assist in transfers, dressing, and toilet use. A review of Resident 74's Physician's Order, on 3/14/18, at 10 :54 a.m., and a concurrent interview was conducted with Licensed Vocational Nurse 2 (LVN 2) she stated Resident 74 did not have padded siderails as indicated in the care plan, and there was no physician order for padded siderails. LVN 2 stated that padded siderails were used for seizure precautions to protect the resident from injury. A review of Resident 74's Plan of Care, titled "At risk for injury secondary to involuntary muscle movements related to seizure disorder," and dated 8/2/17, indicated padded siderails as an approached intervention. The facility's undated policy and procedure titled "Seizure Precautions," indicated to assess the need for padded bed rails to prevent injury to the resident during a seizure. b. A review of Resident 73's Face Sheet indicated the resident was admitted to the facility on 1/5/18 with diagnoses that included congestive heart failure (CHF, heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (decline in mental ability severe enough to interfere with daily life), and respiratory failure (loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and multiple organs). A review of Resident 73's MDS, dated 1/12/18, indicated the resident's brief interview for mental status (BIMS, brief screening that aids in detecting cognitive impairment) score was 12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 31 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 score of 8-12 indicated moderately impaired cognitive skills for daily decision making). The MDS indicated Resident 73 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, locomotion, and bathing. A review of Resident 73 clinical records indicated the resident was admitted under Hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) care on 3/12/18 with new physician's order for Lorazepam (Ativan), one milligram (mg), one tablet sublingual (under the tongue), every eight hours, as needed, for anxiety (worry about future events and fear of a reaction to current events), agitation/restlessness. A review of Resident 73's Medication Administration Record (MAR) indicated that the resident was given Ativan, one mg, by mouth, on 3/13/18, at 12 p.m. A review of Resident 73's Physician Order, dated 3/12/18, indicated to change the medication route to sublingual from by mouth was not reflected on the MAR. On 3/14/18, at 10:27 a.m., during concurrent record review and interview with Licensed Vocational Nurse 5 (LVN 5), she stated that on 3/13/18 at 12 p.m., the family of Resident 73 reported that the resident was twitching. LVN 5 stated she went to see Resident 73 and observed the resident was lying in bed and was moving her left shoulder in a twitching motion. LVN 5 stated she administered Ativan,one mg,by mouth which was based on the MAR. LVN 5 stated he did not administer the medication sublingual because the order was not changed on the MAR. LVN 5 stated that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 32 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Ativan should have been administered sublingual as the physician ordered. A review of the facility's undated policy and procedure (P&P) titled, "Med Pass," indicated to ensure that medications are administered according to right route/method. The policy indicated that sublingual tablets are intended to be dissolved under the tongue.

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 04/15/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide and implement care plan interventions to prevent falls for four of 27 sampled residents (Residents 68, 50, 374, and 60). a. For Resident 68, tab alarm (device that clips onto the resident's clothing and with the string attached to a small piece of metal that when a resident gets up or moves further than the string length, the metal/magnet connection is broken and the alarm sounds) was not used while the resident was on the wheelchair as indicated on the physician's order and care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 33 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 b. For Resident 50, the floor mat was only on one side of the bed and the resident had a bed alarm without a physician's order. c. For Resident 374, there was no floor mat observed on both sides of the bed on 3/12/18 and 3/14/18 as indicated on the physician's order and care plan d. For Resident 60, the floor mat was only on one side of the bed. These deficient practices had the potential to result in repeated falls and injury and/or harm to the residents. Findings: a. A review of Resident 68's clinical record indicated the resident was admitted to the facility on 1/7/18 with diagnoses that included cerebral infarction (area of dead tissue in the brain resulting from blockage of blood supply), dementia (decline in mental ability severe enough to interfere with daily life), right side hemiplegia (loss of muscle movement on one side of the body), ride side hemiparesis (weakness of one side of the body), hypertension (chronic elevated blood pressure), and general muscle weakness. A review of Resident 68's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/13/18 indicated the Resident's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 6 (a score of 1 -7 reflects severe cognitive [mental action or process of acquiring knowledge and understanding] impairment). The MDS indicated Resident 68 required extensive assistance with bed mobility, dressing, eating, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 34 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 personal hygiene and was totally dependent on staff for transfers, locomotion, toilet use, and bathing. During an observation on 3/13/18, at 7:44 a.m., Resident 68 was in her room sitting on a wheelchair without a tab alarms on the wheelchair. A concurrent interview was conducted with Resident 68 she stated that she was waiting for her breakfast. A review of Resident 68's Physician Order, dated 2/1/18, indicated tab alarm when in bed/wheelchair to remind the resident to ask for assistance with ambulation, and transfer. On 3/14/18 at 10:47 a.m., during a review of Resident 68's clinical record and a concurrent interview with Licensed Vocational Nurse 4 (LVN 4), she stated that Resident 68 had the following fall incidents: 1. On 3/1/18, at 3:55 p.m., Resident 68 was in the Activity Room and when she attempted to get out of the wheelchair without assistance she fell down to the floor without injury. 