Health inspection·December 19, 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 prevent sexual abuse (non-consensual sexual contact of any type with a resident) for two (2) of 2 sampled residents (Resident 1 and 2) on 12 /18/2025 in the facility's hallway. On 12/18/2025, Orientee of Dietary (OD) and Certified Nursing Assistant (CNA 1) witnessed Resident 1 pulled down his (Resident 1) pants and pulled out his (Resident 1) penis. Resident 2 then performed oral sex (one partner uses the tongue, mouth or throat to excite the other partner's sex organs) to Resident 1. This failure resulted in Resident 1 and 2 to sexual abuse potentially risking emotional trauma (response to deeply distressing or disturbing event) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event) placing other residents in the facility at risk for sexual abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included cocaine dependence (addictive disorder characterized by compulsive and uncontrollable drug seeking, continued drug use despite negative consequences.), unsteadiness of the feet, and muscle weakness. The admission records also indicated Resident 1 was self- responsible (able to make decisions for himself). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making were moderately impaired. The MDS indicated Resident 1 needs partial moderate assistance on (the helper does less than half the effort) on roll left and right (the ability to roll from lying on back to left and right side and return to lying back on the bed) and walk 10 feet (ft.-unit of measurement) once standing the ability to walk at least 10 ft, in a room, corridor or similar space. During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, tool used by health care professionals when communicating about critical changes in a resident's status), dated 12/18/2025 at 2:25 PM, it indicated there was a situation of inappropriate sexual activity by the hallway. During a review of Resident 1's nurses progress notes dated 12/18/2025 at 2:40 PM, the nurses progress notes indicated on 12/18/2025 at 2:25 PM the Director of Dietary ( DD) and OD came to the nurses station and reported incident to charge nurse that the OD was outside standing in the patio area, facing towards the facility entrance building and witnessed (from the glass window) Resident 1 pulled down his pants and pulled out his penis. The progress notes also indicated, OD witnessed Resident 2 perform oral sex to Resident 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included schizoaffective disorder (a mental illness that causes loss of contact with reality), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypertension (high blood pressure). The admission Record indicated Resident 2 was not self-responsible and the responsible party is Resident Page 1 of 3 555213 555213 12/19/2025 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 Representative 1. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making is cognitively intact skills for daily decision making were intact. The MDS indicated Resident 2 needs substantial maximal assistance (helper does more than half the effort) on roll left and right, walk 10 ft. once standing the ability to walk at least 10 ft, in a room, corridor or similar space. During a review of Resident 2's SBAR dated 12/16/2025 at 10:52 AM, the SBAR indicated Resident 2 with episode of throwing feces to the hallway, attempts to touch or kiss the staff and residents' hands, and wander (the act of a resident with cognitive impairment moving around in the facility without appreciation for personal safety, potentially entering into harm's way) into other residents' room. During a review of Resident 2's care plan initiated on 12/16/2025 the care plan indicated Resident 2 has socially inappropriate / disruptive behavioral symptoms as evidenced by: touching and kissing hands of staff and residents. The care plan indicated an intervention included to observe socially inappropriate, disruptive behavior when around others. During a review of Resident 2's nurses progress notes dated 12/18/2025 at 4:13 PM, the nurses progress notes indicated at approximately 2:15 PM, CNA 1 saw Resident 2 with Resident 1 having oral sex in the hallway. CNA 1 was coming from outside (not indicated where) and saw Resident 1 and 2 having oral sex then CNA 1 knock on the glass door and Resident 1 immediately pulled his pants up and walked away. During a record review of facility's incident written statement from date 12/18/2025 indicated on 12/18/2025 at 2:15 PM OD witnessed Resident 1 pulled down his pants and pulled out his penis, then Resident 2 performed oral sex to Resident 1 at the hallway. During a record review of facility's Resident Interview Form dated 12/18/2025 at 3:33 PM indicated Resident 1 was interviewed by the Director of Nursing (DON) and Activity Director (AD). The Resident interview form indicated Resident 1 immediately stood up when asked about what happened and stated, I do not want to talk about it, I do not want to say anything at all I am not talking to you both. The Record Review Form also indicated at 4:05 PM, Resident 1 stated to the police officer, I will not do such thing anymore; I love this place. During a record review of facility's Resident Interview Form dated 12/18/2025 at 3:45 PM indicated Resident 2 was interviewed by the DON and AD. The form indicated Resident 2 stated I did it on my own, he put his pants down, so I started kissing and sucking his private area, but no sperm came out, nothing happened at all. I was not satisfied because no sperm came out and I am expecting that he will give me a hamburger and cheeseburger in return, but he did not. During an interview on 12/19/2025 at 9:30 AM with CNA 1, CNA 1 stated on 12/18/2025 at around 2:15 PM, he was on his way back in the facility he saw from outside the glass window, Resident 1 standing in front of Resident 2 while Resident 2 was sitting in the wheelchair holding the penis of Resident 1 and Resident 1's penis was inside the mouth of Resident 2. CNA 1 also stated nobody was in the hallway. During an interview with Resident 1 on 12/19/2925 at 10:39 AM, Resident 1 stated denied Resident 2 performing oral sex on him or that he asked anyone to perform oral sex. During an interview on 12/19/2025 at 12:20 PM with the DD, DD stated on 12/18/2025 OD witnessed from the patio / smoking area, through the glass window of the entrance of the facility that Resident 1 pulled down Resident 1's pants and pulled out Resident 1's penis and Resident 2 performed oral sex. During an interview on 12/19/2025 at 1:10 PM with Resident 2, Resident 2 stated she was not forced nor asked for any sexual favors. During an interview on 12/19/2025 at 5:22 PM with the Registered Nurse (RN1), the RN1 stated Resident 1 and 2's oral sex was witnessed by CNA1 on 12/18/2025. RN 1 stated it was not acceptable even if the residents consented for it because it was in the hallway. During an interview on 12/19/2025 at 5:30 PM with the DON, the DON stated the facility failed to prevent inappropriate sexual act/ sexual abuse between Resident 1 and 2 that happened on 12/18/2025. The DON also stated Resident 2's care plan for the socially 555213 Page 2 of 3 555213 12/19/2025 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 inappropriate / disruptive behavioral symptoms as evidenced by: touching and kissing hands of staff and residents with intervention to observe resident was not enough and not specific to the needs of the resident to ensure to prevent sexual abuse by or to Resident 2. The DON also stated, the facility did not have a policy for consented sexual relationship/ sexual act between the residents in the facility. The DON also stated, the facility is not able to provide documented evidence that Resident 1 and 2 consented to have an oral sex on 12/18/2025. During a record review of the facility's policy and procedures (P&P) titled, Abuse Neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Mistreatment and Misappropriation of Resident Property (unlawful, intentional use or conversion of someone else's funds or assets for unauthorized purposes), revised 10/2023, the P&P indicated it is essential for facilities to prohibit and prevent abuse, including sexual abuse, by staff to resident, resident to resident, visitor to resident. 555213 Page 3 of 3