Health inspection·October 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Resident 1's name was found in the narcotic (a drug or other substance that affects mood or behavior) drawer. LVN 1 stated she was aware the phone was in the medication cart and does not know why Resident 1's cellphone was being kept in the cart. LVN 1 stated since Resident 1 never asked her to return his cellphone, she did not return it to him. LVN 1 also stated she did not document Resident 1's cellphone being in the medication cart because I am not the one who took it from him. Residents Affected - Few During a concurrent interview and review of Resident 1's medical chart on 10/29/2024 at 11:37 AM with RNS, RNS stated the medical record did not indicate Resident 1 was made aware, agreed to, or asked for his cellphone to be taken and kept with facility staff. RNS stated the chart did not indicate why Resident 1's cellphone was kept in the medication cart. RNS stated when facility keeps a resident's property and/or valuables, the resident should be informed and then documented by staff in either a progress note or on the resident's inventory list. During an interview on 10/29/2024 at 11:53 AM with Resident 1, Resident 1 stated that staff told him they were taking his cellphone so that he will not call 911, but he did not want the staff to take his cellphone. Resident 1 stated he would use his cellphone to call family, friends, and order door dash (an on-demand food delivery service) prior to it being taken. During an interview on 10/29/2024 at 12:21 PM with Family member 1 (FM 1), FM 1 stated the facility took Resident 1's cellphone because she told the staff to take it away from Resident 1 and keep with them. FM 1 stated she asked them to take his phone. FM 1 stated she does not have any legal authority to make decisions for Resident 1. During an interview on 10/29/2024 at 1:44 PM with Assistant Director of Nursing (ADON), ADON stated when FM 1 had requested for Resident 1's care, staff should check if FM 1 has power of attorney (POA - a legal document that gives someone the authority to make decisions on behalf of another person). ADON stated there were no documentation on Resident 1's medical record that indicated FM 1 as POA or decision maker for Resident 1, so staff must follow Resident 1's wants. ADON also stated, Resident (Resident 1) has the right to have his phone, we cannot just take it. During an interview on 10/29/2024 at 2:00 PM with the Director of Nursing (DON), the DON stated the facility needs to follow Resident 1's wants, as long as it was safe because resident was self-responsible. The DON stated staff should have checked with Resident 1 to see if he wanted staff to keep his cellphone before taking it. DON added, if Resident 1 did not agree, staff should not have removed his cellphone. DON also stated if Resident 1 agreed and was informed that his cellphone would be kept with staff, it should have been documented in a progress note. During an interview on 10/29/2024 at 2:09 PM with LVN 2, LVN 2 stated on 10/17/2024 (Resident 1's admission date), during the NOC shift (3 PM to 11 PM), FM 1 requested for staff to remove and keep Resident 1's cellphone, so she placed and kept Resident 1's cellphone at the nurses' station. During a concurrent interview and review of Resident 1's electronic medical chart on 10/29/2024 at 2:58 PM with DON, DON stated there was no documentation indicating why Resident 1's cellphone was taken and/or that he requested and wanted his cellphone removed. DON also stated the chart did not indicate why staff did not return Resident 1's cellphone. The DON stated even if FM 1 requested for cellphone removal, Resident 1 was self-responsible, and it was his right to have his cellphone to call whoever he wants. DON stated removing Resident 1's cellphone without his permission could have impacted his well-being negatively causing depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Resident's Rights, revised 5/1/2023, the P&P indicated: 1. The purpose is to promote and protect the rights of all residents at the facility. 2. The facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. 3. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 4. Residents have the right to retain and use personal possessions to the maximum extent that space and safety permit. During a review of the facility's P&P titled, Resident Rights- Accommodation of Needs, dated 5/1/2023, the P&P indicated to accommodate residents' individual needs and preferences, facility staff will assist residents in maintaining independence, dignity, and wellbeing to the extent possible according to residents' wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management to two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the physician's order and facility policy by failing to: Residents Affected - Some 1. Administer Acetaminophen (a medication used to treat minor aches, pains, and to reduce fevers) to Resident 1 as indicated in the physician's order and notify physician of increased onset of pain. Resident 1 received Acetaminophen 325 milligrams (mg, unit of measurement) 2 tablets which was indicated for mild pain (1-3/10) when Resident 1 complained of pain level of 7/10 on 10/29/2024. 2. Administer Acetaminophen to Resident 2 as indicated in the physician's order. Resident 2 received Acetaminophen 500 mg which was indicated for mild pain (1-3/10) when Resident 2 complained of pain level of 4/10 on 8/24/2024 and 9/29/2024. These failures had the potential for Residents 1 and 2 to experience unnecessary and preventable pain with the potential to result in a mental, physical and/or emotional health decline for Residents 1 and 2. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis [loss of voluntary movement ] from the neck down, including legs, and arms, usually due to a spinal cord injury), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) and anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). During of review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/23/2024, the MDS indicated Resident 1 had clear speech, ability to express his ideas and wants, clear comprehension and moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 dependent (helper does all effort needed to complete activity) with oral and personal hygiene, toileting, bathing, and dressing. Resident 1 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating. During a review of Resident 1's Order Summary Report, dated 10/29/2024, the order summary report indicated to give acetaminophen tablet 325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) 2 tablets by mouth every six (6) hours as needed for mild pain (1-3). During a review of Resident 1's Care Plan titled, At Risk for Pain, dated 10/21/2024, the care plan interventions included were for staff to administer medications as ordered and to administer acetaminophen for mild pain (1-3). During a concurrent observation in Resident 1's room on 10/29/2024 at 9:14 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 1 stated to LVN 1 that he had a pain level of seven (7) out of 10 in his left shoulder. LVN 1 was then observed giving Resident 1 acetaminophen 650 mg for pain management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent review of Resident 1's Medication Administration Record (MAR), dated 10/2024, and interview with LVN 1 on 10/29/2024 at 9:16 AM, LVN 1 confirmed MAR indicated acetaminophen 325 mg 2 tablets by mouth every 6 hours as needed for mild pain (1-3). LVN 1 stated she administered acetaminophen 650 mg indicated for pain level of 1-3 even though Resident 1's pain level was 7/10. LVN 1 stated she did not notify the doctor of Resident 1's 7/10 pain before administering the acetaminophen 650 mg to Resident 1. LVN 1 also stated, The doctor does not want to order anything stronger because he has a history of drug use. During a concurrent review Resident 1's electronic and physical [paper] chart and interview with Registered Nurse Supervisor (RNS) on 10/29/2024 at 11 AM, RNS stated the chart indicated Resident 1 received acetaminophen 650 mg for pain scale of 7/10. RNS stated the chart did not indicate Resident 1's physician was made aware of increased onset of pain. RNS stated the acetaminophen given to Resident 1 was indicated for mild pain only and should not be given for pain level of 7. RNS stated Resident 1's physician was not and should have been notified of Resident 1's pain level of 7. RNS stated Resident 1 should have been provided non-pharmacological interventions such as repositioning, while waiting for further pain management orders from the physician. RNS also stated it was important to notify the physician so he can be aware of the resident's change in condition to prevent Resident 1 from untreated pain which could lead to agitation, feeling neglected, and becoming uncooperative with care. During an interview on 10/29/2024 at 12:05 PM with the Assistant Director of Nursing (ADON), ADON stated if a resident asks for pain medication, staff need to ask for pain level according to the pain scale numbered 1-10, check which medication is appropriate to give and then administer the indicated pain medication according to physician's order. ADON stated when a resident has a pain level of 7, a pain medication ordered for pain level of 1-3 should not be given. ADON stated the resident's doctor should be notified right away to receive an appropriate order. ADON stated, if staff does not inform the physician, the physician will not be aware of the pain and the resident's pain will not be managed correctly. ADON also stated if the resident's pain is not treated, the resident may become agitated or aggressive because of the untreated pain. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm (a cancerous tumor, or abnormal tissue growth) of right breast, open wound of right breast, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (fear characterized by behavioral disturbances). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 2 needed supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating. Resident 2 required partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral and personal hygiene. Resident 2 was dependent (helper does all effort needed to complete activity) with toileting and bathing. During a review of Resident 2's Care Plan titled, At Risk for Pain, revised 6/17/2024, the care plan interventions included were for staff to administer medication as ordered, administer pain medications as acetaminophen for mild pain (1-3) and ibuprofen for moderate pain (4-6). During a concurrent interview and review on 10/29/2024 at 2:58 PM with Director of Nursing (DON), Resident 2's MAR dated 8/2024 and 9/2024 were reviewed. The MARs indicated to give acetaminophen 500 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm mg every 6 hours as needed for mild pain (1-3), ordered 7/21/2024. The MARS indicated acetaminophen 500 mg was administered on 8/24/2024 and 9/29/2024, when Resident 2 experienced a pain level of 4. DON stated Resident 2 should not have been administered acetaminophen 500 mg on 8/24/2024 and 9/29/2024 because Resident 2's pain was a level of 4. DON stated according to the physician's order, the acetaminophen should have only been given to Resident 2 if her pain level was between 1 and 3. Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Pain Management, revised 11/1/2017, the P&P indicated the purpose is to ensure accurate assessment and management of the resident's pain and facility staff are responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The P&P also indicated the licensed nurse will administer pain medication as ordered and notify the physician if there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication. During a review of the facility's P&P titled, Medication- Administration, revised 11/1/2017, the P&P indicated the purpose to provide practice standards for safe administration of medications for residents in the facility and medication will be administered by a licensed nurse according to the order of an attending physician or licensed independent practitioner. The P&P also indicated nursing staff will keep in mind the seven rights of medication when administering including the right indication (medical condition or situation the medication is approved to treat). During a review of the facility's P&P titled, Change of Condition Notification, revised 11/1/2017, the P&P indicated the purpose to ensure physicians are informed of changes in the resident's condition in a timely manner and defines an acute change of condition (ACOC) as a sudden, clinically important (without intervention, may result in complications or death) deviation from a patient's baseline (normal existing physiologic or functional state prior to an intervention) in physical, cognitive, behavioral, or functional domains. The P&P also indicated the physician will be notified timely, notification to the physician will include a summary of the condition change and the licensed nurse will document the time the physician was contacted, method of contact, response time and whether orders were received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 6 of 6