Health inspection·December 9, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview and record review, the facility failed to ensure that the resident's anti-anxiety (medications that reduce feelings of fear, dread, and tension by calming the nervous system) medication ordered as needed (PRN- a medication or treatment to be administered only when the patient exhibits specific symptoms or the situation requires it, rather than on a fixed, routine schedule) had a stop date and was reevaluated by the physician after 14 days of the order date for the appropriateness of use in accordance with facility policy, for one (1) of one two sampled resident (Resident 1). This deficient practice had the potential to cause serious harm, such as severe confusion, falls, issues, and cognitive (mental action or process of acquiring knowledge and understanding) decline, which could lead to drug dependency (use of drugs that continues even when significant problems related to their use have developed), trauma, and an increased risk of death. Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses that included encephalopathy (a broad term for brain dysfunction from various causes such as toxins, infection, injury, metabolic issues often causing fluctuating consciousness, confusion, and acute symptoms, potentially reversible if the cause is treated), type 2 diabetes mellitus without complications (chronic condition of persistently high blood sugar levels resulted in a condition where the kidneys are damaged and can't function properly), and anxiety disorder (mental disorder that involves persistent and excessive worry that can interfere with daily activities). During a review of Physician Order dated 10/31/2025 indicated lorazepam (a prescription medication for anxiety that works by slowing activity in the brain and central nervous system to produce a calming and relaxing effect) oral tablet 1 milligram (mg, a unit of measurement), give 1 tablet by mouth every 4 hours as for anxiety , irritability (feelings of anger, being annoyed and impatient), and restlessness (unable to relax, sit still, or be quiet, often due to anxiety, boredom, or unease, leading to constant motion or a feeling of being unsettled). The order did not indicate a stop date. During a review of Resident 1's Quarterly Minimum Data Set, (MDSa resident assessment tool) dated 11/13/2025, the MDS indicated Resident 1 had moderate impaired (decisions poor, cues/supervision required) cognitive skills for daily decision making. The MDS also indicated Resident 1 needs substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs but provides more than half the effort) for eating, oral hygiene, upper body dressing and personal hygiene. Resident 1 is dependent (helper does all the effort) for toileting hygiene, shower/ bathe self, lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 12/9/2025 at 10:53 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the prescription of lorazepam is a PRN order and did not have a stop date. LVN 2 stated the lorazepam should not be renewed beyond 14 days which was 11/14/2025. LVN 2 also stated Resident 1's lorazepam order required a renewal or reevaluation from physician per facility's policy and procedure before it can be Page 1 of 2 555213 555213 12/09/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few continued after 11/14/2025. During a concurrent interview and record review on 12/9/2025 at 11:20 AM with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Antipsychotic Medication Use, undated, was reviewed. The P&P indicated anti-psychotic medications will be prescribed at the 1owest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The P&P also indicated as needed (PRN) orders for antipsychotic medications will not be renewed or continued beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of use of that medication and have documented the rationale for continued use and duration of the PRN order will be indicated in the order. The DON stated any as needed medication needs to be renewed or reevaluated within 14 days. The DON stated Resident 1's order for Lorazepam that started on 10/31/2025 did not have a stop date and there was no documented evidence that Resident 1 was reevaluated for appropriateness for continued use of Lorazepam. 555213 Page 2 of 2