2. On 2/5/18, at 7 p.m., Resident 68 crawled out of the bed and sat on the floor mat resulting a skin tear on the right shin, measured 0.5 centimeters (cm) by 0.5 cm and another skin tear measured 0.5 cm by 0.5 cm, on the left knee. 3. On 1/31/18, at 4 p.m., Resident 68 was found on the floor, in front of her wheelchair, at the nurse's station without injuries. A review of Resident 68's Fall Risk Assessment indicated the following: a. 1/8/18 - (admission assessment) score was 22 b. 2/14/18 - (quarterly assessment) score was 24 c. 2/5/18 - (after a fall incident) score was 24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 35 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 d. 1/31/18 - (after a fall incident) score was 18 On 3/14/18, at 10:55 a.m., during an interview, LVN 4 stated that after a fall, the resident will be assessed for level of consciousness, range of motion, pain, and open wounds. LVN 4 stated that licensed nurse will also notify the physician about the incident and obtain new orders as necessary. LVN 4 stated that the care plan will be updated to reflect the fall incident and modified interventions based on the cause of each fall. On 3/14/18, at 2:43 p.m., during an observation, Resident 68 was in the Activity Room sitting on a wheelchair while attending activities with other residents. There was no tab alarm on Resident 68's wheelchair. A concurrent interview was conducted with LVN 4, she stated that there was no tab alarm on the wheelchair and it was important to follow the care plan to use tab alarm to prevent fall. On 3/14/18 at 2:45 p.m., during interview, Certified Nurse Assistant 2 (CNA 2) stated that she had taken cared of Resident 68 for months now and the resident did not have a tab alarm on her wheelchair. On 3/14/18 at 2:51 p.m., during interview, the Activity Director (AD) stated that sometimes it gets difficult to watch all the residents in the Activity Room especially if there were only two activity staff members. The AD stated that Resident 68 had a fall incident while the resident was in the Activity Room. The AD added that Resident 68 gets restless, especially after lunch which could have been a reason why the resident slid down from the wheelchair. The AD stated that a tab alarm would be useful for the resident. A review of Resident 68's care plan titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 36 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 "Actual Fall," dated 1/31/18, indicated the approached staff interventions were to place the call light within reach at all times, frequent visual monitoring, low bed with floor mats, proper non-skid proper fitting socks/shoes as indicated, and tab alarm in bed and when up in wheelchair to remind resident to stop and ask for assistance. A review of the facility's undated policy and procedure titled, "Rehabilitation-Fall Assessment/Risk Assessment," indicated that the interdisciplinary team (IDT, a group of professional that work together to help the resident achieve his/her goals) will meet to discuss alternatives to restraints, such as position devices and environmental changes. The IDT indicated that when a fall occurs, the therapist will re-screen the resident using the fall assessment form including an investigation and IDT meeting to address all the safety issues and develop a care plan to prevent occurrence. A review of the facility's undated policy and procedure titled, "Personal Alarm," indicated that the facility will use, as indicated a sensor pad that conveniently sounds as audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting staff to a potential fall. The policy stipulated that the licensed nurses and therapists will assess the resident for potential safety issues. If fall risk associated with fall from bed/chair is identified, physician orders will be obtained for assessment by appropriate staff. P&P indicated that nursing will monitor proper functioning and positioning of personal alarm. b. A review of Resident 50's clinical record indicated the resident was admitted to the facility on 11/6/17 with diagnoses that included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 37 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 general muscle weakness, osteoarthritis (disease that causes the joints to become very painful and stiff), hypertension (chronic elevated blood pressure), and anemia (lowered ability of blood to carry oxygen resulting in feeling tired and shortness of breath). A review of Resident 50's MDS, dated 1/13/18, indicated the resident's brief interview of mental status score was 13 (a score of 13-15 reflects intact cognition [mental action or process of acquiring knowledge and understanding]). The MDS indicated Resident 50 required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use, personal hygiene, and bathing. The MDS indicated Resident 50 had an unsteady balance during transition and walking. On 3/13/18 at 2:15 p.m., during concurrent observation and interview with MDS nurse 1, Resident 50 was lying in bed awake. Resident 50's bed was situated in between two other residents' beds. Resident 50's bed was in a low position with a floor mat on the right side of the resident's bed. There was a bed alarm attached to the right upper side rail of Resident 50's bed. MDS Nurse 1 stated it was turned off and should have been turned on to prevent fall. On 3/13/18 at 2:17 p.m.., during interview, CNA 2 stated Resident 50 had a bed alarm, but it was used at night when the resident was in bed to prevent fall. CNA 2 stated that the floor mat was on one side of the bed (right side) and stated that the floor mat should have been on both sides to prevent injury. A review of Resident 50's Physician Order, dated 3/12/18, indicated low bed with floor mat to decrease potential injury while in bed and there was no order for the use of bed alarm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 38 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 3/13/18 at 3:02 p.m., during an interview with the Director of Nursing (DON), she stated that there was no order to use a bed alarm for Resident 50. The DON stated before a bed alarm is used, an assessment should have been completed and an order should have been obtained from the physician. The DON stated that if a resident's bed is in between two residents' bed, a floor mat should be placed on each side of the resident's bed to prevent injury. On 3/15/18, at 3:48 p.m., during concurrent record review, and interview with LVN 4, she stated that Resident 50's care plan titled, "At Risk for Fall," reevaluated on 1/18/18, did not reflect the use of floor mat as the physician ordered. LVN 4 stated that it was important to update the care plan interventions to prevent injuries and falls. A review of the facility's form titled, "Fall Risk Observation," dated 1/27/18, indicated Resident 50's fall risk assessment with a score of 20 (a score of 8 or more represents high risk). A review of the facility's undated policy and procedure titled "Rehabilitation-Fall Assessment/Risk Assessment," indicated that the IDT will meet to discuss alternatives to restraints, such as position devices and environmental changes. A review of the facility's undated policy and procedure titled, "Personal Alarm," indicated that if the fall risk associated with a fall from bed/chair is