Health inspection·September 2, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 9/2/2025 at 11:44AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated RP 1 watches constantly in the tablet's camera, He was checking Resident 1's room even if the resident was not inside the room. RP 1 wants to open all the curtains to see the entire room. RP 1 randomly calls the facility and will ask the staff to turn on Resident 1's television, he checks it through the tablet's camera. During a concurrent interview and record review on 9/2/2025 at 3:09PM with the Director of Nursing (DON), Resident 1's Care Plans (CP) were reviewed. There was no CP for Resident 1's electronic device or tablet use in the room. DON stated that they should have a CP for the tablet use in the room to make sure the facility promoted dignity, privacy should be provided and ensure to respect residents' rights for Resident 1 and her roommates. During an interview on 9/2/2025 at 3:10PM with DON, DON stated RP 1 wanted to completely open all the curtains in the room and wanted to see the whole room. The other residents were upset because of that. RP 1 wanted to see Resident 1 in the camera, 24 hours a day/7 day a week. RP 1 was mad when the staff covered the camera and closed the curtain when providing care for his family member. It is an awkward situation when the camera was uncovered, and staff was providing care for Resident 1. The facility informed RP 1 that he was not respecting Residents 1' dignity and privacy. During a concurrent interview and record review on 9/2/2025 at 3:15PM with the DON, the facility's Policy and Procedure (P&P) titled, Resident Use of iPad and Tablet Devices in Rooms, dated 1/2025, was reviewed. The P&P indicated the staff must protect resident privacy; headphones encouraged for video calls. DON stated RP 1 never uses headphones during video calls. RP 1 can see the staff, but the staff were not able to see the screen. RP 1 calls to reposition Resident 1 correctly. Staff draw the curtain when Resident 1 is being changed, and RP 1 will get upset. It was awkward for all the staff. RP 1 was invading the privacy of Resident 1, and other residents. RP 1 calls the facility when the tablet was repositioned. RP 1 was looking at his phone all the time and called the facility right away. DON also stated having RP 1 remotely controls the camera does not respect Resident 1's dignity and privacy and also invading privacy for other residents. 2. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 2's diagnoses included but not limit to polyneuropathy (the most common form of a group of disorders known as peripheral neuropathy, is caused by damage to peripheral nerves [all nerves beyond the brain and spinal cord]), Morbid obesity (weight more than 100 pounds over your ideal body weight and experiencing severe health effects) and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has intact cognitive skills for daily decision making. The MDS indicated Resident 2 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) in toileting hygiene, lower body dressing, putting on/ taking off footwear, sit to stand, chair/ bed-to-chair transfer, During an interview on 9/2/2025 at 10:05 AM with Resident 2, Resident 2 stated she was aware about the tablet/camera in their room. Resident 2 was concerned because she did not agree on RP 1's room surveillance. RP 1 wanted to watch Resident 1 in the facility. RP 1 was allowed to put his own surveillance camera in their room. Resident 2 saw Resident 3 on the tablet monitor before. RP 1 stares on Resident 1's bed and when Resident 2 needs to use the restroom RP 1 can see her on the camera, and Resident 2 loses her privacy. Resident 2 stated, RP 1 wanted to see our entire room, if he could not find Resident 1 on her bed. RP 1 wanted to watch Resident 1 all the time. Where is her privacy on that. I did not agree with having a camera inside my room. It felt like somebody was watching me. During an interview on 9/2/2025 at 11:44 AM with LVN 1, LVN 1 stated the CNAs were complaining that they can see their faces on Resident 1's tablet. CNAs were also complaining about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555908 If continuation sheet Page 2 of 5 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 09/02/2025 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the privacy for all the residents (Resident 1, 2, and 3) in the room. Resident 2 argued with RP 1 because of Resident 1's camera on her tablet which was installed in their room. Resident 2 stated she was not feeling comfortable going to the restroom because of Resident 1's camera on the tablet. During an interview on 9/2/2025 at 3:20PM with DON, DON stated Resident 2 stated she does not want to be recorded. She was okay with the cameras outside her room, but not inside her room. The camera placed inside Resident 2's room felt that it was invading her privacy. 3. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] Resident 3's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and dementia During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 needed substantial/ maximal assistance in toileting hygiene, lower body dressing, putting on/ taking off footwear, sit to stand, chair/ bed-to-chair transfer, and tub/shower transfer. During an interview on 9/2/2025 at 10:57 AM with Resident 3, Resident 3 stated she does not want to have anything to do with them (RP 1 and Resident 1), Resident 3 does not want to deal with them, she just kept quiet. RP 1 was not good. RP 1 talked a lot. Resident 3 cannot sleep in the room because the light was turned on 24 hours and there was too much talking from RP 1 to Resident 1. Resident 3 had a headache because she was tired and could not sleep well in their room because the light was turned on all the time. During an interview on 9/2/2025 at 11:25 AM with CNA 1, CNA 1 stated she saw Resident 3 on the monitor. CNA 1 would always see the residents (Resident 1, 2, and 3) on the monitor when Resident 1's tablet was turned on. RP 1 would always turn it on. The whole room was on the camera. CNA 1 would see herself in the camera. CNA 1 stated it makes them feel weird, the feeling of being watched all the time. Residents felt weird and invaded their privacy. RP 1 controls the tablet remotely and kept turning on the tablet from his house. During an interview on 9/2/2025 at 12:25 PM with LVN 2, LVN 2 stated It was not okay to have a camera inside the residents' room, because of privacy issues for residents/ roommates. During a record review of facility's Policy and Procedure (P&P) titled, Resident Dignity and Personal Privacy, dated 4/2023, the P&P indicated the facility provides care for residents in a manner that respects and enhances each Resident's dignity, individuality, and right to personal privacy.2. Examine and treat residents in a manner that maintains their privacy.a. use a closed door, a