Health inspection·November 26, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete up his wheelchair when Resident 4 saw Resident 1 and Resident 4 rammed his wheelchair against Resident 1. Resident 1 stated Resident 4's wheelchair hit her left arm and Resident 4 also kicked her left leg. Resident 1 stated she informed Licensed Vocational Nurse 2 (LVN 2), LVN 3, and the Assistant Director of Nursing (ADON) about the incident with Resident 4. Resident 1 stated she saw the Social Services Director (SSD), ADON, and the Administrator (ADM) go to the office to talk about the incident after it happened. Resident 1 stated the police did not come and talk to her after the incident. During an interview on 11/25/2025, at 12:07 PM, with LVN 2, LVN 2 stated on 11/25/2025, at around 4:45 PM, Resident 1 informed LVN 2 that Resident 4 crashed into her wheelchair and hit her left arm on her way to the Nurse's Station. LVN 2 stated the ADON, Director of Nursing (DON), and Administrator (ADM) were notified about the incident between Resident 1 and Resident 4. LVN 2 stated what Resident 1 reported about the incident with Resident 4 prompted an investigation of an allegation of abuse. LVN 2 stated if an investigation is prompted then abuse was suspected. LVN 2 stated suspected abuse should be reported to CDPH immediately or within two hours of the incident or when the allegation was made. LVN 2 stated he was not sure if the incident between Resident 1 and Resident 4 was reported to CDPH. During an interview on 11/26/2025, at 12:59 PM, with SSD, SSD stated on 11/25/2025, at approximately 5:20 PM, SSD was notified that Resident 4 allegedly ran over and hit by Resident 1's wheelchair. SSD stated he did not know if the incident between Resident 1 and Resident 4 was reported to CDPH. During an interview on 11/26/2025 at 1:13 PM, with the ADM, the ADM stated she was informed about the incident between Resident 1 and Resident 4 on 11/25/2025, at approximately 5 PM . The ADM stated she did not report the incident to CDPH, local PD and to OMB because she did not see any contact between Resident 1 and Resident 4 in the hallway when she checked the closed-circuit television (CCTV- video surveillance). ADM stated she did not think abuse occurred because she did not see any contact between Resident 1 and Resident 4 in the CCTV recording. ADM stated suspected abuse should be reported to CDPH immediately or within 2 hours from the incident or when the allegation was made on 11/25/2025 around 4:45 PM. ADM stated abuse was suspected if the incident prompted her to check the CCTV. ADM stated she should have reported the incident between Resident 1 and Resident 4 to CDPH. During an interview on 11/26/2025, at 3:32 PM, with ADON, ADON stated she and the ADM watched the CCTV recording after Resident 4 reported the alleged abuse by Resident 1 last 11/25/2025 around 4:45 PM and did not see Resident 4 hit Resident 1. The ADON stated they thought the facility did not need to fill out an SOC 341 (abuse reporting form) form and report to CDPH since there was no proof or witness regarding what happened between Resident 1 and Resident 4. During a review of the facility's P&P, titled, Abuse Investigation and Reporting, revised on 1/21/2025, the P&P indicated the following: All reports of resident abuse, shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing the facility; the local/State Ombudsman; Law enforcement officials. An alleged violation of abuse will be reported immediately, but not later than: two hours if the alleged violation involves abuse OR has resulted in serious bodily injury. During a review of the facility's policy and procedure (P&P), titled, Abuse Prevention Program, revised on 2/21/2025, the P&P indicated as part of the resident abuse prevention, the administration will investigate and report any allegations of abuse within timeframes as required by federal requirements. Event ID: Facility ID: 555893 If continuation sheet Page 2 of 11 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 11/26/2025 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 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 interview and record review, the facility failed to administer medication in accordance with the physician's order and to ensure that the administration of controlled medications (a drug or chemical whose manufacture, possession, and use are regulated by the government due to its potential for abuse or addiction) were accurately documented in the Medication Administration Record (MAR) for two (2) of two sampled residents (Resident 2 and 5). This deficient practice had the potential for harm to Resident 2 and 5 due to missed medications and due to an inaccurate record of controlled medication use, and the possible loss of accountability, which could affect the controls against drug loss, diversion, or theft. