Health inspection·August 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leading up to a seizure, where he could move but could not talk. Resident 1 stated he was taken to the hospital the same day and the hospital ran a whole bunch of tests and Resident 1 stayed in the hospital for two days. Resident 1 stated he usually suffered from grand mal seizures (a type of epileptic seizure characterized by a loss of consciousness, muscle stiffening [tonic phase], and rhythmic jerking [clonic phase]) and he felt tired after suffering from an episode of grand mal seizures and Resident 1 stated the medications have helped to stabilize his condition.During a concurrent interview and record review on 8/4/2025 at 2:52 p.m. with LVN 1, Resident 1's Change of Condition (COC) dated 7/26/2025 was reviewed. The COC indicated altered mental status for Resident 1 on 7/26/2025. LVN 1 stated he was not the nurse taking care of Resident 1 on 7/25/2025 when the facility ran out of Reisdent 1's phenytoin. LVN 1 stated Resident 1 was taken to the hospital on 7/26/2025 but he was not sure if the resident was having seizures. LVN 1 stated if the facility ran out of stock of phenytoin and was not able to give it to Resident 1, it would increase the risk of seizures for Resident 1 and cause shortness of breath, altered mental status, fall risk because of uncontrolled body movements and hospitalization.During an interview on 8/4/2025 at 12:15 p.m. with pharmacist (RPH) 1, RPH 1 stated Pharmacy (PH 1- where the facility orders and received the resident's medications) delivered a 14-day supply of phenytoin 100 mg with instructions of three capsules two times a day to the facility on 7/8/2025 at 2:09 a.m. after receiving a request from the facility on 7/7/2025. RPH 1 stated the facility sent a fax to PH1 on 7/8/2025 at 6:01 p.m. that indicated, CancelRx meaning discontinuation of phenytoin 100 mg, 3 capsules two times a day. RPH 1 stated when the facility requested phenytoin order again on 7/19/2025, RPH 1 informed the facility that facility needed to send a new order for Resident 1's phenytoin because facility had previously informed PH 1 to discontinue previous phenytoin order. RPH 1 stated there would be an increased risk of seizures for Resident 1 if facility was not able to administer the dose of phenytoin on 7/25/2025.During a concurrent interview and record review on 8/4/2025 at 3:44 p.m. with LVN 2, Resident 1's administration details, dated 7/25/2025 at 5:36 p.m. and Medication Administration Record (MAR), dated 7/1/2025 to 7/31/2025 for phenytoin sodium extended-release oral capsule 100 mg, were reviewed. The administration details indicated a documented code of 9 (meaning not given) with progress notes that indicated, give 3 capsules by mouth two times a day for seizures, give 3 caps = 300 mg, follow up pharmacy and said to fax the order. Did faxed the order and will wait for the two medications to be delivered. May give when available. The MAR indicated a documented 9 for 7/25/2025 6:00 p.m. dose. LVN 2 stated the code 9 means the medication was not given and Resident 1's phenytoin 100 mg medication card/bubble pack was empty on 7/25/2025 around 4:00 p.m. and she did not have the phenytoin dose to administer to Resident 1. LVN 2 stated she could not figure out what happened, could not remember much what happened because it was a busy week. LVN 2 stated Resident 1 was taken to the hospital early in the morning on 7/26/2025. LVN 2 stated Resident 1 was at risk for seizures, a fall if the resident was in standing position and hospitalization due to missed dose of phenytoin.During an interview on 8/4/2025 at 5:20 p.m. with the Director of Nursing (DON), the DON stated the licensed nursing staff should order medication from the pharmacy when there are six to seven doses left, so that there would be enough time to prepare and not miss any doses for the residents. The DON stated he could not recall if phenytoin was available in the facility's emergency kit ([E-kit] a container with important medications supplied by the pharmacy to be used by the facility, for the facility's residents in case of emergency or when a medication was not available in stock). The DON stated if phenytoin was not in stock it would delay the residents' treatment and place them at risk for seizures and hospitalization. 2. During a review of Resident 2's admission record, dated 8/4/2025, the admission record indicated Resident 2 was admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555908 If continuation sheet Page 2 of 6 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 555908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Pasadena Care Center 904 Mission St South Pasadena, CA 91030 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to the facility on [DATE] with diagnosis that included but not limited to vitamin D deficiency and other specified disorders of bone, ankle and foot. During a review of Resident 2's history and physical, dated 5/30/2025, the document indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Laboratory Results Report, dated 6/4/2025, the report indicated Resident 2's vitamin D, 25-hydroxy level was low at 20 nanogram ([ng] a unit of measurement for mass) per mL, reference range of 30 to 100 ng/mL.