Health inspection·March 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact (sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment) cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 2 required set up or clean-up assistance with eating. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene, shower/bathe, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a review of Resident 2's Discharge summary dated [DATE], timed at 5:10 PM, indicated Resident 2 was transferred to Facility 2 for change of environment. During an interview on 3/7/2025 at 4:54 PM with Licensed Vocational Nurse (LVN), LVN stated Police Department (PD, local law enforcement) was at Facility 1 on 3/5/2025 to interview Resident 1. LVN stated she should have asked PD the nature of the PD's visit to Resident 1. LVN stated after few days (unable to recall when), she found out that Resident 1 was being accused of sexual abuse to Resident 2 (a previous resident in the facility). LVN stated Facility 1 staff need to report to the Administrator (ADM) for any abuse or allegation of abuse within two (2) hour time frame. During an interview on 3/7/2025 at 4:27 PM with Infection Preventionist Nurse (IPN), IPN stated staffs are mandated reporters and the Facility 1 need to report any abuse incident or allegation of abuse within two hours to SA, ombudsman and local law enforcement. IPN stated that on 3/5/2025, PD was in the Facility 1 and spoke to Resident 1. IPN stated she asked PD regarding the reason for the visit to Resident 1, IPN stated PD mention sexual encounter. IPN stated she informed ADM through telephone call. IPN stated I assumed it was the Director of Nursing (DON) who reported it to the PD, that is why PD came to interview Resident 1. IPN stated there is a form titled SOC 341 (form used by Californian to report suspected dependent adult or elder abuse) that needs to be filled out in case of any abuse and suspected abuse happened to residents. IPN stated that she did not review and should have reviewed if there is a SOC 341 completed for the allegation of sexual abuse by Resident 1 to Resident 2 when PD came to investigate the allegation of sexual abuse on 3/5/2025. During an interview with the ADM on 3/7/2025 at 6 PM, ADM stated OMB was in the other Facility 2 on 3/5/2025 and OMB called the police for a female resident (Resident 2) who was previously residing at the Facility 1 after OMB listened to Resident 2's story and the resident made the sexual abuse allegation by Resident 1 that happened during the time Resident 2 was still at the Facility 1. ADM stated, PD went to the Facility 1 on 3/5/2025 to investigate the allegation of sexual abuse and the police also went to Facility 2 (where Resident 2 is currently residing) and did the investigation over at Facility 2 with the OMB. ADM stated she did not start any investigation and reported to SA when Facility 2 was made aware regarding Resident 2's allegation for sexual abuse by Resident 1 on 3/5/2025. ADM also stated she will start the investigation right away and report it to the agencies only if there is a real abuse case. During a review of the Facility 1's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, the P&P indicated all reports of resident 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), exploitation (treating someone unfairly in order to benefit from their work) and misappropriation (unauthorized use of another's name. likeness, identity, property without permission resulting to harm to that person) of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Nursing Center 1570 North Fair Oaks Ave Pasadena, CA 91103 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 3 of 3