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other seizures (abnormal electrical activity in the brain that happens quickly), unspecified dementia (a brain disorder that results in memory loss, poor judgment and confusion), chronic obstructive pulmonary disease (COPD- a long-term disease causing difficulty breathing), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 2's Minimum Date Set (MDS- a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 2 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with lower body dressing, rolling left and right, and sit to lying. The MDS also indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, sit to stand, and chair/bed-to-chair transfer. During a review of Resident 2's Order Summary Report, dated 11/26/2025, the Order Summary Report indicated a physician order for Clonazepam (a medication used to treat certain seizure and panic disorders [sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause] oral tablet 1 milligram (mg- unit of measurement) give 1 tablet by mouth three times a day related to other seizures, ordered on 9/16/2025. During a review of Resident 2's MAR, dated 11/1/2025 to 11/30/2025, the MAR indicated Resident 2 was administered Clonazepam 1 mg by mouth on 11/13/2025 and 11/19/2025 at 8 PM by Licensed Vocational Nurse 3 (LVN 3). During a concurrent observation of Resident 2's Clonazepam bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles), interview, and record review on 11/26/2025, at 3:15 PM, with LVN 1, Resident 2's Narcotic and Hypnotic Record (a controlled substance count sheet of log used to track the entire lifecycle of a controlled medication including the receipt, administration, inventory, and disposal) from 11/12/2025 to 11/26/2025, was reviewed. LVN 1 counted Resident 2's Clonazepam bubble pack and there were two tablets left. LVN 1 stated Resident 2's Narcotic and Hypnotic Record indicated there was no documentation that Clonazepam 1 mg was taken out from the bubble pack and was given to Resident 2 on 11/13/2025 and 11/19/2025 at 8 PM by LVN 3. During the same interview with LVN 1 on 11/26/2025 at 3:15 PM, LVN 1 stated Resident 2's Narcotic and Hypnotic Record indicated there were two Clonazepam tablets left in Resident 2's bubble pack. LVN 1 stated the Narcotic and Hypnotic record matched the actual clonazepam count and if LVN 3 gave the Lorazepam as indicated in Resident 2's MAR last 11/13/2025 and 11/19/2025 then there should be none left in the bubble pack. LVN 1 stated, it means the MAR was signed by LVN 3, but the medication was not given to Resident 2. 2. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 3 of 11 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 11/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] and was readmitted on [DATE] with diagnoses that included depression (a serious mood illness affecting how you feel, think, and act, characterized by persistent sadness, loss of interest, fatigue, changes in sleep/appetite, and difficulty concentrating), anxiety disorder (excessive, persistent worry and feat that significantly impair daily life), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 5 required supervision or touching assistance with eating, oral/personal hygiene, toileting hygiene, upper body dressing, rolling left and right, sit to lying, sit to stand, and toilet transfer. The MDS indicated Resident 5 also required partial/moderate assistance with shower/bathe self, lower body dressing, tub/shower/transfer, and waling 50 feet (ft- unit of measurement) with two turns. During a review of Resident 5's Order Summary Report, dated 11/26/2025, the Order Summary Report indicated a physician order for Lorazepam (a medication used to treat anxiety) oral tablet 1 mg give 1 tablet by mouth three times a day for anxiety manifested by (m/b) inability to cope with daily living activities causing anger and stress, ordered on 8/17/2025. During a review of Resident 5's MAR, dated 11/1/2025 to 11/30/2025, the MAR indicated Resident 5 was administered Lorazepam 1 mg by mouth on 11/12/2025 at 5 PM by LVN 3. During the same concurrent observation of Resident 5's Lorazepam bubble pack, interview and record review on 11/26/2025, at 3:15 PM, with LVN 1, Resident 5's Narcotic and Hypnotic Record from 11/6/2025 and 11/20/2025 was reviewed. LVN 1 counted Resident 5's Lorazepam left in the bubble pack and there were 28 left. LVN 1 stated Resident 5's Narcotic and Hypnotic Record indicated there was no documentation that Lorazepam 1 mg was given to Resident 5 on 11/12/2025 at 5 PM by LVN 3. LVN 1 stated Resident 5's Narcotic and Hypnotic Record indicated there were 28 Lorazepam tablets left in Resident 5's bubble pack. During the same interview with LVN 1 on 11/26/2025 at 3:15 PM, LVN 1 stated Resident 5's Narcotic and