Pasadena Care Center, Llc

F-F755 Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). There were seven (7) medication errors out of 25 total opportunities for error, to yield an overall medication error rate of 28 % for one (1) of seven (7) residents observed for medication administration (Residents 50). The medication errors were as follows:

1. During a Medication Pass observation, Licensed Vocational Nurse 1 (LVN 1) failed to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024.

2. During a Medication Pass observation, LVN 1 failed to administer the following 9 AM due medications on 6/14/2024:

a. Cozaar (medication to lower blood pressure) oral tablet 50 mg

b. Lasix (medication to treat fluid retention and swelling) oral tablet 20 mg

c. Norvasc (medication to lower blood pressure) oral tablet 5 mg

d. Docusate Sodium (stool softener) oral Capsule 100 mg

e. Levetiracetam (medication to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 750 mg

f. Lidocaine Patch 4 percent (medication, a patch to relieve pain)

These deficient practices had the potential to result in Resident 50 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents health and well-being to be negatively impacted.

Findings:

A review of Resident 50's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnosis including angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system), hypertension (high blood pressure), and seizures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0759 A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/27/2024, indicated Resident 50 had intact cognitive skills (mental action or process of acquiring knowledge Level of Harm - Minimal harm or and understanding) in decision making. The MDS indicated Resident 50 required partial/moderate potential for actual harm assistance (Helper does less than half the effort) from staff with eating. It also indicated Resident 50 was dependent from staff with oral hygiene, toileting, shower, upper and lower body dressing, putting on/taking Residents Affected - Some off footwear and personal hygiene.

During a concurrent observation of medication administration and interview with LVN 1 on 6/14/2024 at 8:56 AM, LVN 1 was observed preparing the following medications for Resident 50:

1. Dexamethasone 2 mg tablet

2. Eliquis 5 mg tablet (prevents blood clots)

3. Senna 8.6 mg tablet, two tablets (for constipation)

4. Magnesium Citrate (used to treat constipation) 200 mg, half a tablet

5. Gabapentin (used to treat nerve pain) 300 mg capsule, one capsule

LVN 1 stated there were five total morning medications to administer for Resident 50.

During an observation on 6/14/2024 at 9:18 AM, in Resident 50's room, Resident 50 was observed taking the five medications by mouth with yogurt and fluids.

During a concurrent record review of Resident 50's Order Summary Report (a summary of all currently active physician orders) and interview on 6/14/2024 at 10:55 AM, LVN 1 stated he failed to administer the following:

1. Cozaar oral tablet 50 mg, give 1 tablet by mouth one time a day for hypertension. Hold if systolic blood pressure (SBP, the top number in a blood pressure reading) is less than120. With order date of 6/6/2024.

2. Lasix oral tablet 20 mg, give 1 tablet by mouth one time a day for edema. Hold if SBP is less than 110. With order date of 6/7/2024.

3. Norvasc oral tablet 5 mg, give 1 tablet by mouth one time a day for hypertension. Hold if SBP is less than 110. With order date of 6/6/2024.

4. Docusate Sodium oral capsule 100 mg. Give 1 capsule by mouth two times a day for bowel management, hold for loose stool. With order date of 6/7/2024.

5. Levetiracetam oral tablet 750 mg. Give 2 tablet by mouth two times a day for Seizures. With order date of 6/6/2024.

6. Lidocaine patch 4 percent for pain. Apply to right hip topically (used on the outside of the body) every 12 hours. With order date of 6/7/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0759 LVN 1 stated, If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition. LVN 1 Level of Harm - Minimal harm or confirmed that the order of dexamethasone oral tablet 2 mg, to give 1 tablet by mouth every eight (8) hours potential for actual harm related to malignant neoplasm (abnormal cells grow, multiply and spread to other parts of your body) of brain, with order date of 6/6/2024, was given at 9:18 AM and per physician's order, it should be given at 2 Residents Affected - Some PM. Medication Administration Record indicated the 6 AM dose was given.

During an interview with Registered Nurse 1 (RN 1) on 6/14/2024 at 2:30 PM, RN 1 confirmed LVN 1 did not administer all of Resident 50's medication. RN 1 stated LVN 1 administered Resident 50's dexamethasone at

a wrong time. RN 1 added that dexamethasone administration time was scheduled at 6 AM, 2 PM and 10 PM. RN 1 stated that missed blood pressure medications might lead to uncontrolled high blood pressure. RN 1 stated that a resident who was not given Levetiracetam might have a seizure. RN 1 stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent complications of inconsistent timing of medication administration.

A review of the facility`s Policy and Procedure (P&P) titled, Policy and Procedure in Medication Administration, revised in 7/2013, indicated all medications will be administered following the scheduled medication administration for routine medication unless otherwise specified by the Doctor which is different from the routine medication administration schedule.

