Other·November 29, 2018

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 a complaint investigation. Complaint Number: CA00602662 Representing the Department: HFEN # 36202 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint number CA00602662

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 12/01/2018 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 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: HCQM11 Facility ID: CA950000059 If continuation sheet 1 of 7 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 11/02/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide necessary services to promote healing, and prevent pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) infection for one of three sampled residents (Resident 1). For Resident 1, the resident was admitted to the facility with stage 4 pressure ulcer (full thickness skin and tissue loss with exposed of muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacrococcyx (the bottom of the spine, the tailbone area), and the facility failed to implement the facility's policy and procedure by: 1. Failure to identify factors that placed Resident 1 at risk for worsening pressure ulcer. 2. Failure to maintain a complete weekly pressure ulcer assessment for Resident 1 that included pressure ulcer/wound measurement and the description of the wound characteristics. 3. Failure to modify and implement new care plans when the current interventions were not effective. These deficient practices resulted in Resident 1's pressure ulcer increase in size on 8/20/18 and had the potential for the resident to develop new pressure ulcer. Findings: On 9/17/18 at 10:15 a.m., an announced visit to the facility to investigate a complaint FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 2 of 7 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 11/02/2018 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 allegation regarding quality of care. A review of the Admission Record indicated Resident 1 was admitted to the facility, on 7/31/18, with diagnoses that included anoxic brain damage (the death of brain cells due to lack of oxygen being provided to the brain), and Stage 4 pressure ulcer of the sacral region. A review of Resident 1's History and Physical form, dated 8/4/18, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 8/7/18, indicated Resident 1 had cognitive (ability to think and process information) impairments. Resident 1's MDS indicated Resident 1 was totally dependent on staff with activities of daily living (ADL). A review of Resident 1's Wound Note Worksheet, dated 8/1/18, indicated the size of Resident 1's pressure ulcer in the sacrococcyx was 2.8 x 2.7 x 0.4 centimeter (cm) (the measurement in length x width x diameter in centimeter). The note indicated the pressure ulcer had no drainage or odor, A review of Resident 1's Wound Note Worksheet, dated 8/10/18, 8/17,18, and 8/24/18, indicated the size of Resident 1's pressure ulcer in the sacrococcyx as follow: 1. On 8/10/18: 2.5 x 2.5 x 07 2. On 8/17/18: 1.9 x 1.6 x 0.4 3. On 8/24/18: 3 x 2.8 x 0.3 Further review of Resident 1's Wound Note Worksheet, dated 8/10/18, 8/17/18, and 8/24/18, indicated there was no description of the wound characteristics to including if there was tunneling (a narrow opening or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 3 of 7 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 11/02/2018 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 passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation), undermining tissue (generally includes a wider area of tissue than tunneling) of wound base and tissue surrounding wound. A review of Resident 1's Advantage Surgical and Wound Care (progress note details), dated 8/13/18, indicated the size of Resident 1's Stage 4 pressure ulcer in the sacrum was 1.9 x 1.6 x 0.4 cm. The noted indicated Resident 1's pressure ulcer had moderate amount of drainage. A review of Resident 1's Wound Care Progress Note, dated 8/20/18, indicated the size of Resident 1's Stage 4 pressure ulcer was 3 x 2.8 x 0.4 cm. The periwound (tissue surrounding a wound) skin exhibited maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture). The note indicated Resident 1's wound had an increase in size from 8/13/18 to 8/20/18 (1.1 cm in length, 1.2 cm in width, and had no changes with depth). A review of Resident 1's Wound Care Progress Note, dated 8/27/18, indicated the size of Resident 1's Stage 4 pressure ulcer was 3 x 2.7 x 0.3 cm. The periwound skin exhibited maceration. The note indicated the post debridement measurement was 3 x 2.7 x 0.3 cm. A review of Resident 1's Physician's Order, dated 8/20/18, indicated to administer Keflex (an antibiotic medication used to treat bacterial infection), 500 milligrams (mg), four times a day, for seven days for sacrococcyx wound infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 4 of 7 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 11/02/2018 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 of Resident 1's Physician Order, dated 8/31/18, indicated to transfer Resident 1 to a General Acute Care Hospital (GACH) due to an increase in white cell count (WBC - are vital components of the blood to fight infection, and they are essential for health and wellbeing. High white blood cell count may indicate that the immune system is working to destroy an infection). On 10/31/18 at 12:20 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated wound/pressure ulcer assessments including measurements and documentation of the wound characteristics was done every Friday. LVN 1 stated he did not performed Resident 1's weekly wound assessment on Friday due to the wound doctor/consultant would come on Monday. LVN 1 stated he used the wound measurement from the wound consultant and documented it in Resident 1's Wound Note Worksheet and he did not measure Resident 1's wound. LVN 1 stated Resident 1's care plan was not revise and was not modified on 8/20/18 when there was an increase in size of Resident 1's sacrococcyx pressure ulcer. On 10/31/18 at 1:40 p.m., during an interview and concurrent record review, the Director of Nurses (DON) stated nursing staff did not identify factors that placed Resident 1 as risk for worsening pressure ulcer. The DON stated Resident 1's care plan was not revised and modify on 8/20/18 when Resident sacrococcyx pressure ulcer was increased in sized. On 10/31/18 at 3:20 p.m., during concurrent interview and record review with the DON, she stated the pressure ulcer/wound assessment was always done weekly on Fridays. The DON stated LVN 1 should assessed and measured Resident 1's pressure ulcer on a weekly basis. The DON stated LVN 1 should not use the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 5 of 7 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 11/02/2018 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 pressure ulcer measurement from the wound doctor/consultant assessment. The DON stated the purpose of the Licensed Nurse to assess Resident 1's pressure ulcer was for the nurse to present the assessment including measurement to the wound doctor/consultant during the consultant visit to the facility and to compare if there was changes and effectiveness with the current treatment. During concurrent interview and record review of Resident 1's Wound Note Worksheet form, the DON stated the form was not completed. The DON stated the form should include the description of the pressure ulcer wound characteristic such as tunneling and undermining. The DON stated there was no care plan developed to address Resident 1's high risk for pressure ulcer development. A review of facility's policy and procedure titled "Pressure Ulcer/Injury Risk Assessment," revised in 7/2017, indicated the purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot or which can be immediately addressed and which will take time to modify. The policy indicated when the assessment is conducted and the risk factors are identified and characterized, a residentcentered care plan can be created to address the modifiable risks for pressure ulcers/injuries. The interventions must be based on current standard of care. The effect of the interventions must be evaluated. The policy indicated the care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation in medical record addressing the Physician notification if new skin alteration noted with change of plan of care, if indicated. Notify the attending Physician if new skin alteration noted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 6 of 7 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 11/02/2018 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 of facility's policy and procedure titled "Pressure Ulcers/Skin Breakdown - Clinical Protocol," revised in 4/2018, indicated the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, with, and depth, presence of exudates or necrotic tissue. b. pain assessment. c. resident mobility status. d. current treatments, including support surfaces and all active diagnoses. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HCQM11 Facility ID: CA950000059 If continuation sheet 7 of 7