Hypnotic Record matched the actual lorazepam count which was 28 and if LVN 3 gave the Lorazepam as indicated in Resident 5's MAR last 11/12/2025 then there should be 27 Lorazepam left in Resident 5 bubble pack. LVN 1 stated, it means the MAR was signed by LVN 3, but the medication was not given to Resident 5. LVN 1 stated it was the facility's policy for controlled medications to document the administration in the MAR accurately and the Narcotic and Hypnotic Record. LVN 1 stated this was done to ensure accuracy that the medication was given to keep track of the controlled medications that were administered and to avoid missing controlled medications. During an interview on 11/26/2025, at 3:40 PM, with the Director of Nursing (DON), the DON stated Resident 5's Lorazepam was not documented as given in the Narcotic and Hypnotic Record on 11/12/2025. The DON stated she was not aware of the discrepancy between Resident 2 and Resident 5's MAR and Narcotic and Hypnotic Record. During an interview on 11/26/2025, at 4:06 PM, with the Assistant DON (ADON), the ADON stated she was not aware that LVN 3 documented the controlled medication as administered (Clonazepam and Lorazepam) for Residents 2 and 5 in the residents' MAR but not in the Narcotic and Hypnotic Record. ADON stated the DON was supposed to do oversight and audits of the narcotic and controlled medications to make sure the residents received the medications in accordance with the physician's order and staff were not taking or stealing medications. ADON stated narcotic and controlled medication audits were also important to make sure the staff administered the medications to the residents on time and the medications matched the MAR. The ADON stated the controlled medications for Resident's 2 and 5 should not have been charted as given in the MAR if they were not administered to Residents 2 and 5. During a review of the facility's policy and procedure (P&P), titled, Medication Orders, revised 1/2018, the P&P under Controlled Substance Prescriptions, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 4 of 11 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 11/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. During a review of the facility's P&P, titled, Controlled Substances, revised 6/2/2025, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. During a review of the facility's P&P, titled, Administering Medications, revised 6/2/2025, it indicated the medications are administered in a safe and timely manner and as prescribed. Event ID: Facility ID: 555893 If continuation sheet Page 5 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three (3) of 3 sampled residents (Residents 2, 3, and 4) when Licensed Vocational 1 (LVN 1) and LVN 2 did not document medications administered from 3 PM to 11 PM on 11/25/2025 in the residents' Medication Administration Record (MAR). This deficient practice had the potential to result in a lack of or a delay in delivery of necessary care or services and in medication errors. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other seizures (abnormal electrical activity in the brain that happens quickly), unspecified dementia (a brain disorder that results in memory loss, poor judgment and confusion), chronic obstructive pulmonary disease (COPD- a long-term disease causing difficulty breathing), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 2's Minimum Date Set (MDS- a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 2 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with lower body dressing, rolling left and right, and sitting to lying. The MDS also indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, sit to stand, and chair/bed-to-chair transfer. During a review of Resident 2's Order Summary Report, dated 11/26/2025, the Order Summary Report indicated a physician order for the following: a. Buspirone (a medication used to treat anxiety [a natural feeling of worry, fear, or unease] disorder and its symptoms) HCl oral tablet 10 milligrams (mg- unit of measurement) give one (1) tablet by mouth three times a day related to anxiety disorder manifested by (m/b) restlessness causing irritability and frustration, with a start date of 9/17/2025.b. Clonazepam (a medication used to treat seizure disorders and panic [an intense, sudden feeling of fear or terror] disorder) oral tablet 1 mg. To give 1 tablet by mouth three times a day related to other seizures, with a start date of 9/16/2025. c. Donepezil HCl (a medication used to manage symptoms of dementia) oral tablet 10 mg. Give 1 tablet by mouth at bedtime related to unspecified dementia, unspecified severity with other behavioral disturbance, with a start date of 9/16/2025.d. Lithium Carbonate (a medication used to treat bipolar disorder) oral tablet 300 mg give 1 tablet by mouth three times a day, with