Other·December 21, 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 California Department of Public Health during an investigation of one complaint during an abbreviated survey. Complaint number: CA00605487 Representing the Department: HFEN 36904 The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. Five deficiencies were written for CA00605487.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 12/20/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accommodate the needs for one of two sampled residents (Resident 2) as indicated in the facility's policy 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: 3LR211 Facility ID: CA970000075 If continuation sheet 1 of 26 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 11/21/2018 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 and plan of care. 1. For Resident 1, staff failed to answer the resident's call light (device used by a patient to signal his or her need for assistance from professional staff) promptly. This deficient practice had the potential for Resident 2 and other residents not to receive assistance promptly. Findings: A review of the face sheet (admission record) indicated Resident 2 was admitted to the facility on 1/9/17 and was readmitted on 6/24/17 with diagnoses including muscle weakness, and unspecified cerebrovascular accident (CVA, death of some brain cells due to lack of oxygen). A review of Resident 2's History and Physical, dated 10/20/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set ([MDS] a resident assessment and care screening tool), dated 1/9/18, indicated the resident was cognitively (ability to think and process information) was intact. The MDS indicated Resident required extensive assistance (resident involved in activities, staff provide weight-bearing support) with oneperson assist for toilet use, personal assistance, and limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weightbearing assistance) for transfers. A review of Resident 2's Care Plan, dated 2/12/18, indicated the resident had self-care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 2 of 26 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 11/21/2018 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 deficits related to unsteady gait, weakness, poor balance. The approach intervention was to assist Resident 2 with activities of daily living (ADLs) as needed, place the call light within reach and attend to the resident's needs promptly. On 10/10/18 at 11:13 a.m., Resident 2 was sitting in wheelchair awake. A concurrent interview was conducted; Resident 2 stated that staff in general during the evening shift would take more than one hour to answer his call light. Resident 2 stated that he needed assistance in general for ADLs and that he was able to tell the time by looking at his wristwatch. During a telephone interview on 11/9/18 at 1:19 p.m., the facility's Director of Staff Development 2 (DSD 2) stated that staff needed to answer the call lights as soon as possible to assist residents. A review of the facility's undated policy and procedure titled "Call Lights," indicated that the facility required staff to monitor the call lights and to make sure that call lights were answered promptly, regardless of who was assigned to each resident to assure residents receive prompt assistance.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 12/20/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 3 of 26 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 11/21/2018 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 (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to develop and implement specific individualized plan of care for one of two sampled residents (Resident 1), as indicated in the facility's policy and procedure and standard of practice. Resident 1 did not have the care plans to address: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 4 of 26 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 11/21/2018 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 1. Resident 1's weight loss. 2. Resident 1's left heel deep pressure injury(localized damage to the skin and or underlying soft tissue usually over a bony prominence or related to a medical or other device [DTI]persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue). 3. Resident 1's diagnosis of irritable bowel syndrome ([IBS] -a mix of belly discomfort or pain and trouble with bowel habits). These deficient practices resulted in Resident 1 did not receive specific interventions to address Resident 1's weight loss and had the potential for resident to not receive specific treatment for the deep pressure injury and symptoms of irritable bowel syndrome. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on 7/18/18 with diagnoses including Type 2 diabetes mellitus (long term disorder that is characterized by high blood sugar), and irritable bowel syndrome ([IBS] -a mix of belly discomfort or pain and trouble with bowel habits). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment and care screening tool), dated 7/24/18, indicated that Resident 1's cognitive (ability to think and process information) was intact. The MDS indicated Resident 1 required extensive assistance (resident involved in activities, staff provide weight-bearing support) with oneFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 5 of 26 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 11/21/2018 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 person assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. 1. A review of Resident 1's Vital Signs record, dated 7/18/18 to 9/19/18, indicated the following: On 7/18/18, Resident 1 weighed 222 pounds (lbs.) On 8/9/18, Resident 1 weighed 224 lbs. (two lbs. weight gain) On 9/7/18, Resident 1 weighed 200 lbs. (24 lbs. weight loss) On 9/19/18, Resident 1 weighed 196 lbs. (4 lbs. weight loss) During an interview on 10/10/18 at 3:18 p.m., Registered Nurse 1 (RN 1) stated that Registered Dietitian 1's (RD 1) recommendations were not addressed by nursing staff and that there no nursing care plan to address Resident 1's weight loss. RN 1 stated that the nurses were supposed to monitor Resident 1's weight loss, develop a plan of care and inform the resident's Physician for overall care of the resident. 2. A review of Resident 1's Skin Integrity Events-Pressure Ulcer Situation, Background, Assessment, Recommendation (SBAR), dated 9/9/18, and timed at 3:39 p.m., indicated that resident was noted with a left heel DTI that measured 3.5 centimeter (cm) x 2.5 (cm) with deep red discoloration. During a telephone interview on 10/10/18 at 7:29 a.m., Resident 1's Family Member 1 (FAM 1) stated that on 9/24/18 she requested facility's staff to transfer Resident 1 to the hospital due to Resident 1 "looked horrible," the resident lost weight, and had diarrhea which was not controlled at the facility. During an interview on 11/6/18 at 1:52 p.m., Licensed Vocational Nurse 3 (LVN 3) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 6 of 26 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 11/21/2018 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 that there was no care plan created for Resident 1's left heel DTI on 9/9/18. LVN 3 stated that the nurses were supposed to create a care plan with interventions to address Resident 1's DTI on the left heel. 3. During a telephone interview on 11/9/18 at 2:40 p.m., Resident 1's Primary Physician (MD 1) stated that the nurses did not inform him regarding Resident 1's weight loss. MD 1 stated that he expected licensed nurses to inform him regarding Resident 1's weight loss so that he could make decision for the treatment. MD 1 stated nursing staff supposed to create a care plan to address Resident 1's weight loss and Resident 1's diagnosis of IBS. MD 1 stated that he did not know the reason why Resident 1's weight loss was not presented to him. A review of the facility's policy and procedure titled "Care Planning," with a revised date of September 2013, indicated that the facility's care planning interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.

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

F684 12/20/2018 § 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 of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 7 of 26 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 11/21/2018 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 provide the necessary care and services for one of two sampled residents (Resident 1), in accordance with facility's policy and procedure, and recognized standards of practice to meet the needs of the resident, by failing to: 1. Ensure Resident 1 received prompt nursing interventions and to follow the physician orders during changes of conditions (COC). 2. Monitor and assess Resident 1's bowel movement (BM, evacuation of the bowels) amount, and consistency (such as hard, soft, normal, diarrhea [loose, watery stools]), and to promptly send Resident 1's stool sample to the laboratory as ordered for testing. 3. Ensure that Resident 1 who was diagnosed with clostridium difficile (C-Diff, a bacterium [germ] that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) received Vancomycin (medication to fight bacteria) as ordered by the physician. 4. Failed to address Resident 1's episodes of diarrhea during an interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) conference. 6. Conduct complete neurological assessments (an assessment of brain functions and level of consciousness) after Resident 1 sustained a fall. As a result, Resident 1's BM was not monitored, and the resident's COC was not promptly identified. Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services) per family's request FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 8 of 26 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 11/21/2018 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 and was admitted to the hospital's in critical condition with diagnoses of Clostridium difficile colitis, sepsis with septic shock (life-threatening low blood pressure due to [sepsis] caused by an overwhelming immune response to infection). *Cross references F656 and F692 Findings: A review of Resident 1's Face Sheet (admission record) indicated that resident was admitted to the facility on 7/18/18 with diagnoses that included sepsis, Type 2 diabetes mellitus (long term disorder that is characterized by high blood sugar), and irritable bowel syndrome (IBS, a mix of belly discomfort or pain and trouble with bowel habits). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/24/18, indicated that Resident 1's cognitive (ability to think and process information) was intact. The resident required extensive assistance (resident involved in actives and staff provide weightbearing- support) with one-person assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. A review of Resident 1's Resident Progress Notes, dated 8/13/18, and timed at 3:14 a.m., indicated that Resident 1 complained of having loose stools, weakness, and poor appetite and that the stool softener was placed on hold and that a message was left for Resident 1's physician. A review of Resident 1's Change of ConditionCOC/Interact Assessment Form (SBAR), dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 9 of 26 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 11/21/2018 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 8/13/18, and timed at 7:07 p.m., indicated that resident at 4 p.m. (13 hours later), stated that he felt weak and had diarrhea, and that Resident 1's physician ordered blood laboratory (blood test) and to collect a stool sample. A review of Resident 1's Resident Progress Notes indicated that there were no nursing notes from 8/17/18 to 8/21/18. A review of Resident 1's SBAR, dated 8/22/18, and timed at 9:44 p.m., indicated that Resident 1's family reported that resident had ongoing diarrhea and the physician was aware and that per family request Resident 1's physician ordered a stool culture. A review of Resident 1's Care Plan, dated 8/22/18, indicated that resident had diarrhea, and that the nursing approach was to collect stool, and to record the duration and frequency of diarrhea, characteristics, consistency, and quality of stool. A review of Resident 1's Resident Progress Notes, dated 8/23/18, and timed at 5:02 a.m., indicated that at 4:30 a.m., Resident 1 had a soft mucoid yellowish stool with foul smell and that a stool sample was collected. A review of Resident 1's SBAR, dated 8/25/18, and timed at 5:06 p.m., indicated that Resident 1 was noted with a positive C- Diff results and resident was placed in contact isolation. A review of Resident 1's untimed Physician Orders Report dated 8/25/18, indicated for resident to receive vancomycin 125 mg/2.5 ml, 5 ml, four times a day for 21 days. A review of Resident 1's Physician and Telephone Orders, dated 9/6/18, and timed 3 p.m., indicated for resident to receive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 10 of 26 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 11/21/2018 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 vancomycin (no dose provided) "for 14 days not 21 days." A review of Resident 1's Medications Flowsheet, dated from 8/26/18 to 8/31/18, indicated that resident received vancomycin 125 mg/2.5 ml, amount administered 5 ml, oral four times a day (for a total of six days). A review of Resident 1's Medications Flowsheet, dated from 9/1/18 to 9/7/18, indicated the resident received vancomycin 125 mg/2.5 ml, amount administered 5 ml, oral four times a day (for a total of seven days). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 9/13/18, and timed at 2:15 p.m., indicated that Resident 1 had an unwitnessed fall inside his room. A review of Resident 1's SBAR, dated 9/22/18, and timed at 7:48 a.m., indicated that resident had four episodes of loose foul smelling bowel movements and abdominal discomfort. A review of Resident 1's Progress Notes, dated 9/24/18, and dated 2:40 p.m., indicated that at 1:30 p.m., Resident 1's family requested to transfer resident to the hospital and that Registered Nurse 1 (RN 1) explained to resident's family that he (RN 1) needed to do his assessment prior to him calling 911. The notes indicated that resident was noted with cool extremities, weaker, increased respiratory rate, oxygen saturation (a test that measures the amount of oxygen being carried by red blood cells) at 84% (normal 95%-100%), and that at 1:35 p.m., RN 1 was not able to obtain a blood pressure. The notes indicated that at 1:37 p.m., Resident 1's physician ordered one liter of normal saline (sterile fluid) bolus (rapid administration of fluid) and to transfer resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 11 of 26 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 11/21/2018 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 via 911. A review of Resident 1's GACH Emergency Documentation dated 9/24/18, and timed at 2:46 p.m., indicated that Resident 1's blood pressure was 67/50 milliliter of mercury (mm/Hg) (low, normal is 120/90) and that the resident