drawn curtain or both to shield the resident during all personal care and treatment procedures4. Maintain Resident's privacy during toileting, bathing, and other activities of personal hygiene. During a record review of facility's P&P titled, Resident Use of iPad and Tablet Devices in Rooms , dated 1/2025, the P&P indicated the facility supports the safe and appropriate use of personal or facility-issued iPads/tablets by residents for communication, education, recreation, and telehealth purposes, while ensuring resident privacy, infection-control standards, and protection of facility equipment and networks.4. Wi-Fi access is for communication/recreation; no unauthorized photos/videos. Event ID: Facility ID: 555908 If continuation sheet Page 3 of 5 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 09/02/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (1) of three (3) residents (Residents 3) received treatment and care as indicated on the facility's Policy and Procedure (P&P) titled, Changes in Resident Condition when, 1. Licensed Vocational Nurse 2 (LVN 2) did not inform physician immediately and assessed Resident 3's complaint for generalized itching on 9/2/2025.2. Licensed Staff has no documented evidence that Resident 3 was assessed for Skin Evaluation and formulated a Care Plan (CP) specific for generalized itching from 6/6/2025-9/2/2025. These deficient practices had the potential to result in delays in the necessary care and treatment of Resident 3 which could affect the residents' overall wellbeing.Findings:During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] Resident 3's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks) During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated 8/20/2025, the MDS indicated Resident 3 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, lower body dressing, putting on/ taking off footwear, sit to stand, chair/ bed-to-chair transfer, and tub/shower transfer. During a record review of Resident 3's SBAR (situation, background, assessment, recommendation -a communication tool used by healthcare workers when there is a change of condition among the residents) indicated,1. On 6/5/2025, Resident 3 had lower body generalized rash. During rounds CNA reported that Resident 3 complained of itching of the lower body, lower back, glutes, thighs and legs. Resident 3's skin was red, flaky, with scratches from resident itching affected areas. Resident 3 stated she was very itchy and had been scratching her body.2. On 8/23/2025, Resident 3 had itchiness on the frontal torso. The licensed staff observed Resident 3 scratching her abdomen. Resident 3 had patchy redness on the frontal torso and scalp. During a concurrent observation and interview on 9/2/2025 at 10:52 AM with Resident 3, Resident 3 stated her whole body was itchy during the night. There were scratch marks observed on Resident 1's left chest. Resident 3 also stated she has scratch marks on her bilateral thighs and lower legs. Resident 3 told Licensed Vocational Nurse 2 (LVN 2) this morning, but nothing was done. The staff did not give her any medications or treatment. LVN 2 did not come back to her room. Resident 3 also stated her legs were itchy at night and all day. Resident stated, I feel so itchy, I feel bad, because nobody looked at my body to check. I did not know what to do. LVN 2 did not do anything, I told the nurse to put cream, he said he does not know what to put. I am tired and could not sleep well. During an interview on 9/2/2025 at 11:13 AM with the Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she did provide ADLs (Activities of Daily Living, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) to Resident 3 this morning. CNA 1 stated Resident 3 has scratch marks all over her body and reminded Resident 3 not to scratch herself, but the resident kept scratching her thighs. CNA 1 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 5 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 09/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated she changed Resident 3's briefs and put lotion on her arms, legs and back. CNA 1 stated the staff knew that Resident 3 had been itching and scratching herself. During an interview and record review on 9/2/2025 at 12:01 PM with LVN 1, Resident 3's current order summary was reviewed. LVN 1 stated Resident 3 has been itching occasionally. Resident 3 has no medications for itching. If there was no medication for itching. Resident 3 will continue to scratch her skin, and it can get worse. During a concurrent interview and record review on 9/2/2025 at 12:19 PM with LVN 2, Resident 3's current order summary was reviewed. There was no medication or treatment for Resident 3's generalized itching. LVN 2 stated Resident 3 has been itching for 2 weeks now since 8/23/2025. The staff should have follow-up with the physician. The staff should have called the physician for a follow up treatment for Resident 3's skin issue. LVN 1 also stated Resident 3 has no medication for itching. Resident 3 will still experience itching and possibly have a skin breakdown. During an interview on 9/2/2025 at 12:30 PM with LVN 2, LVN 2 stated He did not immediately inform the physician about Resident 3's generalized itching complaint. LVN 2 stated Resident 3 complained of her whole body itching before 10AM and still have not called Resident 3's physician. LVN 2 stated he must do the SBAR Form before calling the physician. During a concurrent interview and record review on 9/2/2025 at 3:28PM with the Director of Nursing (DON), Resident 3's current order summary was reviewed. No medication was ordered for Resident 3's itching. DON stated the stated the staff should have called the physician as soon as we identify the problem. The sooner the staff notified the physician the better, to prevent delays treatment for Resident 3's itching. Resident 3 will continue scratching her skin and might have skin breakdown. During a concurrent interview and record review on 9/2/2025 at 3:37PM with the DON, Resident 3's CPs were reviewed. There was no CP for Resident 3's generalized itching. DON stated that there was no CP for Resident 3's itching. The staff should have formulated a CP to provide treatment and evaluate if treatment was effective. If it is not effective, the staff can approach in a different way to solve the problem. If there was no CP, there were no interventions and no way to see if the treatment was effective or not. During a record review of facility's Policy and Procedure (P&P) titled, Changes in Resident Condition, dated 1/2024, the P&P indicated,1. The resident, attending physician and legal representative or designated family member are notified when there is:b. a significant change in the residents' physical, mental or psychosocial status.4. Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Event ID: Facility ID: 555908 If continuation sheet Page 5 of 5