a start date of 9/16/2025.e. Melatonin (a medication used to regulate sleep) oral tablet 5 mg give 1 tablet by mouth at bedtime for balance circadian rhythm (the pattern the body follows based on a 24 hour day), with a start date of 9/16/2025.f. Memantine HCl (a medication used to treat moderate to severe Alzheimer's disease [a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out he simplest tasks]) oral tablet 10 mg give 1 tablet by mouth two times a day related to unspecified dementia, unspecified severity with other behavioral disturbance, with a start date of 9/17/2025.g. Olanzapine (a medication used to treat schizophrenia [a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and related to others] and bipolar disorder) oral tablet 10 mg give 1 tablet by mouth two times a day related to schizoaffective disorder (a mental illness blending symptoms of schizophrenia with symptoms of bipolar mania [a state or abnormally elevated energy, mood, and activity] or depressive episodes), bipolar type m/b rapid mood swings, calm to agitated and pretending to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 6 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shoot staff, with a start date of 11/1/2025.h. Trazodone HCl (a medication used to treat major depressive disorder [a mood disorder causing persistent sadness and loss of interest with impacts daily life]) oral tablet 100 mg give 1 tablet by mouth at bedtime related to depression unspecified m/b no motivation or interest in activities of daily living, with a start date of 9/16/2025.i. Antidepressant Trazodone side effects monitoring: indicate letter if observed: A=Sedation; B= Drowsiness; C= Dry mouth; D= Blurred vision; E= Urinary retention; F= Tachycardia; G= Muscle Tremor; H=Agitation; I= Headache; J= Skin rash; K= Photosensitivity; L= Weight gain; NA= None every shift, with a start date of 9/16/2025.j. Antidepressant use Trazodone behavior monitoring- document number of episodes observed of target behavior depression m/b no motivation or interest in activities of daily living every shift for Trazodone use, with a start date of 11/1/2025.k. Antipsychotic (medications that treat mental health conditions) Haloperidol use behavior monitoring: document number of episode per shift of target behavior m/b inability to cope with delusional ideas, causing agitation and anger towards staff every shift, with a start date of 9/15/2025.l. Antipsychotic Lithium use behavior monitoring: document number of episodes per shift of target behavior m/b delusion ideation, out of touch with reality and surrounding environment every shift, with a start date of 9/16/2025.m. Antipsychotic Olanzapine use behavior monitoring: document number of episodes per shift of target behavior rapid mood swings, calm to agitated and pretending to shoot staff every shift, with a start date of 9/16/2025.n. Antipsychotic Olanzapine, Lithium, Haloperidol, clonazepam use side effect monitoring: Chart N for none or use letter indicator as follows: T)= tardive dyskinesia (facial and tongue movement), (A)= akathisia (inability to sit still), (C)= cognitive impairment (decreased mental state), (P)= Parkinsonism (tremors, drooling, rigidity) every shift, with a start date of 9/16/2025.o. Anxiolytic Buspirone use behavior monitoring: document number of episodes per shift of target behavior m/b restlessness causing irritability and frustration every shift, with a start date of 9/16/2025.p. Anxiolytics Ativan and Buspar use side effects monitoring: indicate letter if observed: A= sedation; B= drowsiness; C= ataxia (drunk walk); D= dizziness; E= nausea; F= vomiting; G= confusion; H= headache; I= blurred vision; J= skin rash; NA= none every shift, with a start date of 9/16/2025.q. For Lorazepam use anxiolytic behavior monitoring: document number of observed episodes per shift of target behavior (auditory and visual hallucinations, hearing voices, and seeing things that are not there causing restlessness) every shift, with a start date of 11/3/2025.r. Keep head of bed (HOB) elevated when in bed for shortness of breath (SOB) when lying flat secondary to (2/2) COPD every shift, with a start date of 10/8/2025. s. Monitor for signs and symptoms of respiratory illness and COVID-19: C= cough, SOB, CB= difficulty breathing, F= fever, CH= chills, BA= body aches, V= vomiting or D= diarrhea, LTS= new loss of taste or smell. Notify MD if any sign and symptoms are noted, with a start date of 9/16/2025.t. Sedative, hypnotic, Temazepam use behavior monitoring: document number of episodes per shift of target behavior difficulty falling asleep, staying asleep, waking up too early and not being able to return to sleep at night, with a start date of 9/16/2025. During a review of Resident 2's Medication Administration Record (MAR), dated 11/1/2025 to 11/30/2025, the