was thin. A review of Resident 1's GACH Emergency Documentation dated 9/24/18, and timed at 10:30 p.m., indicated that Resident 1 received broad-spectrum antibiotics (medication for infection) for sepsis and septic shock, and that a rectal Foley (tube in rectum) was placed due to perfuse watery diarrhea in the emergency room. The GACH notes indicated that Resident 1 was admitted to an Intensive Care Unit (ICU, unit for patients in critical condition) in critical condition with diagnoses of Clostridium difficile colitis, sepsis with septic shock, acute kidney injury, and hyperglycemia (high blood glucose). A review of Resident 1's GACH Perioperative Procedural Record, dated 9/26/18, and timed at 6:40 p.m. indicated on 9/25/18, Resident 1 abdominal surgery under general endotracheal (tube in trachea) anesthesia in hopes of saving resident's life. The record indicated that Resident 1's preoperative (before surgery) and postoperative (after surgery) diagnosis was fulminant Clostridium difficile colitis (acute severe inflammation of the lining of the colon). A review of Resident 1's GACH Perioperative Procedural Record, dated 9/27/18, and timed at 10:21 p.m., indicated that Resident 1 underwent a second surgery. A review of Resident 1's GACH Discharge Documentation dated 10/9/18, and timed at 3:01 p.m., indicated that Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 12 of 26 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 11/21/2018 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 admitted to the hospital from 9/24/18 and was discharged on 10/9/18. The Discharge Documentation indicated that Resident should get a gastrostomy tube placement (a tube inserted through the abdomen that delivers nutrition directly to the stomach) and that there was a possibility that Resident 1 would never regain swallow. During a telephone interview on 10/10/18 at 7:29 a.m., Resident 1's Family Member 1 (FAM 1) stated that on 9/24/18 she requested facility's staff to transfer Resident 1 to the hospital because Resident 1 "looked horrible," lost weight, and had diarrhea which was not controlled at the facility. During an interview on 10/10/18 at 2:41 p.m., Registered Nurse 1 (RN 1) stated that Certified Nursing Assistants (CNAs) were supposed to document episodes of BM so that they (licensed nurses) could establish a trend. RN 1 stated that the CNAs did not document Resident 1's BM episodes from 9/20/18 to 9/24/18 and that there were other entries that were not readable and some dates were not completely filled out. RN 1 stated that CNAs were supposed to document the actual number of Resident 1's BM. During an interview on 11/6/18 at 11:03 a.m., RN 2 stated that licensed nurses were supposed to actually see Resident 1's stool and to describe and document the stool. During a telephone interview on 11/9/18 at 11:33 a.m., the facility's Medical Director (MD 2) stated that the nurses were supposed to follow Resident 1's physician orders of vancomycin for fourteen days. During a review of Resident 1's medical record on 11/6/18 at 11:53 a.m., RN 2 stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 13 of 26 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 11/21/2018 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 there were discrepancies between CNAs and licensed nurses BM documentation's. RN 2 stated that here was a nine day delay to obtain a stool sample, no description of Resident 1's BM, and that some CNAs notes were unreadable and some without documentation. During a review of Resident 1's 72 Hours Neuro Check List on 11/6/18 at 2:35 p.m., RN 2 stated that the neurological assessment was incomplete. RN 2 stated that the purpose of neurological exam was to assess for any neurological changes. A review of the facility's policy and procedure titled "Clostridium Difficile," with a revised date of September 2017, indicated that measures would be taken to prevent the occurrence of Clostridium Difficile infections among residents and precautions would be taken while caring for residents with Clostridium Difficile to prevent transmission to other residents. The policy indicated that suspected infection with C-Diff would be verified by evidence by of positive cytotoxin assay and to transport to the laboratory as soon as possible. A review of the facility's policy and procedure titled "Bowel Disorders-Clinical Protocol," with a revised date of September 2017, indicated that the nurse should assess and document quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount consistency, etc.), and that the staff and physician would monitor the individual's response to interventions and overall progress. A review of the facility's policy and procedure titled "Change in a Resident's Condition or Status," with a revised date of May 2017, indicated that the facility should promptly notify the resident, his or her attending physician, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 14 of 26 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 11/21/2018 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 representative of changes in the resident's medical/mental condition. A review of the facility's policy and procedure titled "Assessment, fall," with a date revised of October 2014, indicated that the facility required staff to observe for delayed complications of a fall for approximately seventy-two hours and document.