identified, the physician orders will be obtained for assessment by appropriate staff. A review of the facility's undated policy and procedure titled, "Initial Fall Risk Assessment," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 39 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 indicated that the plan of care will be reviewed by the IDT, quarterly and as needed for update of the resident's current needs. The policy indicated that the recommended interventions included the use of floor mats, side rails and low bed. A review of the facility's undated policy and procedure titled, "Care Plans," indicated that any changes in the resident's status will be put on the care plan as they occur. c. A review of Resident 374 indicated the resident was admitted to the facility on 3/1/18 with diagnoses that included hypertension (chronic elevated blood pressure), anemia (lowered ability of blood to carry oxygen resulting in feeling tired and shortness of breath), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (decline in mental ability severe enough to interfere with daily life) (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). a review of Resident 374's MDS, dated 3/8/18, indicated the resident's brief interview of mental status score was 7 (a score of 1-7 reflects severe impairment with cognition [mental action or process of acquiring knowledge and understanding]). The MDS indicated Resident 374 required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Resident had an unsteady balance during transition and walking. A review of Resident 374's Physician Order, dated 3/1/18, indicated low bed with floor mat to decrease potential injury. On 3/12/18 at 2:38 p.m., during an observation, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 40 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Resident 374 was lying in bed with the bed positioned low. Resident 374's bed was situated in between two other residents' beds and there was no floor mat observed on both sides of the resident's bed. On 3/12/18 at 2:46 p.m., during an observation, Resident 374 was lying in bed with the bed positioned low. A floor mat was observed on the right side of the resident's bed. On 3/14/18 at 2:36 p.m., during an observation, Resident 374 was lying in bed, with a floor mat on the left side of the resident's bed. A concurrent interview was conducted with MDS nurse 1, she stated Resident 374 should have the floor mats on each side of the resident's bed to prevent injury. A review of the facility's form titled "Fall Risk Observation," dated 3/1/18, indicated that Resident 374 had a fall risk assessment with a score of 16 (a score of 8 or more represents high risk). A review of Resident 374's care plan titled, "Falls," dated 3/1/18, indicated the approached interventions were to provide personal assistive devices as indicated, call light in reach at all times, environment free of clutter, and low bed with floor mat. A review of the facility's undated policy and procedure titled, "Promoting Safety, Reducing Falls," indicated that by focusing on fall preventions, caregivers can enhance the quality of life for residents, promote their independence, and maintain their highest practicable level of functioning. A review of the facility's undated policy and procedure titled, "Initial Fall Risk Assessment," indicated that the plan of care will be reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 41 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 the IDT quarterly, and as needed for update of the resident's current needs. The policy indicated that the recommended interventions as needed included the use of floor mats, side rails and low bed.d. A review of Resident 60's clinical record indicated the resident was admitted to the facility on 7/17/17 with a diagnoses that included muscle weakness, difficulty walking, and chronic pulmonary obstructive disease (difficulty breathing). A review of Resident 60's MDS, dated 1/22/18, indicated the resident's cognition was intact. The MDS indicated Resident 60 required extensive assistance with one person physical assist in transfers, dressing, and toilet use. During initial tour with CNA 4, on 3/12/18, at 1:45 p.m., Resident 60 was observed in bed with one floor mat to the right side of the bed. A review of Resident 60's "Fall Risk Observation" assessment, dated 1/22/18, indicated the resident was assessed at high risk for falls. During an interview with the DON, on 3/13/18, at 3:35 p.m., she stated that floor mats were used to prevent injury for fall risk residents and the floor mats should be placed on the floor, on both sides of the bed. a review of Resident 60's plan of care titled "Fall Reduction related to Risk for Falls," indicated the approached intervention was to provide floor mats. A review of the facility's undated policy and procedure titled, "Promoting Safety, Reducing Falls," indicated that by focusing on fall preventions, caregivers can enhance the quality of life for residents, promote their independence, and maintain their highest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 42 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 practicable level of functioning.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 04/15/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 43 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Residents 68) who has a urinary indwelling catheter (a tube inside that removes urine from the bladder to a collection bag) receive appropriate care by failing to: a. keep the urinary indwelling catheter secured and anchored. b. follow the Physician's Order to assess the urinary indwelling catheter for urinary tract infection (UTI), every shift from 3/1/18 to 3/10/18. These deficient practices had the potential to result in catheter related complications such as urethral tear (injury to the urethra [tube-like organ that carries urine from the bladder out of the body] or catheter dislodgement, delay in care, treatment, and possible infection. Findings: A review of Resident 68's clinical record indicated the resident was admitted to the facility on 1/7/18 with diagnoses that included cerebral infarction (area of dead tissue in the brain resulting from blockage of blood supply), dementia (decline in mental ability severe enough to interfere with daily life), and neurogenic bladder (disorder usually causes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 44 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 difficulty or full inability to pass urine without use of a catheter or other method). A review of Resident 68's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/13/1,8 indicated Resident 68's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 6 (a score of 1 -7 reflects severe cognitive [mental action or process of acquiring knowledge and understanding] impairment). The MDS indicated Resident 68 required extensive assistance with bed