MAR was left blank on 11/25/2025 for the 3 PM to 11 PM shift for the following medications: a. Buspirone HCl 10 mg by mouth.b. Clonazepam 1 mg by mouth. c. Donepezil HCl 10 mg by mouth.d. Lithium Carbonate 300 mg by mouth.e. Melatonin 5 mg by mouth.f. Memantine HCl 10 mg by mouth.g. Olanzapine 10 mg by.h. Trazodone 100 mg by mouth. During a review of Resident 2's MAR, dated 11/1/2025 to 11/30/2025, the MAR was left blank on date? for the 3 PM to 11 PM on the following:a. Antidepressant Trazodone side effects monitoring. b. Antidepressant use Trazodone behavior monitoring for Trazodone use.c. Antipsychotic Haloperidol use behavior monitoring.d. Antipsychotic Lithium use behavior monitoring. e. Antipsychotic Olanzapine use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 7 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some behavior monitoring.f. Antipsychotic Olanzapine, Lithium, Haloperidol, clonazepam use side effect monitoring.g. Anxiolytic Buspirone use behavior monitoring.h. Anxiolytics Ativan and Buspar use side effects monitoring. i. For Lorazepam use anxiolytic behavior monitoring.j. Keep head of bed elevated when in bed for shortness of breath when lying flat 2/2 COPD every shift. k. Monitor for signs and symptoms of respiratory illness and COVID-19 l. Sedative, hypnotic, Temazepam use behavior monitoring. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included other seizures, bipolar disorder, and schizoaffective disorder bipolar type. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was assessed having severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 required substantial/maximal assistance with eating, oral hygiene, upper body dressing, sitting to lying, sitting to standing, and toilet transfer. The MDS also indicated Resident 3 was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, personal hygiene, and tub/shower transfer. During a review of Resident 3's Order Summary Report, dated 11/26/2025, the Order Summary Report indicated a physician order for the following: a. Gabapentin (medication used to treat nerve pain and seizures) oral capsule give 900 mg (300 mg/3 tabs = 900 mg) by mouth at bedtime for neuropathy (nerve damage often affecting the nerves outside the brain and spine), with a start date of 10/30/2025.b. Melatonin oral tablet 10 mg give 2 tablets by mouth at bedtime for improvement of circadian rhythm, with a start date of 10/30/2025.c. Tamsulosin HCl (medication used to treat symptoms of an enlarged prostate) oral capsule give 0.8 mg by mouth at bedtime related to benign hyperplasia without lower urinary tract symptoms (enlarged prostate without noticeable symptoms like a weak urine stream or frequent urination), with a start date of 10/30/2025.d. Valproic Acid (medication used to treat seizures) oral capsule 250 mg give 1000 mg by mouth two times a day related to bipolar disorder, current episode hypomanic (a mild form of mania) m/b rapid mood changes from calm to agitation with staff, with a start date of 10/30/2025.e. Vimpat (a medication used to treat seizures) oral tablet 100 mg give 1 tablet by mouth two times a day for seizure disorder, with a start date of 10/30/2025.f. Ziprasidone HCl (medication used to treat mental disorders including schizophrenia, mania, or bipolar disorder) oral capsule 80 mg give 1 capsule by mouth two times a day for schizophrenia related to other schizophrenia manifested by auditory and visual hallucinations as evidenced by hearing voices and seeing things that are not there causing agitations, with a start date of 10/30/2025. g. Anticonvulsant Valproic and Lacosamide use monitor for side effects by using letter 0= none; A= anorexia; B= blurred vision; C= constipation; F= fatigue; S= sleepiness; U= upset stomach; N= nausea; V= vomiting; D= diarrhea; Z= dizziness; DM= dry mouth; UR= urinary retention every shift, with an order date of 10/30/2025.h. Anticonvulsant Valproic use behavior monitoring: document number of episodes per shift or target behavior bipolar disorder m/b rapid mood changed from calm to agitation towards the staff every shift, with a start date of 10/30/2025.i. Antipsychotic (valproic acid) use behavior monitoring; document number of episodes per shift of target behavior m/b rapid mood changes from calm to agitation with staff, with a start date of 11/05/2025.j. Antipsychotic side effect monitoring for Ziprasidone: Chart 0 for none or use letter indicator as follows: (T)= tardive dyskinesia; (A)= akathisia; (C)= cognitive impairment; (P)= Parkinsonism every shift, with an order date of 10/30/2025.k. Antipsychotic Ziprasidone use behavior monitoring: document number of episodes per shift of target behavior schizophrenia m/b auditory and visual hallucinations as evidenced by hearing voices and seeing things that are not there causing agitations every