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 12/20/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide nutrition and hydration to prevent weight loss and dehydration (a severe reduction in the amount of water in the body) for one of two sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 15 of 26 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 11/21/2018 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 1). For Resident 1, the facility: 1. Failed to implement its policy on Weight Assessment and Interventions, when licensed nurses did not notify Resident 1's Physician (Physician 1) and the Registered Dietitian (RD a healthcare professional licensed to assess, diagnose, and treat nutritional problems) for follow up recommendation when Resident 1 had a significant weight change. 2. Failed to implement its policy on Resident Hydration and Prevention of Dehydration, when nursing staff did not provide Resident 1 enough hydration as assessed by the RD. 3. Failed to implement its policy on Change in a Resident's Condition or Status by licensed nurses not notifying Physician 1 of Resident 1's weight loss of 24 pounds (lbs.) in one month. 4. Failed to implement its policy on Calculating Percentages at Meal Times when Certified Nursing Assistants (CNAs) did not accurately document Resident 1's meal intake. As a result, Resident 1 sustained a severe weight loss of 24 lbs. in one month without medical and nutritional interventions. On 9/24/18, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (emergency services). *Cross-references F656 and F684 Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on 7/18/18 with diagnoses including type 2 diabetes mellitus (DM, high blood sugar level) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 16 of 26 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 11/21/2018 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 and irritable bowel syndrome (IBS - a chronic disorder that affects the large intestine. Signs and symptoms include cramping, stomach pain, bloating, gas, and diarrhea [loose stools] or constipation [difficulty in emptying the bowels, usually associated with hardened feces, having fewer than three bowel movements a week], or both). A review of the Minimum Data Set (MDS standardized assessment and care-planning tool), dated 7/24/18, indicated Resident 1 had no cognitive (ability to think and process information) problem and the resident required extensive assistance (resident involved in activity, staff provided weight-bearing support) with one-person assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. A review of the Nutritional Observation Notes, completed by RD 1, dated 7/26/18, indicated Resident 1's estimated kilocalories (kcals is 1,000 calories, in nutrition terms, the word calorie is commonly used to refer to a unit of food energy) needs were 1,800 - 2,000 kcals. Resident 1's fluid intake needs were greater than 1,500 milliliters (ml). The note did not include Resident 1's usual body weight range. A review of Resident 1's Weight Record Form, dated 8/9/18 to 9/18/18, indicated Resident 1's weights were as follows: On 8/9/18, 224 lbs., two lbs. weight gain (admission weight = 222 lbs.) On 9/7/18, 200 lbs., 24 lbs. weight loss in one month. On 9/19/18, 196 lbs., four lbs. weight loss in 12 days. A review of the Resident Progress Notes dated 8/13/18, timed at 3:14 a.m., indicated Resident 1 complained of having loose stools, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 17 of 26 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 11/21/2018 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 weakness, and poor appetite. A review of the Resident Progress Notes dated 8/14/18 to 8/17/18, indicated Resident 1 did not have any episodes of loose stools. There were no nursing notes from 8/17/18 to 8/21/18. A review of the Resident Progress Notes dated 8/22/18, timed at 8:30 p.m., indicated FM 1 informed Registered Nurse (RN 4) that Resident 1 had smelly diarrhea for two weeks. FM 1 was concerned that Resident 1 might have infection. RN 4 notified Physician 1 and obtained order to collect stool for sampled to test for C-diff. A review of the Resident Progress Notes dated 8/26/18, timed at 6:06 a.m., indicated Resident 1 received the first dose of Vancomycin (antibiotic), 250 milligram (mg)/5 milliliter (ml), by mouth, three time a day, for 21 days, for Cdiff. A review of the Resident Progress Notes dated 9/13/18, timed at 9:30 a.m., indicated RD 1 noticed Resident 1 with a significant weight loss of 24 lbs. in thirty days. RD 1 requested to obtain blood tests to evaluate Resident 1's nutritional status, and recommended weekly weight. A