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 needed supervision level assistance from the facility staff for eating and moderate assistance for oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene. During an observation on 8/4/2025 at 10:19 a.m., LVN 1 prepared and administered the eight medications and supplements to Resident 2 which did not include ergocalciferol (vitamin D2). During a review of Resident 2's physician order on 8/4/2025 at 11:50 a.m., the order, dated 8/4/2025 indicated: Vitamin D (Ergocalciferol) oral capsule 1.25 mg (50000 International Units [IU] a unit of measurement for dose) give 1 capsule by mouth one time a day every Monday related to vitamin D deficiency for 8 weeks, order date 7/6/2025, start date 7/7/2025, end date 9/1/2025. Vitamin D3 oral tablet 25 micrograms ([mcg] a unit of measurement for mass) (1000 IU) (cholecalciferol) give 2 tablets by mouth one time a day related to vitamin D deficiency (2 tabs = 2000 IU), order date 7/6/2025, start date 9/2/2025. During a concurrent interview and record review on 8/4/2025 at 2:38 p.m. with LVN 1, the administration details in electronic medical record and MAR for 8/4/2025 were reviewed. The administration details indicated ergocalciferol was administered to Resident 2 on 8/4/2025. LVN 1 stated he could not find ergocalciferol for Resident 2 in stock in the resident's medication cart LVN 1 was not sure until when it was not in stock. LVN 1 stated he documented ergocalciferol as administered by mistake when it was not administered on 8/4/2025. LVN 1 stated he would request medication from the pharmacy. LVN 1 stated medication should not be documented as given when it was not administered and would be reflected inaccurately in medical records. LVN 1 stated Resident 2 would not be treated for vitamin D deficiency because he did not receive the Vitamin D2 as ordered. During an interview on 8/4/2025 at 5:20 p.m. with the DON, the DON stated Resident 2 would not be treated for vitamin D deficiency which could cause Resident 2 to feel weak and fatigued with the possibility of not being able to participate in ADLs.During a review of the facility's P&P titled, Administering Medications, dated 7/2024, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must initial the resident's MAR after giving each medication and before administering the next ones.During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, Ordering and Receiving Medications from the Dispensing Pharmacy, dated 1/2022, the P&P indicated, If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered . and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand b. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in the directions of use.During a review of the facility's P&P titled, Seizure Precautions, dated 7/2019, the P&P indicated, Residents will be protected prior to and during seizure activity. 1. Seizure precautions for residents who have a history of seizure activity include the following: Obtain orders for dosage change as needed based on laboratory values. Event ID: Facility ID: 555908 If continuation sheet Page 3 of 6 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 555908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Pasadena Care Center 904 Mission St South Pasadena, CA 91030 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 0760 Ensure that residents are free from significant medication errors. 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 prevent significant medication error (a type of error which causes the resident discomfort or jeopardizes his or her health and safety) for Resident 1 by failing to ensure Resident 1's phenytoin sodium (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) was available in stock to be administered on 7/25/2025 at its scheduled time of administration, in accordance with facility's policy and procedure (P&P) titled, Administering Medications, dated 7/2024. This deficient practice placed Resident 1 at risk for seizures, falls and other adverse consequences of not getting the medication.Findings:During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 8/4/2025, the admission record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included, but not limited to, epilepsy, unspecified intractable, without status epilepticus (seizures that are difficult to control with medication, but do not involve prolonged seizures).During a review of Resident 1's History and Physical, dated 7/8/2025, the document indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 7/11/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was intact. The MDS indicated Resident 1 needed supervision level assistance from the facility staff for activities of daily living (ADL - tasks of everyday life that include personal and oral hygiene, toileting, showering, and dressing) such as eating and moderate assistance for oral hygiene, toileting hygiene, showering, upper and lower body dressing and putting on or taking off footwear. During a review of Resident 1's Physician Order Summary Report (a document containing a summary of all active physician orders), dated 8/4/2025 and 7/28/2025, the order summary report indicated Phenytoin sodium extended oral capsule 100 milligrams ([mg] a unit of measurement for mass), give 3 capsules by mouth two times a day related to epilepsy, 3 caps= 300mg, order date 8/3/2025, start date 8/3/2025 During an interview on 8/4/2025 at 1:40 p.m. with Resident 1, Resident 1 stated the facility ran out of his phenytoin 300 mg two times a day for seizures about a week ago. Resident 1 stated he did not remember the female Licensed Vocational Nurse's (LVN) name, but when Resident 1 requested the female LVN to administer phenytoin for afternoon dose, the female LVN stated that the facility did not have phenytoin in stock to administer to Resident 1 and the female LVN showed the empty medication card for phenytoin. Resident 1 stated he had been on the phenytoin for several years, for at least 10 years. Resident 1 stated, I was not feeling like myself and was acting a little slower and usually that was a usually a symptom leading up to a seizure, where he could move but could not talk. Resident 1 stated he was taken to the hospital the same day and the hospital ran a whole bunch of tests and Resident 1 stayed there