shift, with an order date of 10/29/2025.l. Monitor level of pain every shift (scale 0- 10): (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10 = severe pain. If Resident is nonverbal, utilize facial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 8 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pain scale and medicate as ordered), with an order date of 10/29/2025. During a review of Resident 3's Medication Administration Record (MAR), dated 11/1/2025 to 11/30/2025, Resident 3's MAR was left blank on date? for the 3 PM to 11 PM for the following medications: a. Gabapentin 900 mg by mouth.b. Melatonin 10 mg by mouth.c. Tamsulosin HCl 0.8 mg by mouth.d. Valproic Acid 1000 mg by mouth.e. Vimpat 100 mg by mouth.f. Ziprasidone HCl 80 mg by mouth. During a review of Resident 3's MAR, dated 11/1/2025 to 11/30/2025, the MAR was left blank on date? for the 3 PM to 11 PM for following:a. Anticonvulsant Valproic and Lacosamide use side effects monitoring.b. Anticonvulsant Valproic use behavior monitoring.c. Antipsychotic valproic acid use behavior monitoring.d. Antipsychotic side effect monitoring for Ziprasidone.e. Antipsychotic Ziprasidone use behavior monitoring.f. Level of pain monitoring. 3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included other COPD, hypertensive heart disease (a medical condition where the heart is affected by high blood pressure), and schizophrenia. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was assessed to have intact memory and cognitive skills for daily decision making. The MDS indicated Resident 4 required supervision or touching assistance with eating, oral/toileting hygiene, upper body dressing, personal hygiene, sit to stand and toilet transfer. The MDS indicated Resident 4 required partial/moderate assistance with shower/bathe self, lower body dressing, and tub/shower transfer. During a review of Resident 4's Order Summary Report, dated 11/26/2025, the Order Summary Report indicated a physician order for the following: a. Ipratropium-Albuterol Inhalation (a medication used to treat COPD) aerosol solution 20-100 micrograms (mcg- unit of measurement) 1 puff inhale orally four times a day for asthma (when the airways become swollen and narrowed leading to breathing difficulties) related to COPD, with a start date of 11/22/2025.b. Losartan Potassium (a medication that lowers the blood pressure) oral tablet 50 mg. To give 1 tablet by mouth two times a day for hypertension related to hypertensive health disease without heart failure hold if systolic blood pressure (SBP- the top number in a blood pressure reading) is less than 110, with a start date of 9/28/2025.c. Quetiapine Fumarate ER (a medication used to treat schizophrenia, bipolar disorder, and as an adjunctive (added) therapy for major depressive disorder) oral tablet extended release 24 hour give 500 mg by mouth at bedtime related to schizophrenia unspecified m/b delusional out of touch with reality and surroundings environment, with a start date of 9/28/2025.d. Monitor vital signs and for signs and symptoms of respiratory illness: cough, shortness of breath, difficulty breathing, fever, chills, muscle, body aches, vomiting, diarrhea, new loss of taste or smell. Notify physician (MD) if any sign or symptoms are noted every shift. During a review of Resident 4's Medication Administration Record (MAR), dated 11/1/2025 to 11/30/2025, the MAR was left blank on date?? for the 3 PM to 11 PM for the following medications: a. Ipratropium-Albuterol Inhalation aerosol solution 20-100 mcg 1 puff orally.b. Losartan Potassium 50 mg by hold if SBP is less than 110.c. Quetiapine Fumarate ER 500 mg by mouth. During a review of Resident 4's MAR, dated 11/1/2025 to 11/30/2025, the MAR was left blank on date?? for the 3 PM to 11 PM for the monitoring of Resident 4's vital signs and for signs and symptoms of respiratory illness: cough, shortness of breath, difficulty breathing, fever, chills, muscle, body aches, vomiting, diarrhea, new loss of taste or smell. During an interview on 11/26/2025, at 12:07 PM, with LVN 2, LVN 2 stated LVN should initial/ sign the MAR immediately after administering medications to the residents. LVN 2 stated it was standard nursing practice to document medications administered to the residents in the MAR. LVN 2 stated if medications were not documented in the MAR, then that means the medications were not given. LVN 2 stated the behaviors of residents who are taking psychotropic medications (medications that affect brain activities associated with mental processes and behavior) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 9 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some are also monitored and documented in the MAR. LVN 2 stated it was important to monitor and document these behaviors to see the effectiveness of the medications