review of the Resident Progress Notes dated 9/13/18 timed at 3:46 p.m., indicated Registered Nurse 3 (RN 3) received RD 1's recommendations to obtain weekly weight for 4 weeks. The notes did not indicated RN 3 notified Physician 1 regarding RD 1's request to obtain the blood tests to check Resident 1's nutritional status. A review of the Resident Progress Notes dated 9/16/18, at 2:20 p.m., indicated FM 1 approached Licensed Vocational Nurse 4 (LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 18 of 26 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 11/21/2018 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 4) and requested LVN 4 to obtain a blood test for Resident 1. A review of the Dietary Recommendations dated 9/20/18, indicated RD 1 recommended for Resident 1 to receive vitamin C and zinc sulfate (nutritional supplements) for fourteen days, and Active Liquid Protein® sugar-free (ALP SF is a ready-to-use liquid form of protein supplement), 30 ml twice a day, check weekly weights, and monitor Resident 1's weight loss. A review of the Resident Progress Notes dated 9/21/18, timed at 9:09 a.m., indicated RD 1's recommendations for the nutritional and protein supplements were not relayed to Physician 1 for implementation. A review of nursing Progress Notes dated 9/24/18, indicated at 1:30 p.m., FM 1 requested to transfer Resident 1 to the hospital. Registered Nurse 1 (RN 1) explained to FM 1 that he needed to do his assessment before calling 911. Resident 1 had cool extremities, weakness, increased respiratory rate, the oxygen saturation (a test that measures the amount of oxygen carried by red blood cells) was 84% (normal 95%-100%), and RN 1 was not able to obtain a blood pressure. At 1:37 p.m., RN 1 called Physician 1, who ordered one liter of normal saline (sterile fluid) intravenous (through veins) bolus (rapid administration of liquid) and to transfer Resident 1 to a GACH via 911. A review of GACH 1 Emergency Room Documentation dated 9/24/18, timed at 2:46 p.m., indicated Resident 1's blood pressure was 67/50 millimeters of mercury (mmHg normal level was 120/90), and Resident 1 was thin. At 10:30 p.m., Resident 1 received broadspectrum antibiotics (medication for infection) for sepsis and septic shock (life-threatening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 19 of 26 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 11/21/2018 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 infection), placement of a rectal tube for profuse watery diarrhea. Resident 1 was admitted to ICU in critical condition with diagnosis of Clostridium Difficile colitis (C-Diff infection that causes diarrhea and inflammation of the bowels), lactic acidosis (when too much acid builds up in the bloodstream), and acute kidney injury (a sudden kidney failure). During a telephone interview on 10/10/18 at 7:29 a.m., FM 1 stated on 9/24/18 she asked the nurses to transfer Resident 1 to a GACH because Resident 1, "Looked terrible," had lost weight, and uncontrolled diarrhea. On 10/10/18 at 1:35 p.m., during an interview with the Director of Staff Development (DSD) and a review of Resident 1's record, the DSD stated the licensed nurses did not address Resident 1's weight loss. On 10/10/18 at 3:18 p.m., during an interview with RN 1 and a review of Resident 1's clinical record, RN 1 stated the nurses did not follow RD 1's recommendations. RN 1 was unable to find documentation Physician 1 was informed about Resident 1's weight loss. RN 1 stated there was no plan of care addressing Resident 1's weight loss. During an interview on 10/10/18 at 3:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 9/24/18 the night shift endorsed to her Resident 1 had loose stools during the night. LVN 1 stated Resident 1 looked pale, and his blood pressure was low, and she informed RN 1. During an interview on 11/6/18 at 11:03 a.m., RN 2 stated the facility did not monitor Resident 1's fluid intake. RN 2 stated there was no documentation in Resident 1's clinical record to show that Resident 1 received the needed amount of fluids. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 20 of 26 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 11/21/2018 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 11/6/18 at 11:44 a.m., during a review of Resident 1's CNA Daily Charting for the month of 9/2018 with the DSD indicated that on 9/23/18, Resident 1 refused to eat dinner. The resident had extreme lose BM and had to be changed six times. The DSD stated CNAs were supposed to report to the licensed nurses when Resident 1 refused meal and had extreme lose BM. During a review of Resident 1's medical record on 11/6/18 at 11:53 a.m., with RN 2, RN 2 stated the nurses did not notify Physician 1 about Resident 1's weight loss, and there was no weight loss care plan developed. RN 2 stated that Resident 1's weight loss was a change of condition, and the nurses had to inform Physician 1. During a telephone interview on 11/7/18 at 1:29 p.m., RD 1 stated that nursing staff was responsible