for two days. Resident 1 stated, someone from the facility must have informed my wife about him in the hospital. Resident 1 stated he usually suffered from grand mal seizures (a type of epileptic seizure characterized by a loss of consciousness, muscle stiffening [tonic phase], and rhythmic jerking [clonic phase]) and he felt tired after suffering from an episode of grand mal seizures and Resident 1 stated the medications have helped to stabilize his condition.During a concurrent interview and record review on 8/4/2025 at 2:52 p.m. with LVN 1, Resident 1's Change of Condition (COC) dated 7/26/2025 was reviewed. The COC indicated altered mental status for Resident 1 on 7/26/2025. LVN 1 stated he was not the nurse taking care of Resident 1 on 7/25/2025 when the facility ran out of Resident 1's phenytoin. LVN 1 stated Resident 1 was taken to the hospital on 7/26/2025 but he was not Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555908 If continuation sheet Page 4 of 6 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 555908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Pasadena Care Center 904 Mission St South Pasadena, CA 91030 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sure if the resident was having seizures. LVN 1 stated if the facility ran out of stock of phenytoin and was not able to give it to Resident 1, it would increase the risk of seizures for Resident 1 and cause shortness of breath, altered mental status, fall risk because of uncontrolled body movements and hospitalization.During an interview on 8/4/2025 at 12:15 p.m. with pharmacist (RPH) 1, RPH 1 stated Pharmacy (PH 1- where the facility orders and received the resident's medications) delivered a 14-day supply of phenytoin 100 mg with instructions of three capsules two times a day to the facility on 7/8/2025 at 2:09 a.m. after receiving a request from the facility on 7/7/2025. RPH 1 stated the facility sent a fax on 7/8/2025 at 6:01 p.m. that indicated, CancelRx meaning discontinuation of phenytoin 100 mg, 3 capsules two times a day. RPH 1 stated when the facility requested phenytoin order again on 7/19/2025, RPH 1 informed the facility via fax that facility needed to send a new order for Resident 1's phenytoin because facility had informed PH 1 to discontinue previous phenytoin order. RPH 1 stated there would be an increased risk of seizures for Resident 1 if facility was not able to administer the dose on 7/25/2025.During a concurrent interview and record review on 8/4/2025 at 3:44 p.m. with LVN 2, Resident 1's administration details, dated 7/25/2025 at 5:36 p.m. and Medication Administration Record (MAR), dated 7/1/2025 to 7/31/2025 for phenytoin sodium extended-release oral capsule 100 mg, were reviewed. The administration details indicated a documented code of 9 (meaning not given) with progress notes that indicated, give 3 capsules by mouth two times a day for seizures, give 3 caps = 300 mg, follow up pharmacy and said to fax the order. Did faxed the order and will wait for the two medications to be delivered. May give when available. The MAR indicated a documented 9 for 7/25/2025 6:00 p.m. dose. LVN 2 stated the code 9 means the medication was not given and Resident 1's phenytoin 100 mg medication card/bubble pack was empty on 7/25/2025 around 4:00 p.m. and she did not have the phenytoin dose to administer to Resident 1. LVN 2 stated she could not figure out what happened, could not remember much what happened because it was a busy week. LVN 2 stated Resident 1 was taken to the hospital early in the morning on 7/26/2025. LVN 2 stated Resident 1 was at risk for seizures, a fall if the resident was in standing position and hospitalization due to missed dose of phenytoin.During an interview on 8/4/2025 at 5:20 p.m. with the Director of Nursing (DON), the DON stated the licensed nursing staff should order medication from the pharmacy when there are six to seven doses left, so that there would be enough time to prepare and not miss any doses for the residents. The DON stated he couldn't recall if phenytoin was available in the facility's emergency kit ([E-kit] a container with important medications supplied by the pharmacy to be used by the facility for the facility's residents in case of emergency or when a medication was not available in stock). DON stated if phenytoin was not in stock it would delay the residents' treatment and place them at risk for seizures and hospitalization. During a review of the facility's P&P titled, Administering Medications, dated 7/2024, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must initial the resident's MAR after giving each medication and before administering the next ones.During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, Ordering and Receiving Medications from the Dispensing Pharmacy, dated 1/2022, the P&P indicated, If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered . and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand b. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in the directions of use.During a review of the facility's P&P titled, Seizure Precautions, dated 7/2019, the P&P indicated, Residents will be protected prior to and during seizure activity. 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555908 If continuation sheet Page 5 of 6 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 555908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Pasadena Care Center 904 Mission St South Pasadena, CA 91030 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 0760 Seizure precautions for residents who have a history of seizure activity include the following: Obtain orders for dosage change as needed based on laboratory values. 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: 555908 If continuation sheet Page 6 of 6