mobility, dressing, eating, personal hygiene and was totally dependent on staff for transfers, locomotion, toilet use, and bathing. MDS also indicated that Resident 68 had an indwelling catheter and was incontinent of bowel movement. On 3/12/18 at 2:25 p.m., during an observation of Resident 68's catheter and a concurrent interview was conducted with Licensed Vocational Nurse 3 (LVN 3), she stated that Resident 68's catheter was not secured. LVN 3 stated that it was important to secure it with a leg bag (which the facility uses) to avoid accidental dislodgment or pulling to prevent trauma and reinsertion of Foley catheter. A review of Resident 68's Physician Order, dated 1/19/18, indicated Foley catheter, French 18/10 milliliters, attached to bedside drainage bag due to neurogenic bladder. On 3/12/18 at 2:31 p.m., during concurrent review of Resident 68's clinical record and an interview with LVN 3, she stated that the treatment administration record (TAR) did not show documented evidence that the Foley catheter was monitored for signs and symptoms (s/s) of UTI for multiple nights from 3/1/18 to 3/10/18 as evidenced by missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 45 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 licensed staff initials and a dash (-) sign documented for s/s of UTI. LVN 3 stated that it was important to check for s/s of UTI such as urinary urgency, hematuria (blood in the urine), decreased in urine output, bladder distention and temperature, so if resident was observed with it, licensed nurse can call the physician to report the change in condition (COC), request for urinalysis and treatment such as use of antibiotic (after results of culture and sensitivity). A review of the care plan titled, "Indwelling Catheter," dated 1/8/18, indicated staff interventions included were to provide catheter care daily, monitor signs and symptoms of UTI, change bedside drainage bag every week and as needed, and change Foley catheter as needed. According to Spring house Nursing procedures, Third edition, the indwelling urinary catheter is used most often to relieve bladder distention caused by urine retention. The procedures indicated that after the insertion of the indwelling urinary catheter, to tape the catheter to the female patient's thigh to prevent possible tension on the urogenital trigone (triangular region of the internal urinary bladder). http://www.public.asu.edu/~cbaldwi1 /swborderlands/Stabilizing_the_Urinary_Cathet er.pdf indicated that the indwelling urinary catheter is secured or stabilized to prevent accidental removal, reduce trauma to the urethra and bladder, and reduce inflammation of urinary tissues. The goal of stabilization is to prevent excessive pull or traction on the catheter. There are a variety of methods used to stabilize a catheter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 46 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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)

F695 Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/15/2018 § 483.25(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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three of 27 sampled Residents (Residents 119, 73, and 43) receive the respiratory treatment and care that was specific to their needs by: a. For Resident 119, the resident was observed on oxygen, at two liters per minute, during the day shift ,on 3/12/18 and 3/13/18, and the Physician's Order indicated to administer oxygen at 2 liters per minute at night. b. For Resident 73, the resident was observed on oxygen at three liters per minute, and the Physician's Order indicated to administer oxygen at 4 liters per minute. c. For Resident 43, the Physician's Order for oxygen, at two liters per minute, via nasal cannula, as needed had no parameters, and the facility's staff also failed to revise the resident's care plan to reflect the resident's need for oxygen and intervention such as checking oxygen saturation. These failures had the potential to result in complications due to inappropriate oxygen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 47 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 intake. Findings: a. A review of Resident 119's Admission Record indicated the resident was admitted to the facility on 2/7/18, with diagnoses that included congestive heart failure (heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen), generalized muscle weakness, and atherosclerotic heart disease (an occlusion or blockage due to a buildup of plaque in the arteries which supply blood to the heart muscle). A review of Resident 119's Minimum Data Set, (MDS, resident assessment and care screening tool), dated 2/14/18, indicated the resident's brief interview of mental status (BIMS, brief screener that aids in detecting cognitive impairment) score was 14 (a score of 13-15 indicated intact cognitive skills for daily decision making). The MDS indicated Resident 119 required extensive assistance with bed mobility, transfer, locomotion, eating, and personal hygiene. The MDS indicated Resident 119 was totally dependent on staff for toilet use, bathing, and dressing. A review of Resident 119's Physician's Order, dated 2/25/18, indicated to administer oxygen, at two liters per minute (LPM), via nasal cannula (oxygen administered to nares through a tube) at night. On 3/12/18 at 2:48 p.m., during an observation, Resident 119's oxygen cannula was hanging on the resident's upper right side rail while the oxygen concentrator was on. Licensed Vocational Nurse 11 (LVN 11) applied the nasal cannula to Resident 119's nostrils with the oxygen set at two liters per minute. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 48 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 3/13/18, at 3:12 p.m., during an observation, Resident 119's oxygen concentrator was set at 2 LPM, but the nasal cannula was on the right side of Resident 119's face. A concurrent interview was conducted with LVN 5, she stated that the Physician's Order indicated to administer oxygen at night only. A review of Resident 119's care plan titled "Resident is at Risk for Respiratory Distress," dated 2/8/18, indicated staff interventions were to apply oxygen as ordered, assess for shortness of breath, irregular respiration, and assist with activities of daily living as needed. A review of the facility's undated policy and procedure (P&P) titled "Oxygen Administration," indicated that oxygen will be administered to the resident's need per attending physician's orders by licensed personnel. b. A review of Resident 73's Admission Face Sheet indicated the resident was admitted to the facility on 1/5/18 with diagnoses that included congestive heart failure (CHF, heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (decline in mental ability severe enough to interfere with daily life), and respiratory failure (loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and