or if the medication's dose needed to be adjusted. LVN 2 stated Residents 2, 3, and 4's medications were in Medication Cart 1 (MC 1) and LVN 3 was assigned to MC 1 on 11/25/2025 from 3 PM to 11 PM. During an interview on 11/26/2025, at 1:13 PM, with the Administrator (ADM), the ADM stated LVN 3 only worked at the facility from 3 PM to approximately 7 PM on 11/25/2025. The ADM stated LVN 3 was assigned to MC 2 and administered Resident 2, 3 and 4's medications until LVN 3 left the facility. The ADM stated the medications that LVN 3 should have documented were Resident 2's memantine and olanzapine; Resident 3's Valproic acid, Vimpat, and ziprasidone HCl and; Resident 4's losartan and ipratropium-albuterol medications. The ADM stated LVN 4 took over LVN 3's assignment from approximately 7 PM to 11 PM. During the same interview on 11/26/2025, at 1:13 PM, with the ADM, the ADM stated LVN 4 should have documented and initialed the MAR after the medications for Residents 2, 3, and 4 were administered. The ADM stated the medications that LVN 4 should have documented were Resident 2's donepezil, melatonin, and trazodone; Resident 3's gabapentin, melatonin, and tamsulosin and; Resident 4's quetiapine. The ADM stated LVN 4 should have documented that the behavior monitoring was performed for Residents 2, 3, and 4 from 3 PM to 11 PM shift on 11/25/2025. The ADM stated the policy for administering medications was not followed by LVN 3 and LVN 4 During an interview on 11/26/2025, at 3:32 PM, with the Assistant Director of Nursing (ADON), the ADON stated LVN 3 and LVN 4 did not initial the MAR for Residents 2, 3, and 4 after the 3 PM to 11 PM medications were given on 11/25/2025. ADON stated it was important to accurately chart the medications given in the MAR because the residents in the facility have mental and physical conditions and needed to take their medications as ordered. ADON stated the MAR communicates to the staff if medications were not given or given as ordered by the physician. ADON stated residents could get sick or their behaviors could worsen if their medication administration was not documented due to potential medication errors (any preventable event that may cause of lead to patient harm, or has the potential to do so, while the medication is in the control of a healthcare professional, patient, or consumer) such as under or over medicating the resident. ADON stated it was important to document medications to ensure continuity of care and the proper care is provided to the residents. During the same interview on 11/26/2025, at 3:32 PM with ADON, the ADON stated LVN 3 and LVN 4 did not initial the MAR after Resident's 2, 3, and 4's vital signs, pain assessment, medication side effects, non-pharmacological interventions and behavior were monitored from 3 PM to 11 PM on 11/25/2025. ADON stated the MAR was used to determine and understand why a resident was having an exacerbation of a certain behavior. ADON stated it was important to document Resident 4's vital signs, pain assessment, medication side effects, non-pharmacological interventions and behavior were monitoring in the MAR to prevent over medicating the residents and proper evaluation of the resident's condition. ADON stated the residents' documented behavior was reviewed by the physician to ensure a resident was taking the correct dose of a medication or if a dose adjustment was necessary. ADON stated the resident's behaviors should be documented in the MAR for the safety of the residents. During a review of the facility's policy and procedure (P&P), titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated the following: The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition including:a. onset, duration, intensity and frequency of behavioral symptoms;b. appearance and alertness of the resident, and related observations. During a review of the facility's P&P, titled, Administering Medications, reviewed 6/2025, the P&P indicated the following: The individual administering the medication initials the resident's MAR on the appropriate line after giving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555893 If continuation sheet Page 10 of 11 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 11/26/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:o The date and time the medication was administered; o Any results achieved and when those results were observed; and o The signature and title of the person administering the drug. During a review of the facility's P&P, titled, Carting and Documentation, revised 6/2/2025, the P&P indicated the following: All services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: objective observations; medications administered. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Event ID: Facility ID: 555893 If continuation sheet Page 11 of 11