Health inspection·December 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for two (2) of 2 sampled residents (Resident 1 and Resident 2) in accordance with the facility policy by failing to:1. Administer Resident 1's morning medications timely on 12/23/25.2. Administer Resident 2's morning medications timely on 12/23/25.This deficient practice had the potential to result in ineffectively managing Resident 1 and Resident 2's medical condition, which could result to harm, hospitalization and death.3. Leaving Resident 2's Medication unattended at bedside.This deficient practice had the potential for other residents to take the medications, which could result in harm to the other residents if ingested.Findings:1. During a review of Resident 1'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 (a mental illness that is characterized by disturbances in thought), hyperlipidemia (having to many fats in the blood which raises risk for heart attack, stroke and heart disease), major depressive disorder (a serious, common mood disorder that causes persistent feelings of sadness, loss of interest, and changes in thinking, feeling, and behavior, affecting daily life, work, sleep, and eating) and gastroesophageal reflux disease (GERD - digestive disorder where the stomach acid frequently flows back into the esophagus [food pipe]).During a review of Resident 1's Care Plan with focus on anti-coagulant (blood thinner), revised 2/5/2025, the Care Plan indicated to administer medication as physician ordered.During a review of Resident 1's Care Plan with focus on Resident 1's on antidepressants (prescription drugs that treat depression, anxiety [fear characterized by behavioral disturbances], and other conditions by altering brain chemistry), revised 2/5/2025, the Care Plan indicated medication as ordered: Paroxetine (medication for depression) 20 milligrams (mg - unit of measure).During a review of Resident 1's Care Plan with focus on antipsychotics (prescription psychiatric drugs that manage psychosis symptoms like hallucinations [sensory experiences {seeing, hearing, smelling, tasting, or feeling things} that seem real but are not] and delusions[fixed, false beliefs held with strong conviction despite evidence to the contrary]), revised 2/5/2025, the Care Plan indicated medication as ordered: Abilify (antipsychotic-psychiatric medications used mainly to treat psychosis [hallucinations, delusions] ) 10 mg.During a review of Resident 1's Physician Orders, dated 4/30/2025, the Physician Orders indicated Eliquis (Apixaban [blood thinner]) oral tablet 5 mg. Give 1 tablet by mouth two times a day for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) prophylaxis (action to prevent disease).During a review of Resident 1's Care Plan with focus on at risk for constipation (difficulty emptying the bowels), revised 5/18/2025, the Care Plan indicated to administer medications per physician's order and monitor effectiveness and side effects.During a review of Resident 1's Care Plan with focus on nutritional problems related to the following but Page 1 of 3 555213 555213 12/23/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not limited to hyperlipidemia, GERD, major depressive disorder, and schizoaffective disorder, revised 5/20/2025, the Care Plan indicated to administer medications as ordered and monitor/document for side effects and effectiveness.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/17/2025, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, upper body dressing and personal hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two (2) or more helper is required for the resident to complete the activity) with toileting hygiene, shower/bath self, lower body dressing and putting on/taking off footwear.During a review of Resident 1's Physician Orders, dated 2/1/2025, the Physician Orders indicated the following:1. Baclofen (medication for skeletal muscle relaxants and antispasmodic agent) oral tablet 10 mg. Give 1 tablet by mouth two times a day for back pain.2. Clopidogrel Bisulfate (a prescription antiplatelet medication used to prevent the formation of blood clots) oral tablet 75 mg. Give 1 tablet by mouth one time a day for coronary artery disease (CAD - when plaque builds up in the heart arteries, narrowing them and reducing blood flow and oxygen to the body)3. Docusate Sodium (stool softener) oral tablet 100 mg. Give 2 tablets by mouth one time a day for bowel management. Hold for loose stool. 2 tabs = 200mg4. Famotidine (medication that decreases the amount of stomach acid) oral tablet 20 mg. Give 1 tablet by mouth one time a day for GERD.5. Methocarbamol (skeletal muscle relaxant) oral tablet 1000 mg. Give 1 tablet by mouth three times a day for muscle spasms.During a review of Resident 1's Physician Orders, dated 2/6/2025, the Physician Orders indicated the following:1. Abilify (a prescription used to treat a variety of mental health conditions) oral tablet 10 mg. Give 1 tablet by mouth two times a day for manifested by visual and auditory hallucination (an experience involving the apparent perception of something not present), talking to unseen other related to schizoaffective disorder, bipolar (episodes of both manic and depressive) type inform consent obtained by medical doctor.2. Paroxetine HCL oral tablet 20 mg. Give 2.5 tablet