multiple organs). A review of Resident 73's MDS, dated 1/12/18, indicated the resident's brief interview for mental status score was 12 (a score of 8-12 indicated moderately impaired cognitive skills for daily decision making). The MDS indicated Resident 73 required extensive assistance with bed mobility, transfer, dressing, toilet use, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 49 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 personal hygiene, locomotion, and bathing. A review of Resident 73's Physician's Order, dated 3/12/18, indicated to administer oxygen at four liters per minute (LPM) via nasal cannula at night. On 3/13/18 at 7:28 a.m. Resident 73 was observed in bed sleeping with oxygen on at three LPM via nasal cannula. On 3/13/18, at 7:32 a.m., during an observation, and a concurrent interview with Licensed Vocational Nurse 4 (LVN 4), she stated that Resident 73 was on oxygen at three LPM via nasal cannula. LVN 4 stated that oxygen should have been administered at four LPM as indicated on the Physician's Order. LVN 4 stated that it was important to maintain oxygen level and comfort especially Resident 73 was on hospice care (designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure). A review of the facility's undated policy and procedure (P&P) titled, "Oxygen Administration," indicated that oxygen will be administered to resident's need per attending physician's orders by licensed personnel. c. A review of Resident 43's face sheet indicated the resident was admitted to the facility on 12/20/17 with the diagnoses that included kidney disease, heart failure, and cardiomegaly (heart muscle disease). A review of Resident 43's MDS, dated 1/2/18, indicated the resident's cognition was intact. The MDS indicated Resident 43 required total dependence on staff with one person physical assist for transfers. The MDS indicated for other activities of daily living such as dressing and toilet use, the resident required extensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 50 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 assistance with one person physical assist. A review of Resident 43's Physician's Order, dated 3/2/18, indicated to administer oxygen at 2 liters (L/Min), via nasal cannula continuously as needed. A review of Resident 43's Mediation Administration Record (MAR) indicated 3/5/18 and 3/14/18, the resident received 2L of oxygen via nasal cannular. A review of Resident 43's plan of care, titled "Respiratory Care," and dated 2/27/18, indicated the was no oxygen monitoring and administration as interventions for the resident. During an interview with Licensed Vocational Nurse 6 (LVN 6), on 3/14/18, at 2:20 p.m., she stated there were no parameters within the oxygen order as to when to administer the oxygen. LVN 6 stated that the Physician should have been called to clarify the oxygen order. LVN 6 stated that there should have been an oxygen monitoring order and there was not in the clinical record. LVN 6 stated the respiratory care plan should have been revised to reflect the resident's need for oxygen.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 04/15/2018 §483.25(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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 51 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 Based on interview, and record review, the facility failed to ensure that residents who require dialysis receive services consistent with professional standards of practice for one of 27 sampled residents (Resident 46). For Resident 46, there was inaccurate documentation on the dialysis communication form, and inconsistent assessment of the pre and post dialysis on several occasions. These deficient practices had the potential to result in inaccurate assessment, and had the potential to result in significant adverse consequences for the resident. Findings: A review of Resident 46's clinical record indicated the resident was admitted to the facility on 9/6/17 and was readmitted on 1/29/18 with diagnoses that included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis, dependence on renal dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream]), difficulty in walking, and muscle weakness. A review of Resident 46's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 9/13/17, indicated the resident's was cognitively intact. The MDS indicated Resident 46 required total dependence (full staff performance) with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of the Physician's Order for Resident 46 indicated hemodialysis to be done outpatient with treatment days on Tuesday, Thursday and Saturday. (Order date- 1/29/18; Site: Right Upper Chest- PermaCath [special FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 52 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 catheter inserted in the jugular vein on the neck or upper chest area to aid in dialysis]). A review of Resident 46's Dialysis Communication Record indicated the following: 1. On 3/13/18- Pre Dialysis Assessment: Access Site: bruit and thrill present. Post Dialysis Assessment- Bleeding at access site not assessed. 2. On 3/10/18- Post Dialysis AssessmentBleeding at access site not assessed. 3. On 3/8/18- Pre Dialysis Assessment: Access Site: bruit and thrill present. Post Dialysis Assessment- Bleeding at access site not assessed. 4. On 3/1/18- Pre Dialysis Assessment: Access Site: bruit and thrill present. Post Dialysis Assessment- Bleeding at access site not assessed. 5. On 2/27/18- Post Dialysis AssessmentBleeding at access site not assessed. On 3/14/18, at 3:40 p.m., an interview was conducted with the facility's Director of Nursing (DON) she stated the pre dialysis assessment was inaccurately done on 3/13/18, 3/8/18, and 3/1/18. The DON stated the bruit and thrill cannot be assessed for Resident 46 since his access site is a perma cath and not an AV shunt (connection that shunts blood from an artery to a vein, bypassing the microscopic network in the tissues that normally connect them which allows a high blood flow access for pulling blood from the body to the dialysis filter). The DON stated the access site must be assessed for bleeding post dialysis. The DON stated the access site was not assessed post dialysis on 3/13/18, 3/10/18, 3/8/18, 3/1/18 and 2/27/18. The DON stated the facility uses the dialysis communication record to coordinate care between facility and dialysis center. A review of the undated facility's policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 53 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 procedure titled" Care of Resident Receiving Renal Dialysis" indicated: (9) Complete Dialysis Communication Record during dialysis days and send the form with the resident to be completed by the dialysis nurse. (a) Complete pre-dialysis assessment. iii. Access site (central line, shunt, graft site) (b) Complete post dialysis assessment on return from treatment.

