Health inspection·September 3, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some depressive disorder [a mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life], anxiety disorders [persistent and excessive worry that interferes with daily activities), and insomnia [sleep disorder characterized by difficulty failing asleep, staying asleep, or both]), give one tablet by mouth at bedtime for depression manifested by inability to sleep at night. -On 7/18/2025, Divalproex Sodium (an anticonvulsant medication used to treat certain types of seizures and the manic phase of bipolar disorder) Oral Tablet Delayed Release 500 milligrams (mg, unit of measurement), give one tablet by mouth every 12 hours for mood disorder manifested by mood swings as evidenced by irritable mood. -On 7/18/2025, Olanzapine Oral Tablet 10 mg (medication used in the treatment of schizophrenia), give one tablet by mouth two times a day for schizophrenia manifested by paranoid delusion (fixed, false beliefs that a resident insists ae true) as evidenced by saying people were poisoning Resident 1. During a review of Resident 1's care plan, dated 7/10/2025, the care plan indicated Resident 1 was at risk for clinical or social decline due to history of noncompliance or refusal of medication. The care plan interventions indicated to monitor episodes of noncompliance and notify doctor for three episodes of noncompliance behavior consecutively, encourage family of the risks and consequences of being noncompliant with the plan of care, and discuss with the IDT the resident's behavior of being noncompliant for any further recommendations. During a review of Resident 1's care plan, dated 8/8/2025, the care plan indicated Resident 1 was noncompliant with medications and diet. The care plan interventions indicated to administer medications as ordered, monitor/document for side effects and effectiveness, explain the importance of the prescribed medication and diet to the resident and the need for adequate nutritional intake, and obtain and monitor lab/diagnostic work as ordered and report results to doctor and follow up as indicated. During a review of Resident 1's Medication Administration Record for the month of August 2025, the MAR indicated as follows:- Divalproex Sodium refused doses: 8/2/2025 PM, 8/3/2025 PM, 8/4/2025 PM, 8/6/2025 PM, 8/9/2025 PM, 8/10/2025 PM, 8/11/2025 PM, and 8/13/2025 PM (eight refused doses). - Olanzapine refused doses: 8/2/2025 PM, 8/8/2025 AM, 8/9/2025 PM, 8/11/2025 PM (four refused doses).- Trazodone HCl refused doses: 8/2/2025 PM, 8/9/2025 PM, 8/10/2025 PM, and 8/11/2025 PM (four refused doses). - Insulin Glargine refused doses: 8/2/2025 AM and PM, 8/3/2025 AM and PM, 8/4/2025 PM, 8/5/2025 PM, 8/6/2025 PM, 8/8/2025 AM, 8/9/2025 AM, 8/10/2025 PM, 8/11/2025 PM, 8/12/2025 PM, 8/13/2025 PM, and 8/14/2025 AM (14 refused doses). - Insulin Glargine was administered, and blood glucose was not tested by licensed nurse prior to administration for the following doses: 8/1/2025 AM and PM, 8/4/2025 AM, 8/5/2025 AM, 8/6/2025 AM, 8/7/2025 AM and PM, 8/8/2025 PM, and 8/9/2025 PM (nine doses of insulin administered without obtaining blood glucose). During a concurrent interview and record review on 9/3/2025 at 8:10 AM with the Director of Nursing (DON), Resident 1's care plans, nursing notes, MAR, and SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) were reviewed. The DON stated the doctor should have been notified and was not notified of Resident 1's noncompliance and refusals with the medications. The DON stated the doctor needed to be informed to possibly adjust the medications or transfer Resident 1 to another hospital. The DON stated Resident 1 refused the medications used for mood disorder, schizophrenia, and depression. The DON stated noncompliance with medications could lead to a decline in Resident 1's behavior and inability to sleep. During a follow up interview and record review on 9/3/2025 at 9:25 AM with the DON, Resident 1's care plans, nursing notes, MAR, IDT and SBAR were reviewed. The DON stated licensed nurses did not document the education given to Resident 1 on the MAR progress notes for Resident 1's medication refusals. The DON stated licensed nurses did not check Resident 1's blood glucose prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055617 If continuation sheet Page 2 of 3 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 09/03/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete administering Insulin Glargine and the doctor was not notified of Resident 1's refusal of insulin doses. The DON stated hyperglycemia could result in Resident 1 going into a coma since her body was unable to produce enough insulin. The DON also stated the IDT should have addressed and did not address Resident 1's refusal for blood glucose checks and medication refusals. During a review of the facility's Policy and Procedure (P&P) titled, Refusal of Treatment, revised 5/1/2023, the policy indicated the Charge Nurse or DON would document information relating to the refusal in the resident's medication record. Documentation would include at least the following: a. The date and time a medication or treatment was attempted. b. The medication or treatment refused.c. The resident's reason(s) for refusal.d. The name of the person attempting to administer the treatment.e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication. f. The residents' condition and any adverse effects due to such refusal.g. The date and time the Attending Physician was notified and his or her response. The P&P indicated the IDT would assess the resident's needs and offer the resident alternative treatments while continuing to provide other services in the care plan. During a review of the facility's P&P titled, Medication - Administration, revised 11/1/2017, the policy indicated when administration of the drug was dependent upon vital signs or testing, the vital signs/testing would be completed prior to administration of the medication and recorded in the medical record (i.e., blood pressure, pulse, finger stick blood glucose monitoring etc.). Event ID: Facility ID: 055617 If continuation sheet Page 3 of 3