Health inspection·February 5, 2026

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to fully inform the resident's conservator (a person or organization appointed by a court to manage the personal car, finances, or both, of an adult who can no longer make their own decisions due to physical or mental limitations) in advance, of the risks and benefits of proposed care for one (1) of two (2) sampled residents (Resident 1) in accordance with the facility policy when an informed consent was not obtained prior to residents use of the following three (3) psychotropic medications (mind - altering or mood-regulating medications). 1. Paliperidone (drug used to treat schizoaffective disorder [a mental illness that can affect thoughts, mood, and behavior] and schizophrenia [a mental illness that is characterized by disturbances in thought]).2. Haldol (drug used to treat schizophrenia).3. Buspirone (anti-anxiety [a feeling of fear, dread, and uneasiness that may occur as a reaction to stress] medication). This deficient practice had the potential for Residents 1 not able to exercise his right to choose his treatment plan.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder. During a review of Resident 1's Physician Order Summary Report, dated 1/23/2026, the Physician Order Summary Report indicated the following orders:1. Paliperidone Extended Release (ER) oral tablet 6 milligrams (mgmetric unit of measurement, used for medication dosage and/or amount). Give one tablet by mouth 2 times a day related to schizoaffective disorder, bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) type manifested by dilutional ideation (stubbornly believing something that is clearly not true, even when proven wrong, and refusing to accept logic or reality) causing him sudden anger, verbal, and physical aggression2. Haldol 5 mg to intramuscularly (IM) every eight (8) hours as needed for schizoaffective disorder, bipolar type for 14 days manifested by poor coping, easily irritated, angered and combative with staff.3. Buspirone Hydrochloride (HCL)oral tablet 30 mg. Give 1 tablet by mouth 2 times a day related to anxiety disorder manifested by poor coping, causing restlessness, irritability and inability to relax. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/25/2026, the MDS indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required supervision (helper provides cues) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with oral hygiene and upper body dressing and was independent with eating. During a review of the Medication Administration Record (MAR) for the month of January 2026, the MAR Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555893 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 02/05/2026 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)