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 04/15/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 54 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the Drug Regimen Review of 3 of 27 sampled residents (Residents 73, 68, and 41) included mediation in excessive dose or lacking indications for the use by failing to: a. For Resident 73, there was no specific target behavior monitored for the use of Lorazepam (antianxiety, drug used to treat anxiety [state of excessive uneasiness and apprehension]). b. For Resident 68, there was no specific target behavior monitored for the use of Seroquel (antipsychotic, drug used to treat psychosis [a serious mental disorder characterized by defective or lost contact with reality often with hallucinations or delusions] and other mental and emotional conditions). c. For Resident 41, the behavior and side effect for the use of Cymbalta (to treat depression FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 55 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 [mood disorder that causes a persistent feeling of sadness and loss of interest]), and Trileptal (for mood disorder) were not monitored as ordered. These failures had the potential to result in significant adverse (harmful) consequences to the resident. Findings: a. A review of Resident 73's Admission Face Sheet indicated the resident was admitted to the facility on 1/5/18 with diagnoses that included congestive heart failure (CHF, heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (decline in mental ability severe enough to interfere with daily life), and respiratory failure (loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and multiple organs). A review of Resident 73's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 1/12/18, indicated Resident 73's brief interview for mental status (BIMS, brief screening that aids in detecting cognitive impairment) score was 12 (a score of 8-12 indicated moderately impaired cognitive skills for daily decision making). The MDS indicated Resident 73 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, locomotion, and bathing. On 3/13/18 at 7:28 a.m. Resident 73 was observed in bed sleeping with oxygen on at three LPM via nasal cannula. A review of Resident 73's Physician's order, dated 3/12/18, indicated Lorazepam 1 milligram (mg), one tablet, as needed daily for anxiety FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 56 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 (state of excessive uneasiness and apprehension) manifested by restlessness/agitation. On 3/14/18 at 9:46 a.m., during a concurrent record review and an interview with Licensed Vocational Nurse 4 (LVN 4), she stated that Resident 73's Physician Order for Ativan did not have a specific behavior for nurses to monitor. LVN 4 stated that the indication which was anxiety for restlessness and agitation was too general. LVN 4 stated that it was important for nursing staff to monitor specific behavior in order to be able to monitor the effectiveness of medication. Further review of Resident 73's clinical record indicated a care plan was not developed to address Resident 73's use of antianxiety medication. LVN 4 stated that it was important to have a care plan to guide the staff in managing Resident 73's behavior through the use of both pharmacological and nonpharmacological interventions. b. A reivew of Resident 68's clinical record indicated the resident was admitted to the facility on 1/7/18 with diagnoses that included cerebral infarction (area of dead tissue in the brain resulting from blockage of blood supply), dementia (decline in mental ability severe enough to interfere with daily life), right side hemiplegia (loss of muscle movement on one side of the body), ride side hemiparesis (weakness of one side of the body), hypertension (chronic elevated blood pressure), and general muscle weakness. A reiview of Resident 68's MDS, dated 1/13/18, indicated the resident's brief interview of mental status score was 6 (a score of 1-7 reflects severe cognitive [mental action or process of acquiring knowledge and understanding] impairment). The MDS indicated Resident 68 required extensive assistance with bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 57 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 mobility, dressing, eating, personal hygiene and was totally dependent on staff for transfers, locomotion, toilet use, and bathing. A review of Resident 68's Physician's Order, dated 1/24/18, indicated Seroquel (antipsychotic, drug used to treat psychosis which is a serious mental disorder characterized by defective or lost contact with reality often with hallucinations or delusions, and other mental and emotional conditions), 25 milligrams (mg), by mouth, twice a day for psychotic disorder, manifested by paranoid thinking. On 3/14/18 3:19 p.m., during a concurrent record review and interview with Licensed Vocational Nurse 4 (LVN 4), she stated that Resident 68 was being given Seroquel for Paranoid (characterized by suspiciousness) thinking. LVN 4 stated that the manifestation of paranoid thinking was not specific. LVN 4 added that Resident 68 specific behavior manifestation was verbalization that someone will harm her. LVN 4 stated that it was important that a specific behavior was monitored to be able to use this information for gradual dose reduction. A review of Resident 68's care plan titled "Psychotropic Drug Use," dated 1/8/18, included staff interventions were to monitor behavior as ordered, utilize alternative interventions such as redirection, activity, 1:1 visits as needed for behavior management, monitor response to medication as needed, and observe for side effects. A review of the facility's undated policy and procedure (P&P) titled "Psychotherapeutic Medications," indicated that the use of psychotherapeutic medications shall be kept to a minimum. The medications are to be used FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 58 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 only for specific behaviors by a resident, quantitatively and qualitatively document by the facility. The policy indicated that a specific diagnosis and a specific behavior or thought process justifying the need for psychotherapeutic medications are to be identified in the resident's health record. c. A review of the clinical record indicated Resident 41 was admitted to the facility on 6/15/16 and was readmitted on 10/26/17 with diagnoses that included adjustment disorder with mixed disturbance of emotions and conduct, mood disorder due to known physiological conditions, unspecified and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) with behavioral disturbance. The Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 7/3/17 indicated Resident 41's cognition was moderately impaired. Resident 41 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, dressing and toilet use. Resident 41 required total dependence (full staff performance) with transfer, locomotion on and off unit, eating and personal hygiene. A review of Resident 41's physician's order dated 10/26/17indicated the following: - Cymbalta delayed release 30 mg for depression manifested by verbalization of sadness - Monitor behavior for depression manifested by verbalization of sadness and tally by hash marks every shift. - Monitor for adverse side effects (ASE) of Cymbalta and tally hash marks every shift FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 59 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 - Trileptal 150mg for mood disorder manifested by combativeness. - Target behavior for mood disorder manifested by combativeness (Medication: Trileptal) at the end of each shift, mark episodes every shift. A review of Resident 41's Medication Flowsheet indicated the following: - Behavior monitoring for depression manifested by verbalization of sadness was not done on 2/22/18( 3-11 shift) and 2/24/18 (11-7 shift) - Cymbalta side effect was not monitored as ordered on 2/22/18 (7-3 shift and 3-11 shift) and on 2/24/18 (11-7 shift). - Monitoring for targeted behavior for mood disorder manifested by combativeness for the use of Trileptal every shift as ordered was not done on 2/7/18 (PM shift) and 2/22/18 (PM shift). - Trileptal