by mouth one time a day for manifested by excessive feelings of sadness related to major depressive disorder, single episode, unspecified informed consent obtained by medical doctor. During a review of Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/2025, the MAR indicated the following medications were due at 9AM:1. Clopidogrel Bisfulfate 75 mg2. Docusate Sodium (stool softener) 100 mg3. Famotidine 20 mg4. Paroxetine Hydrochloride (HCL) 20 mg5. Abilify 10 mg6. Baclofen 10 mg7. Eliquis 5 mg8. Methocarbamol 1000 mg During a concurrent medication administration observation and interview on 12/23/2025 at 10:55 AM, Resident 1's electronic MAR (eMAR), dated 12/2025, was reviewed. Licensed Vocational Nurse 1 (LVN 1) stated the medications marked in pink on the eMAR means the medications were overdue. LVN 1 the following medications were observed overdue and highlighted in pink were the following:1. Clopidogrel Bisfulfate 75 mg2. Docusate Sodium 100 mg3. Famotidine 20 mg4. Paroxetine HCL 20 mg5. Abilify 10 mg6. Baclofen 10 mg7. Eliquis 5 mg8. Methocarbamol 1000 mg LVN 1 stated Resident 1's eight (8) medications should but were not given 1 hour before or 1 hour after 9AM as ordered. LVN 1 stated the medications were administered late since they were given at _11:03AM__.During an interview on 12/23/2025 at 11:15 AM, Resident 1 stated he would get his medications late. 2. During a review of Resident 2'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 benign prostatic hyperplasia (BPH - the common, noncancerous 555213 Page 2 of 3 555213 12/23/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enlargement of the prostate gland in older men), GERD, and chronic venous hypertension (high blood pressure in leg veins, caused by faulty valves that cannot return blood to the heart).During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance with oral hygiene, upper body dressing, and personal hygiene but was dependent on toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 2's Physician Orders, dated 1/31/2025, the Physician Orders indicated the following but not limited to:1. Finasteride (is used to treat men who have symptoms of benign prostatic hyperplasia [BPH]) oral tablet 5 mg. Give 1 tablet by mouth one time a day for BPH.2. Multiple Vitamin-Minerals (a supplement containing a combination of vitamins) oral tablet. Give 1 tablet by mouth one time a day for supplement. During a review of Resident 2's Physician Orders, dated 4/5/2025, the Physician Orders indicated Vitamin C (a vital water-soluble nutrient and antioxidant that the body needs daily for growth, tissue repair, collagen formation) oral tablet 500 mg (Ascorbic Acid) Give 1 Tablet by mouth one time a day for supplement. During a review of Resident 2's Physician Orders, dated 10/29/2025, the Physician Orders indicated Pro-Stat (a medical liquid protein supplement) oral liquid Give 30 milliliters (ml - unit of measure) by mouth one time a day for supplement. During a review of Resident 2's MAR, dated 12/2025, the MAR indicated the following medications are due at 9AM:1. Finasteride 5 mg2. Multiple Vitamins-Minerals 1 tab3. Pro-stat Oral Liquid 30 milliliters (ml - unit of measure)4. Vitamin C 500 mgDuring a concurrent observation and interview on 12/23/2025 at 11:30 AM in Resident 2's room, four (4) medications were observed on top of Resident 2's bedside table unattended. The medications observed were one (1) unidentified blue tablet, 1 unidentified white tablet and 1 unidentified orange tablet were observed in a medication cup along with 30ml of brown, honey like consistency fluid in another medication cup. Resident 2 stated the nurse left his medication with him and the resident was observed taking the medication at 11:45AM. During an interview on 12/23/2025 at 11:49AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 was given his 9AM medications at 10:30AM and they were left at his bedside table. LVN 1 also stated the medication was given late and she should not have left the medications on the resident's bedside table without observing the resident taking his medication. LVN 1 stated the resident can throw it away or another resident can take it. During an interview on 12/23/2025 at 12PM, the Director of Nursing (DON) stated medications should be given at least an hour before or 1 hour after the prescribed time. The DON also stated medication cannot be left at the bedside and the nurses should observe the resident taking the medication.During an interview on 12/23/2025 at 1:30PM, the Policy and Procedure (P&P) titled, Policy and Procedure in Medication Administration, dated revised 7/2013, was reviewed. The DON stated the policy indicated meds should not be left unattended. The DON also stated the policy should but does not indicate that medications are not to be left at bedside and the nurse should observe the resident taking the medication. The DON stated the facility does not have any residents who can self-administer medication. During a review of the facility's P&P titled, Policy and Procedure in Medication Administration, revised 7/2013, the P&P indicated medications must not be prepared in advance and/or left unattended. The P&P also indicated medications must be administered within one hour before or after administration time per physician's order. 555213 Page 3 of 3