Health inspection·December 12, 2025

F 0580 Level of Harm - Actual harm Residents Affected - Few than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, walking 10 feet, eating and upper body dressing. The MDS indicated Resident 1 is dependent (Helper does all of the effort. The resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 1's Weights and Vitals Summary dated 12/8/2025 indicated Resident 1's BP read 153/91 mmHg at 8:07 AM. During a review of Resident 1's Progress Notes, dated 12/8/2025 from 10:11 AM to 10:12 AM, the progress notes indicated Resident 1 refused medication, offered three times, physician made aware. The progress notes did not specify the physician was made aware regarding Resident 1's elevated BP of 153/91 mmHG. During a review of Resident 1's Progress Notes, dated 12/8/2025 at 1:00 PM, the Progress Notes indicated the resident was sleepy and refused to open his mouth. During a review of Resident 1's Weights and Vitals Summary dated 12/08/2025 at 1:00 PM, it indicated Resident 1's BP was 210/92 mmHg. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [is a significant, sudden shift in a person's physical, mental, behavioral, or functional state from their baseline, requiring clinical attention] among the residents), dated 12/8/2025, the SBAR indicated the resident refused lunch and was sleepy. The SBAR indicated Resident 1 refused to open mouth when given medication at 1 PM and was very lethargic and was unable to respond verbally. During a review of Resident 1's Progress Notes, dated 12/8/2025 at 2:10 PM, the progress notes indicated Resident 1 was transferred to GACH at around 2 PM. During a review of Resident 1's GACH Emergency Department (ED) Hospital admission notes, dated 12/8/2025 at 4:31 PM, the notes indicated Resident 1 had an altered mental status, and blood pressure is elevated. The notes also indicated Resident 1 was very lethargic and confused. During a review of Resident 1's GACH ED Hospital admission notes, dated 12/8/2025 at 5:16 PM, the notes indicated a CT of the brain was done with a result of bleeding in the cerebral hemisphere of 7.4 cm in craniocaudal by 2.7cm by 3.5cm. During a review of Resident 1's GACH ED Hospital admission notes, dated 12/8/2025 at 5:20 PM, the notes indicated Resident 1 had a diagnosis of intracranial hemorrhage and hypertensive emergency. During a review of Resident 1's GACH Discharge Summary Note, dated 12/8/2025, the Summary Note indicated Resident 1 arrived at the ED completely unresponsive, did a CT scan which showed a large left cerebral hemisphere parenchymal (tissue of the brain) hemorrhage. Resident 1 was intubated in the ED and was admitted to the ICU. During an interview on 12/11/2025 at 4:43 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was sleepier than usual and did not open his mouth to eat his lunch on 12/7/2025 on 7 AM to 3 PM shift and reported it to Registered Nurse 1 (RN 1) at noon on 12/7/2025. CNA 1 also stated Resident 1 is normally active. During an interview with Resident 1's Responsible Party (RP) on 12/12/2025 at 11:15AM, RP stated when she went to go see Resident 1 on 12/7/2025 around 5 PM to 5:30 PM at the facility, RP was unable to wake Resident 1 up and reported it to the facility staff. During a phone interview on 12/12/2025 at 11:33 AM, Licensed Vocational Nurse 3 (LVN 3), who works 3PM to 11PM shift, stated Resident 1 is usually active but was more sleepy than usual on 12/7/2025. LVN 3 stated she did not notify the physician but endorsed the resident about being unusually sleepy to 11-7 shift licensed nurse (unable to recall who). During an interview on 12/12/2025 at 12:05 PM, RN 1 stated, on 12/7/2025 from 7 AM to 3 PM shift, CNA 1 stated Resident 1 was more sleepy than usual, but RN 1 did not notify the physician. During an interview on 12/12/2025 at 12:26 PM, CNA 2 stated Resident 1 did not eat his breakfast and lunch on 12/8/2025 and was unusually sleepier. CNA 2 also stated this is not Resident 1's (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 12/12/2025 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 0580 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete normal behavior and CNA 2 did not report it to the licensed nurse. During an interview on 12/12/2025 at 1:35 PM, Resident 1's current Care Plan dated 4/22/2025 to 12/11/2025, were reviewed. The care plan indicated a care plan with focus hypertension and chest pain was initiated on 4/22/2025. The care plan to monitor vital signs (key measurements of your body's most basic functions, including temperature, pulse (heart rate), respiratory (breathing) rate, and blood pressure) and report any abnormal findings to the physician. The Director of Nursing (DON) stated Resident 1 is sleepy more than the resident's usual level of consciousness, is considered a change of condition and the physician should have been notified timely after RP reported it to the facility on [DATE] and when Resident 1's BP was 153/91 mmHG on 12/8/2025 around 8:07 AM. During an interview on 12/12/2025 at 2:09 PM, Nurse Practitioner (NP) stated he was not informed of Resident 1's change of condition of sleepiness and of the resident's elevated BP on 12/8/2025 at 8:07 AM. NP also stated Resident 1's BP of 153/91 mmHg should have been reported and if not, that can delay care for Resident 1. NP stated if the BP of 153/91 mmHg was addressed to him, he would order the resident to be transferred to GACH. During an interview on 12/12/2025 at 2:15 PM, with the DON, the DON stated Resident 1's BP of 153/91 mmHg is a change of condition. The DON stated the license nurse should have notified the physician/ NP regarding Resident 1's elevated BP of 153/91 mmHg to obtain an order. The DON also stated Resident 1's change of condition should be reported in a timely manner, and timely manner in the policy means 15 minutes and Resident 1's change of condition was not reported timely. During an interview on 12/12/2025 at 3:15 PM, LVN 1 (who worked a 7AM-3 PM shift when the incident happened) stated Resident 1's elevated BP pf 153/91 mmHg and sleepier than usual is considered a change of condition and the physician needs to be notified within 15 minutes. LVN 1 also stated the physician was not notified within 15 minutes from when Resident 1's BP was assessed to be at 153/91 mmHg on 12/8/2025 at 8:07AM. LVN 1 stated she should have notified Resident 1's physician so the facility could have provided interventions and prevented Resident 1's BP progressing to 210/92 mmHg and avoiding the resident's hospitalization. During an interview on 12/15/2025 at 1:16 PM, the facility's Medical Director (MD) stated if the resident's BP is elevated, the nurse should report it to the physician timely, and the resident should have been sent to the hospital. MD stated the resident was sleepy more than usual and elevated BP on 12/8/2025 at 8:07AM, it should have been reported to the physician timely and not wait until the BP was 210/92 mmHg in the afternoon. During a review of the facility's P&P titled Change of Condition Notification, revised 11/1/2017, was reviewed. The P&P indicated the facility will promptly inform the resident's attending physician when the resident endures a change in condition which included the physical status. Event ID: Facility ID: 055617 If continuation sheet Page 3 of 3