side efffect was not monitored as ordered on 2/22/18 (PM shift) On 3/14/18 at 2:30 p.m., an interview was conducted with registered nurse (RN1) who confirmed behavior monitoring for depression manifested by verbalization of sadness was not done on 2/22/18( 3-11 shift) and 2/24/18 (11-7 shift). RN 1 confirmed Cymbalta side effect was not monitored as ordered on 2/22/18 (7-3 shift and 3-11 shift) and on 2/24/18 (11-7 shift). RN1 confirmed monitoring for targeted behavior for mood disorder manifested by combativeness for the use of Trileptal every shift as ordered was not done on 2/7/18 (PM shift) and 2/22/18 (PM shift). RN1 confirmed Trileptal side effect was not monitored as ordered on 2/22/18 (PM shift). RN 1 indicated behavior monitoring and monitoring for side effects should be completed with accuracy since it was ordered by the physician and the physician's order should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 60 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 followed by staff. . On 3/15/18 at 7:45 a.m. an interview was conducted with the facility's director of nursing (DON) who stated it is important to monitor the targeted behavior to ensure medication is working. DON also stated it is important to monitor the effectiveness of the medication and side effects to determine effectiveness of the medication and if there were any side effects on the use of the medication for the resident's safety. DON stated based on the documentation, there were missing days for monitoring side effects and monitoring of targeted behavior for Cymbalta and Trileptal use as ordered. A review of the facility's undated policy and procedure (P&P) titled, "Psychotherapeutic Medications," indicated that the use of psychotherapeutic medications shall be kept to a minimum. The medications are to be used only for specific behaviors by a resident, quantitatively and qualitatively document by the facility. P&P indicated that a specific diagnosis and a specific behavior or thought process justifying the need for psychotherapeutic medications are to be identified in the resident's health record.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 04/15/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 61 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 failed to administer medications appropriately for two of three residents observed during the medication pass observation (Residents 37 and 58). During the medication pass observation, there were nine medication errors for Resident 37 and one medication error for Resident 58, for a total of 10 medication errors out of 32 opportunities. These medication administration errors resulted in a medication error rate of 31.25%. Findings: a. During a medication pass observation, on 3/14/18, at 9:31 AM, at the South Unit, Licensed Vocational Nurse 1 (LVN 1) was observed to have placed nine medications that belonged to Resident 37 in a plastic pouch, and crushed them all together. A review of Resident 37's clinical record, to validate the medications crushed together, indicated the medication were: 1. One tablet (tab) of Linzess (a medication to treat constipation [hard stool that are difficult to expel] in patients with irritable bowel syndrome [a disorder that affects the large intestine and cause abdominal cramping, bloating, and a change in bowel habits]) 145 micrograms (mcg). 2. One tablet of Florinef Acetate (medication used to treat conditions in which the body does not produce enough of its own steroids) 0.1 milligrams (mg). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 62 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 3. Two tablets of Sinemet (medication to treat Parkinson's disease [a disease due to the loss of brain cells that produce dopamine [a chemical messenger that carries signals between brain cells; Early signs and symptoms include tremors or trembling, slow movement, body rigidity and stiffness, and problems walking]) 25-100 mg. 4. One tablet Rasagiline (medication to treat symptoms of Parkinson's disease), 1 mg. 5. One tablet of Mestinon (medication to improve muscle strength in patients with a certain muscle disease), 60 mg. 6. One tablet of Vitamin D3 (the "sunshine vitamin" because it is produced in our skin in response to sunlight). 7. One tablet of multivitamins with iron. 8. One tablet of Northera (medication used to treat low blood pressure that causes severe dizziness or a light-headed feeling) 300 mg. During an interview, on 3/14/18, at 10:20 AM, LVN 1 stated there was a physician's order to crush the medications because it was difficult for resident to swallow the tablets. A review of Resident 37's Physicians Orders for March 2018, indicated the Physician did not order for staff to crush the medications or crush all medications together. During an interview, on 3/14/18, at 2:17 PM, LVN 1 stated she couldn't find an order in the Resident 37's medical record to crush the medications. LVN 1 stated that she verified with the physician after she couldn't find any order to crush the medications, and physician said it was okay to crush the medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 63 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 During a record review with the Director of Nurses (DON), on 3/14/18, at 2:55 PM, she presented a list of medications that should not be crushed. Among the nine medications that were crushed together, Northera is the one included in the list of "do not crush medication," due to there were no studies given by company. A review of the facility's policy and procedure, titled "Specific Medication Administration Procedures," dated 2/23/15, indicated that medications can be crushed and mixed with applesauce or pudding, per physician order, for ease of palatability for administration. Further review of the policy and procedure did not indicate if medication can be crushed together.b. During a medication pass observation, on 3/14/18, at 8:23 a.m., Licensed Vocational Nurse 8 (LVN 8) was observed administering the following medications to Resident 58: 1. Aspirin 81 (medication to reduce inflammation, pain and fever) milligram (mg), 1 tablet. 2. Finasteride (medication for enlarged prostate) 5 mg, 1 tablet. 3. Folic acid (Vitamin B) 1 mg, 1 tablet. 4. Metoprolol (blood pressure medication) 50 mg, 1 tablet. 5. Colace (medication for constipation) 100 mg, 1 tablet. A review of Resident 58's Physician Order, dated 7/22/17, indicated to administer multivitamin with minerals, orally, once a day, at 9 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 64 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 During an interview with LVN 8, on 3/13/18, at 8:11 a.m., he confirmed he had not given the multivitamin for Resident 58. LVN 8 stated he would go back to the resident and give the medication.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 04/15/2018 §483.45(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 instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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 properly label a bottle of liquid stored in the medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 65 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 with the name of the resident and name of the medication. This failure had the potential to administer a wrong medication to the resident. Findings: During an inspection of the west station medication room, on 3/13/18, at 9:05 a.m. with Licensed Vocational Nurse (LVN 7), an opened bottle of liquid with 25 milliliter (ml) left in a 30 ml bottle was inside the refrigerator missing the last name of the resident and showing only "pam" as the name of the medication. A concurrent interview was conducted with LVN 7, he stated he would clarify because the label was unclear. During an interview, on 3/13/18, at 9:33 a.m., Registered Nurse (RN 1) looked at the bottle and stated she would call the doctor to verify. RN 1 further stated that whomever the receiving nurse for the resident should have been properly stored and clearly labeled. The facility's policy and procedure titled " Medication Ordering and Receiving," and dated 2/23/15, indicated that each prescription medication label should include name of the medication and the resident.

