Health inspection·October 19, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hanging above the handwashing catching a small leak and dripping into a gray trash bin. On the opposite side of the kitchen, there was a second leak that was dripping in a yellow trash bin. During an interview on 10/18/2025, at 7:15 AM, the ADMN stated the water leak found in the facility kitchen ceiling was first noticed on 10/10/2025. ADMN stated, Plumber Company staff 1 (PC1) came to the facility on [DATE] to repair leaks in kitchen, and it was PC 1 who opened the kitchen ceiling to determine the cause of the leak. ADMN stated PC1 does not repair drywall, so he had to get another company (PC2) to fix the ceiling. During an interview on 10/18/2025, at 7:45am, ADMN confirmed the facility continued to use their kitchen for resident food preparation including the residents' breakfast on 10/18/2025. ADMN stated the facility has 50 residents who are receiving their food prepared in the facility kitchen out of their 51 residents. ADMN stated he asked the plumber (did not specify if PC1 or PC2) if it was still safe to use the kitchen and the plumber told the ADMN yes. ADMN stated, ADMN did not consult any outside company or the facility's Dietary Supervisor (DS) to confirm if it was safe to use the facility's kitchen to prepare the residents' food and felt that expertise of plumbers was enough. During an interview on 10/18/2025, at 7:5 AM, PC1 stated they came out on 10/11/2025, discovered a leak in the facility's kitchen ceiling, and they opened the ceiling to expose the leaking pipe which created the large gaping hole over the hand washing sink. PC 1 stated PC 1 repaired the leak and placed a plastic tarpaulin (plastic tarp) over the large gaping hole. PC1 stated that it was safe to prepare the residents' food with the plastic tarp covering the large gaping hole on the kitchen's ceiling but does not know if it is safe to prepare the residents' food if the large gaping hole is not covered. During an interview on 10/18/2025, at 8:04 AM, ADMN stated, PC2 came on the morning of 10/17/2025 and removed the plastic tarp from the kitchen's ceiling. ADMN confirmed food preparations in the facility's kitchen continued after the plastic tarp was removed by PC2 on 10/17/2025. PC2 also stated, the large gaping hole in the facility's kitchen above the handwashing sink measured 3 ft. by 4 ft. During an interview on 10/18/2025, at 8:10 AM, PC2 stated, they came to the facility on [DATE] around 10 AM and PC2 removed the plastic tarp covering the large gaping hole from the kitchen's ceiling. During an interview on 10/18/2025, at 8:22 AM, [NAME] 1 stated that food preparation continued in the facility's kitchen even though there was a large gaping hole in the kitchen's ceiling. [NAME] 1 stated that food was not prepared while the plumbers were working, but sometimes the tarp was on and sometimes it was off while the plumbers worked. [NAME] 1 confirmed, today 10/18/2025, the residents' breakfast was prepared with no plastic tarp covering the ceiling. During an interview on 10/18/2025, at 9:52am, DS stated they were informed by PC1 on 10/11/2025 that the kitchen was safe to use while there is a plastic tarp covering the large gaping hole in the kitchen's ceiling. DS stated if there is no plastic covering large gaping hole in the kitchen's ceiling, then the kitchen should not be used for residents' meal preparation. DS stated they should be preparing food in the kitchen of their sister facility across the street to ensure patient food safety. DS states that there is potential for something to drop from the open ceiling into the food which could potentially harm the patients. During an interview on 10/18/2025, at 2:54 AM, ADMN stated the facility did not have a policy or a kitchen emergency plan that includes the facility's plan if kitchen is under construction and/or is deemed not safe to be used to prepare the residents' meals. The only policy the facility have is the Dietary Considerations for Residents: Disaster Emergency Preparedness. A review of the Facility's policy titled, Dietary Considerations for Residents: Disaster Emergency Preparedness, dated 1/20/2025, indicated that emergency dietary planning for residents and staff includes the consideration of such situations as evacuation and long-term sheltering in place without the support of outside resources food, water and food service supplies or utilization of sister facility's (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 10/19/2025 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 0921 kitchen if available. 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