Health inspection·July 30, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create and implement a comprehensive person-centered care plan for one (1) of two (2) sampled residents (Resident 1) to address Resident's 1's diagnosis of alcohol dependence (also known as alcohol use disorder [[NAME]], a chronic disease characterized by a compulsive need to drink alcohol despite negative consequences).This failure resulted in Resident 1 going out on pass (OOP - a non-medical visit outside of the facility most commonly used for visits with family or friends) from the facility on 7/15/2025 at 11:45 AM and not returning. The facility was notified by the local police on 7/15/2025 at 10:51 PM that Resident 1 was found at the general acute care hospital (GACH) emergency department. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of alcohol abuse (drinking in a manner, situation, amount, or frequency that could cause harm to the person who drinks or to those around them) with intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) and hypotension (the pressure of blood circulating around the body is lower than normal). During a review of Resident 1's History and Physical Examination (H&P), dated 6/18/2025, the H&P indicated Resident 1 had a diagnosis of alcohol abuse.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/29/2025, the MDS indicated the resident had an intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 1 needed partial/moderate assistance (helper does less than half the effort) with walking 10 feet, chair/bed-to-chair transfers, going from a sitting position to standing, rolling left and right in bed, putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing (the ability to dress and undress above the waist), personal hygiene and eating. During a review of Resident 1's Nurses Note dated 7/15/2025 timed at 5:41 PM by Registered Nurse 2 (RN 2), Resident 1's Nurses Note indicated RN 2 had called Resident 1's friend (listed on the face sheet as alternate contact) to inform them that Resident 1 had not returned to the facility from his OOP from that morning and was inquiring if they knew Resident 1's whereabouts. Resident 1's friend informed RN 2 that they had not spoken to or seen Resident 1. RN 2 then informed MD of situation on 7/15/2025 at 5:47 PM. During a review of Resident 1's Nurses Note, dated 7/15/2025, timed at 8:49 PM by RN 2, Resident 1's Nurses Note indicated that Resident 1 had not returned from his OOP from 11:45 AM on 7/15/2025 and indicated the following timeline: 7:44 PM: RN 2 notified the DON and ADM that Resident 1 had not come back from being OOP. 9:27 PM: Called Resident 1's friend a second time to see if they had any update on Resident 1. Resident 1's friend had not heard anything from Resident 1. 9:30 PM: RN 2 contacted the local police to report resident's status. 9:43 PM: RN 2 left a Page 1 of 3 555213 555213 07/30/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few message for the California Department of Public Health (CDPH). 10:02 PM: the local police department arrived at the facility to investigate and (local police) left around 10:12 PM. 10:51 PM: the local police called the facility to inform them that Resident 1 was found at the general acute care hospital (GACH) emergency department (ED) and were on their way to check on the resident. 10:56 PM: RN 2 contacted GACH ED and spoke with Resident 1's assigned nurse who stated Resident 1 was seen lying down in the street with bottles of alcohol around him and was transported to ED around 7:13 PM and was being treated for alcohol intoxication and hypotension and might be admitted to the GACH. During a review of Resident 1's GACH Discharge summary, dated [DATE], the GACH Discharge Summary indicated Resident 1 was found unconscious outside by Emergency Medical Services (EMS) after drinking approximately 48 ounces (oz) of beer. Resident 1 had no recollection of events prior to coming to the ED. However, he had been staying at a Skilled Nursing Facility (SNF) and got a one day pass to leave, which is when he bought the alcohol and consumed it. During an interview on 7/30/2025 at 11:40 AM with RN 2, RN 2 stated, on 7/15/2025 around 5 PM, she had called Resident 1's friend to see if he knew where Resident 1 was since he had not returned. RN 2 stated after the local police visited the facility and left, RN2 then received a call from local police letting RN 2 know the local police had found Resident 1 in the GACH EDDuring an interview on 7/30/2025 at 1:43 PM with RN 1, RN 1 stated she obtained an OOP order from MD for Resident 1 on 7/14/2025. MD was made aware that Resident 1 was AAOx4, self-responsible and ambulatory without assist. RN 1 stated she did not relay to the MD that Resident 1 had a history of alcohol dependence.During a concurrent interview and record review on 7/30/2025 at 1:50 PM with RN 1, Resident 1's admission Record dated 6/16/2025 and Care Plan dated June 2025 were reviewed. RN 1 stated Resident 1 did have an admitting diagnosis of alcohol dependence and stated that there was no care plan initiated or implemented specifically to address Resident 1's alcohol dependence. RN 1 stated some interventions that would be implemented to address a resident's diagnosis or history of alcohol dependence would normally include things such as diversional activities (engaging activities that shift one's focus away from negative or stressful thoughts and feelings, promoting relaxation and enjoyment) so the resident does not think of alcohol, observing the resident for signs and symptoms of alcohol withdrawal, and encouraging the resident to verbalize his feelings and thoughts as to why he is dependent on alcohol. RN 1 stated a care plan should have been initiated and implemented to address Resident 1's alcohol dependence so that the facility staff and nurses would know how to provide care for Resident 1's history of alcohol dependence. During a concurrent interview and record review on 7/30/2025 at 2:03 PM with the DON, Resident 1's Care Plan dated June 2025 was reviewed. Resident 1's Care Plan indicated there was no care plan developed or implemented to address Resident 1's diagnosis of alcohol dependence. The DON stated interventions that would have normally been implemented for residents with a history of alcohol dependence would have included diversional activities such as going to activities, smoking, and allowing the residents to express themselves. The DON stated Resident 1 should have had a care plan developed and implemented to address his alcohol dependence so that the facility staff and nurses would know to observe and address any potential behaviors that Resident 1 could have exhibited such as alcohol withdrawal symptoms of expressing the need or want to have alcohol. During the same interview on 7/30/2025 at 2:03 PM with the DON, the DON stated on 7/15/2025 Resident 1 had stated he was going out to go to the bank and get a haircut, however when the resident went out, he got money and decided to buy alcohol. During an interview on 7/30/2025 at 2:52 PM with RN 1, RN 1 stated since Resident 1 did not have a care plan specifically to address the resident's diagnosis of alcohol dependence, there was a risk for the resident (Resident 1) going out and reverting to his dependence on alcohol. RN 1 further stated this could 555213 Page 2 of 3 555213 07/30/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have led to the resident leaving to go OOP and seeking alcohol. During an interview on 7/30/2025 at 3:04 PM with MDS Nurse, MDS Nurse stated Resident 1 did not have a care plan developed specifically to address the resident's diagnosis of alcohol dependence. MDS Nurse stated a care plan should have been developed so that the facility staff would know what interventions they could implement such as informing the MD of the resident's diagnosis of alcohol dependence, monitoring for any behaviors, and the resident's physical appearance for any signs and symptoms of seeking alcohol.During a review the facility's P&P titled, Care Plans, Comprehensive, Person-Centered, (undated), the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated:A. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.B. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.C. The comprehensive, person-centered care plan:a. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Reflect currently recognized standards of practice for problem areas and conditions. 555213 Page 3 of 3