F849 SS=E Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 04/15/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 66 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 67 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 68 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 69 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure that the hospice services (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) meet professional standards for 2 of 27 sampled residents who received hospice care (Residents 65 and 73). The facility failed to ensure effective communication regarding the residents' plan of care between the hospice agency and the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 70 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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. For Resident 65, the hospice calendar was not updated, and the physician certification for hospice benefit expired on 3/13/18. b. For Resident 73, there was no physician certification for the hospice benefit. These failures had the potential to cause inappropriate plan of care for the residents. Findings: a. A review of Resident 65's clinical record indicated the resident was admitted to the facility on 11/29/17, and was readmitted on 12/10/17, with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain), and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) without behavioral disturbance. A review of Resident 65's Physician Order, dated 2/13/18, indicated admit resident to hospice (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life) starting 12/14/17 with diagnosis of CVA (Cerebrovascular Disease includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow). A reivew of Residdent 65's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/22/17, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 71 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 indicated Resident 65 required total dependence (full staff performance) with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. On 3/14/18, at 10:35 a.m., a review of Resident 65's clinical record/hospice binder with Registered Nurse 1 (RN 1) was conducted. The hospice calendar in the resident's hospice binder was dated January 2018, and there was no calendar for March 2018. On 3/14/18, at 10:38 a.m., a review of Resident 65's Physician Certification for Hospice Benefit with RN 1 was conducted. The Physician Certification for Hospice Benefit indicated the following: 1. Effective date of certification 12/14/17 to 3/13/18. 2. Terminal Diagnosis: Cerebral Infarction, unspecified. On 3/14/18, at 10:40 a.m., an interview was conducted with RN 1 who confirmed the hospice calendar Resident 65's hospice binder was for January 2018 and there was none for March 2018. RN 1 stated the hospice calendar in the hospice binder should be updated. RN 1 stated she could not find any February or March calendar in the hospice binder or in any part of the resident's clinical record. RN 1 stated the facility needed a current calendar to determine when the hospice staff will come and which discipline will come to provide care to the resident. RN 1 stated the calendar serves as communication between facility and the hospice agency. RN 1 stated the physician certification for hospice benefit for Resident 65 expired on 3/13/18. RN 1 stated the certification for hospice benefit is a document FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 72 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 from the physician to determine terminal illness of the resident. RN 1 stated the certification for hospice benefit should be current as a documented evidence that the resident remained qualified for hospice service. RN 1 stated the certification of hospice benefit was effective 12/14/17 to 3/13/18, and it was expired and is no longer valid. A review of the facility's undated policy and procedure titled" Hospice ServicesCoordination of Services," indicated the facility will provide services for hospice residents that are coordinated with the hospice staff.b. A review of Resident 73's Admission Face Sheet indicated the resident was admitted to the facility on 1/5/18 with diagnoses that included congestive heart failure (CHF, heart muscle is weakened and cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (decline in mental ability severe enough to interfere with daily life), and respiratory failure (loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and multiple organs). A review of Resident 73's MDS, dated 1/12/18, indicated the resident's brief interview for mental status (BIMS, brief screening that aids in detecting cognitive impairment) score was 12 (a score of 8-12 indicated moderately impaired cognitive skills for daily decision making). The MDS indicated Resident 73 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, locomotion, and bathing. A review of Resident 73's Physician's Order, dated 3/12/18, indicated to admit resident to hospice care (designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) under routine level of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 73 of 74 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: _______________ 056080 (X3) DATE SURVEY COMPLETED 03/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE BELLEFONTAINE HEALTHCARE CENTER 150 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 3/13/18, at 7:45 a.m., during concurrent record review and interview with Licensed Vocational Nurse 4 (LVN 4), she stated that Resident 73 was recently enrolled in hospice on 3/12/18. Further review of the clinical record did not show hospice certification on file. LVN 4 stated it was important that this was on file for the staff to be aware of resident's condition/diagnosis and eligibility to be on hospice as well as to aid in the care plan development for Resident 73. On 3/14/18, at 9:26 a.m., during concurrent record review and interview with LVN 4, she stated that Resident 73's hospice certification still was not in the resident's clinical record. LVN 4 stated hospice should have brought it yesterday. A review of the facility's undated policy and procedure titled, "Hospice Services," indicated that the facility will provide services for hospice residents that coordinated with the hospice staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WGOL11 Facility ID: CA970000075 If continuation sheet 74 of 74