for notifying Physician 1 about Resident 1's weight loss. During a telephone interview on 11/9/18 at 11:33 a.m., the facility's Medical Director (MD) stated she was not aware of Resident 1's condition, and she expected the licensed nurses to report the weight loss to Physician 1. During a telephone interview on 11/9/18 at 2:40 p.m., Physician 1 stated the nurses did not inform him about Resident 1's weight loss. A review of the facility's policy and procedure titled, "Weight Assessment and Interventions," revised on 6/2015, indicated nursing would notify the physician and dietitian for follow up recommendation when there is any significant weight change. A review of the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 21 of 26 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 11/21/2018 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 titled, "Resident Hydration and Prevention of Dehydration," revised on 10/2017, indicated the facility would strive to provide adequate hydration, prevent, and treat dehydration. The intake would be documented in the medical records, and CNAs would report intake of fewer than 1200 ml per day to the nursing staff. A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," revised on 5/2017, indicated to promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. A review of the undated facility's policy and procedure titled, "Calculating Percentages at Meal Times," indicated nursing to make the charts available to the CNAs to assure accurate meal intake charting.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 12/20/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 22 of 26 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 11/21/2018 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 §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 23 of 26 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 11/21/2018 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 and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to accurately document in the resident's medical record for one of two sampled residents (Resident 1) as indicated in the facility's policy and procedure. Certified Nursing Assistants (CNAs) failed to document episodes of Resident 1's bowel movement (BM, an act of defecation) in the C.N.A. Daily Charting Form. This deficient practice resulted in missing pertinent information in Resident 1's medical record. Findings: A review of Resident 1's Face Sheet (admission record) indicated that resident was admitted to the facility on 7/18/18 with diagnoses including Type 2 diabetes, mellitus (long term disorder that is characterized by high blood sugar), and irritable bowel syndrome (IBS - a mix of belly discomfort or pain and trouble with bowel habits). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/24/18, indicated that Resident 1's cognitive (ability to think and process information) was intact. The MDS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 24 of 26 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 11/21/2018 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 the resident required extensive assistance (resident involved in activities and staff provide weight-bearing support) with oneperson assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. During a telephone interview on 10/10/18 at 7:29 a.m., Resident 1's Family Member 1 (FAM 1) stated that on 9/24/18 she requested facility's staff to transfer Resident 1 to the hospital because Resident 1 "looked horrible." FAM 1 stated Resident 1 lost weight and he had diarrhea, which was not controlled at the facility. During a review of Resident 1's C.N.A. Daily Charting Form, and a concurrent interview on 10/10/18 at 2:41 p.m., Registered Nurse 1 (RN 1) stated that CNAs were supposed to document episodes of bowel movement (BM) in the C.N.A. daily charting form so that licensed nurses could establish a trend. RN 1 stated that CNAs did not document Resident 1's BM episodes from 9/20/18 to 9/24/18 and that there were some unreadable entries and some dates the entries were not completely filled out. RN 1 stated that CNAs were supposed to document the actual number of Resident 1's BM. During a review of Resident 1's C.A.N. Daily Charting Form, Nurses Progress Notes and a concurrent interview on 11/6/18 at 11:53 a.m., RN 2 stated that there were discrepancies between CNAs' and licensed nurses' documentation regarding Resident 1's bowel movement. RN 2 stated some CNAs notes were unreadable and some without documentation. A review of the facility's policy and procedure titled "Record Content," dated 1/14, indicated that Certified Nursing Assistants (CNAs) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 25 of 26 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 11/21/2018 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 providing care to the residents should enter daily narrative notes after proper instruction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LR211 Facility ID: CA970000075 If continuation sheet 26 of 26