Health inspection·November 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact). Resident 1 had a change of behavior of screaming towards Resident 3 on 11/11/2025 and the facility did not have documented evidence the behavior was addressed. This resulted in Resident 2 hitting Resident 1 on the face on 11/12/2025.and Resident 1 sustained a scratch under the resident's right eye and redness on the right side of the nose. Findings:During a review of Resident 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a serious mood disorder characterized by persistent sadness and loss of interest, affecting how a person thinks, feels, and acts) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/8/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated, the resident is dependent (Helper does all of the effort. The MDS also indicated Resident 1 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 toileting hygiene, shower/bathe self but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk and provides more than half the effort) with lower body dressing, putting on/taking off footwear, and oral hygiene. The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs but provides less than half the effort) with eating, upper body dressing and personal hygiene. 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 among the residents), dated 11/12/2025, the SBAR indicated Resident 1 had a resident-to-resident altercation and had a scratch under the right eye and redness on the right side of the nose. During a review of Resident 1's Progress Notes, dated 11/12/2025 at 11:30 AM, the Progress Notes indicated Resident 1 stated he was hit by Resident 2 in the face. The progress notes indicated Resident 1 had a scratch under the resident's right eye and discoloration on the right side of the resident's nose. During an interview on 11/25/2025 at 12:48 PM, Treatment Nurse (TN) stated she heard Resident 1 screaming on 11/12/2022 around 10:30AM and when TN went into the resident's room and checked on Resident 1, the reisdent had a scratch under his right eye. During an interview on 11/25/2025 at 1:02 PM, Resident 1 stated Resident 2 hit Resident 1 in the face (unable to recall when). During an interview on 11/25/2025 at 1:28PM, Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 Page 1 of 3 555213 555213 11/26/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few likes to get into other residents' personal space. CNA 1 also stated she did not report it, because everyone knows about Resident 1's behavior. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of muscle weakness and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body that can affect the arm, leg, hand, or face) of the right dominant side. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident is moderately impaired in cognitive skills for daily decision making. The MDS also indicated, the resident required substantial/maximal assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear but required partial/moderate assistance with oral hygiene, toileting hygiene, upper body dressing and personal hygiene. During an interview on 11/25/2025 at 1:20PM, Resident 2 stated, he did hit Resident 1 in the face (unable to recall when). During a review of Resident 3's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of schizoaffective disorder, depression and anxiety. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident was dependent on toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear but required substantial/maximal assistance with oral hygiene, upper body dressing and personal hygiene. During an interview on 11/25/2025 at 2:24 PM, Resident 3 stated, on 11/11/2025, Resident 1 was trying to get Resident 3's phone (resident unable to recall where in the facility the incident happened) but when Resident 3 did not allow Resident 1, Resident 1 started screaming and staff had to separate both residents. During an interview on 11/26/2025 at 11:22AM, the Director of Nursing (DON) stated if the incident between Resident 1 and Resident 3 had been addressed, then Resident 1 and Resident 2's incident can be prevented. The DON also stated the staff who separated Resident 1 and Resident 3 should have reported the incident to the licensed nurse to ensure there were interventions in place to prevent another incident from happening. During the same concurrent interview and record review on 11/26/2025 at 11:22 AM of Resident 1's Care Plan, dated 11/11/25 to 11/25/2025, the DON stated there is not but should be a care plan for Resident 1's behavior of screaming toward another resident that happened on 11/11/2025 to prevent further occurrences. During the same concurrent interview and record review on 11/26/2025 at 11:22 AM of Resident 1's Medical Record, from 11/11/2025 to 11/25/2025, the DON stated there is no documentation of the incident between Resident 1 and Resident 3, no monitoring done and what other interventions were provided aside from separating the residents. During an interview on 11/26/2025 at 11:57 AM, the DON stated Resident 1's behavior of screaming to staff and/ or resident on 11/11/2025 was a change of condition (COC - A significant shift in a resident's physical, mental, or functional status that won't resolve on its own without intervention) that required a plan of care. During a concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility's Policy and Procedure (P&P) titled, Change of Condition, revised 7/2022, was reviewed. The P&P indicated a sudden change in the resident's condition manifested by a marked mental behavior will be communicated to the physician immediately for evaluation. The DON stated any mental change is a change of condition and needs to be communicated with the physician promptly (within an hour). The DON also stated the incident between Resident 1 and Resident 3 was not communicated to the physician. During the same concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility's undated P&P titled, Abuse Policy, was reviewed. The P&P indicated the purpose is to prevent abuse by establishing a safe environment, identifying, correcting and intervening in 555213 Page 2 of 3 555213 11/26/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few situations in which abuse is more likely to occur, put systems in place for provision of care and services for all residents, assessing and implementing appropriate interventions for residents with behaviors that can lead to conflict or neglect (fail to care properly). The DON stated to identify situations in which abuse is likely to occur such as if the incident between Resident 1 and Resident 3 was addressed, then the incident between Resident 1 and Resident 2 could have been prevented. During the same concurrent interview and record review on 11/26/2025 at 12:10 PM, the facility's P&P titled Behavior Assessment and Monitoring, revised 1/2025, was reviewed. the P&P indicated problematic behavior will be identified and managed appropriately. The P&P also indicated new onset or worsening behavioral symptoms will be identified and will be documented regardless of degree of risk to resident or others. The DON stated Resident 1's behavior should have been identified and managed after the screaming incident with Resident 3 that happened on 11/11/2025. The DON also stated it would prevent the incident with Resident 2. 555213 Page 3 of 3