Other·January 26, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Complaint Visit. Complaint # CA00507233 - Substantiated Category: Injury of Unknown Origin Representing the Department of Public Health: 36396 The inspection was limited to the specific components investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.13(c)(1)(ii)-(iii), (c)(2) - (4)

F225 12/13/2016 The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report 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 to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source 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: L1RH11 Facility ID: CA950000059 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: _______________ 056316 (X3) DATE SURVEY COMPLETED 12/06/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMELLIA GARDENS CARE CENTER 1920 N Fair Oaks Ave Pasadena, CA 91103 (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 misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification 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 observation, interview and record review, the facility failed to report in a timely manner an injury of unknown source to the State survey and certification agency for 1 of 3 sampled residents (Resident 1). This deficient practice had the potential to put Resident 1's safety at risk. Findings: On 10/26/2016 at 2:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an injury of unknown source. A review of the admission face sheet indicated Resident 1 was admitted to facility on 6/16/2016 with diagnoses that included, but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L1RH11 Facility ID: CA950000059 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: _______________ 056316 (X3) DATE SURVEY COMPLETED 12/06/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMELLIA GARDENS CARE CENTER 1920 N Fair Oaks Ave Pasadena, CA 91103 (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 limited to, dysphagia (difficulty swallowing), chronic respiratory failure (impaired gas exchange in the lungs resulting in difficulty of breathing) and hypertension (high blood pressure). A review of document titled "History and Physical Examination" dated 6/17/2016 indicated Resident 1 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS), a comprehensive assessment tool, dated 9/30/2016 indicated that Resident 1 rarely/never understood self and others, had severely impaired cognitive skills for daily decision making, required total dependence with one person assist with bed mobility, transfer, dressing, toilet use and bathing. During the tour on 10/26/2016 at 2:10 pm with the Director of Nursing (DON), Resident 1 was observed with greenish discoloration on the right hip area. A Review of document titled "Progress Notes" dated 10/15/2016 indicated that Certified Nursing Assistant (CNA) 1 noticed a discoloration and swelling on Resident 1's right groin and was reported to charge nurse; assessment was done and noted Resident 1 with bluish-purple discoloration and swelling to right groin area extending to buttocks; attending physician was notified. A review of document titled "Physician's Orders" dated 10/15/2016 indicated "Stat (immediately) X-Ray (imaging study) right hip, right pelvis (hip bone), right thigh for swelling/discoloration. A review of document titled "Final X-ray Report" dated 10/16/2016 indicated "Findings FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L1RH11 Facility ID: CA950000059 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: _______________ 056316 (X3) DATE SURVEY COMPLETED 12/06/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMELLIA GARDENS CARE CENTER 1920 N Fair Oaks Ave Pasadena, CA 91103 (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 are suspicious for a non-displaced fracture (broken bone) of the femoral neck (thigh bone). CT (computerized tomography-more detailed imaging study) recommended. During an interview with CNA 1 on 10/26/2016 at 3:35 pm, CNA 1 stated she noticed the purplish discoloration and swelling on Resident 1's right groin extending to the right hip. CNA 1 also stated she immediately reported it to charge nurse. During an interview with the DON on 10/26/2016 at 3:00 pm, the DON stated that she was informed by the charge nurse regarding Resident 1's bruise and swelling on right groin area extending to right hip. The DON also stated that an investigation was done to determine cause of the swelling and bruising. The DON further stated that the attending physician ordered Resident 1 transferred to general acute care hospital (GACH) after being informed of the results of the x-ray. A review of the GACH document titled progress record dated 10/16/2016 indicated an orthopedic (specialist in bone disorders) notes with impression of right hip strain/muscle tear. A review of the GACH document titled CT scan of the right pelvis dated 10/16/2016 indicated no acute osseous (bone) abnormalities. During another interview with the DON on 10/26/2016 at 4:10 pm, DON stated that she did not report incident to state licensing and certification agency because there was no fracture noted when CT scan was done in the acute hospital and that she discussed it with the administrator. DON further stated that facility should have reported the incident to state licensing and certification agency because it was an injury of unknown origin. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L1RH11 Facility ID: CA950000059 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: _______________ 056316 (X3) DATE SURVEY COMPLETED 12/06/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMELLIA GARDENS CARE CENTER 1920 N Fair Oaks Ave Pasadena, CA 91103 (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 an undated facility policy and procedure titled "Abuse Investigations" indicated that all reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. The administrator will provide a written report of the results of all abuse investigations and appropriate action will be taken to the state survey and certification agency within 2 days of the reported incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L1RH11 Facility ID: CA950000059 If continuation sheet 5 of 5