Other·July 10, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during an Abbreviated Standard Survey. Complaint Intake # CA00541319Unsubstantiated with a one related regulatory deficiencies found. Representing the Department of Public Health: Evaluator ID # 36205 HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 06/27/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against 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: F2G511 Facility ID: CA97000077 If continuation sheet 1 of 5 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: _______________ 555908 (X3) DATE SURVEY COMPLETED 06/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH PASADENA CARE CENTER 904 Mission St South Pasadena, CA 91030 (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 his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F2G511 Facility ID: CA97000077 If continuation sheet 2 of 5 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: _______________ 555908 (X3) DATE SURVEY COMPLETED 06/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH PASADENA CARE CENTER 904 Mission St South Pasadena, CA 91030 (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 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 report in a timely manner, a staff to resident allegation of abuse to the State licensing and certification agency (Department) for one of 3 sampled residents (Resident 1). This deficient practice had the potential to place the resident's safety at risk. Findings: On 6/28/17 at 9:45 am, an unannounced visit was made to the facility to investigate an entity reported incident regarding allegation of staff to resident abuse that occurred on 6/2/17. A review of the clinical record indicated Resident 1 was admitted to the facility on 4/2/17 with diagnoses that included unspecified atrial fibrillation (the atria or the upper chambers of the heart contract at an excessively high rate and in an irregular way) hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following 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) affecting left dominant side and paranoid schizophrenia(a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/26/17 indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F2G511 Facility ID: CA97000077 If continuation sheet 3 of 5 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: _______________ 555908 (X3) DATE SURVEY COMPLETED 06/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH PASADENA CARE CENTER 904 Mission St South Pasadena, CA 91030 (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 was cognitively intact. Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) to total dependence (full staff performance) in performing activities of daily living. On 6/28/17 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON stated on 6/2/17, Resident 1 reported to the local ombudsman an allegation that a female staff physically abused him. DON indicated Administrator 1 immediately conducted an investigation on 6/2/17 following Resident 1's allegation. The DON stated within 24 hours Administrator 1 gathered all the information and concluded that the incident was not reportable to the Department. The DON stated as a mandated reported, the facility must report all allegations of abuse to the Department. The DON stated that Administrator 1 insisted not to report to the Department. The DON stated she should have reported the incident to the Department even if Administrator 1 told her not to do so. The DON stated Administrator 1 was replaced by Administrator 2 as of 6/26/17. Administrator 2 called the ombudsman's office to introduce himself. The ombudsman inquired from Administrator 2 the status of the investigation regarding allegation made by Resident 1 on 6/2/17. The DON stated Administrator 2 did not have any information regarding the above mentioned allegation made by Resident 1. The DON stated the Administrator 2 instructed her to report the incident to the Department immediately on 6/27/17. On 6/28/17 at 3:05 p.m., an interview was conducted with Administrator 2 who confirmed the facility failed to report in a timely manner, a staff to resident allegation of abuse to the Department. Administrator 2 stated Administrator 1 should have reported Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F2G511 Facility ID: CA97000077 If continuation sheet 4 of 5 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: _______________ 555908 (X3) DATE SURVEY COMPLETED 06/28/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH PASADENA CARE CENTER 904 Mission St South Pasadena, CA 91030 (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's allegation of abuse to the Department for investigation. A review of the facility undated policy and procedure titled "Abuse Reporting" indicated the administrator or DON will report the allegation of abuse to the appropriate state agency. The state agencies include: Department of Public Health Licensing and Certification, Nursing Home Administrator's Program, Board of Vocational Nurses and Psychiatric Technicians and the CNA Certification Board, Adult Protective Services and Local Enforcement Agencies. On 6/26/17 (after hours), the facility reported to the Department the staff to resident abuse that occurred on 6/2/17. The report was made 25 days after the incident occurred. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F2G511 Facility ID: CA97000077 If continuation sheet 5 of 5