A review of the facility`s P&P titled, Administering Medications, revised in 4/24/2024, indicated a policy that medications are administered in a safe and timely manner, and as prescribed. It also indicated that medications are administered in accordance with prescriber orders, including any required time frame.

A review of the facility's undated Policy and Procedure titled, Job Description and Performance Standards, it indicated primary functions and responsibilities of charge nurse is to administer and document direct resident care, medications and treatments per physician's order and accurately record all care provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 Residents Affected - Some Based on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to:

1. Remove a box of expired eye gel from medication storage room [ROOM NUMBER] (MSR 1).

2. Remove a box of expired eye drops from MSR 1

This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization .

3. Store four (4) unopened Basaglar Kwik Pen (a medication used to control high blood sugar) in the refrigerator.

4. Store 4 unopened Trulicity (a medication used to lower blood sugar) in the refrigerator.

This deficient practice caused the residents to be exposed to adverse side effects of using expired eye gel and eye drops such as signs of an allergic reaction, like rash, itching, severe dizziness, trouble breathing and blindness if it was used.

5. Defrost (become free of accumulated ice) Refrigerator 1.

This deficient practice had the potential to affect the temperature quality of Refrigerator 1 which might affect

the efficacy of the refrigerated medications for the residents.

Findings:

During a concurrent observation in the MSR 1 and interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE REDACTED] at 12 PM, LVN 1 verified that an opened box of Refresh (brand of an eye lubricant, used for temporary relief of burning, irritation, and discomfort) lubricating eye gel with 20 single use containers were expired in February 2024. LVN 1 also verified that another box of unopened eye drops was also expired, with expiration date of [DATE REDACTED]. LVN 1 stated the eyedrops should have been removed from MSR 1 when they expired. LVN 1 stated that storing expired supplies increase the risk to be mistakenly used and can cause possible harm to the residents.

During a concurrent observation of Medication Cart 2 (MC 2) and interview with LVN 2 on [DATE REDACTED] at 12:24 PM in Nursing Station 2 (NS 1), 4 unopened Basaglar Kwik Pen and 4 unopened Trulicity were found in the plastic bag on the bottom drawer of MC 2 at room temperature. LVN 2 stated 4 unopened Basaglar Kwik Pen and 4 unopened Trulicity should have been stored in the refrigerator. LVN 2 stated according to the product labeling, unopened), 4 unopened Basaglar Kwik Pen and 4 unopened Trulicity should be stored in the refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0761 During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 1 PM, the DON stated that using expired eye gel, eye drops, and supplies might not be beneficial and could cause harm to the residents. The Level of Harm - Minimal harm or DON stated the 4 unopened Basaglar Kwik Pen and 4 unopened Trulicity were considered expired and were potential for actual harm not safe to administer to the residents since they were not stored in the refrigerator and the DON cannot determine when they were stored at room temperature. The DON stated insulin that was not stored properly Residents Affected - Some could be ineffective at controlling the resident's blood sugar which could cause medical complication to the residents leading to harm and hospitalization . The DON stated that medication refrigerators should be defrosted and cleaned weekly. The DON stated, I don't know when the refrigerator was cleaned and defrosted by licensed nurses since there was no log.

During a concurrent observation of Refrigerator 1 and interview with Registered Nurse 2 (RN 2) on [DATE REDACTED] at 12:13 PM, RN 2 stated that half of the freezer space was accumulated with built up ice. RN 2 stated the refrigerator should have been defrosted because it can impact the temperature quality of refrigerator. RN 2 stated, It might damage and cause problem with preservation of efficacy of the stored refrigerated medication for the residents. RN 2 was unable to provide documented evidence when was the last time Refrigerator 1 was defrosted.

A review of facility's Policy and Procedure (P&P) titled, Labeling and Storing Medications, revised in [DATE REDACTED], indicated the resident's medication will be properly labeled and stored in the locked medication room/carts. It also indicated medications requiring refrigeration will be stored in the refrigerator at the appropriate temperature. Weekly defrosting and cleaning of the refrigerator to be done by 11 PM to 7 AM shift every Friday. Drugs required to be stored at room temperature shall be stored at a temperature between 15 degrees Celsius (C, unit of measurement), 59 degrees Fahrenheit (F, unit of measurement) and 30 degrees C, 86 degrees F. Drugs requiring refrigeration shall be stored in a refrigerator between 2 degrees C and 36 degrees F and 8 degrees C and 46 degrees F. And Medications no longer in use or medications which have expired will be disposed of in accordance with Federal and State Laws.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled resident Residents Affected - Few (Resident 22) who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence) utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order.

This deficient practice placed Resident 22 at risk for further decline in physical functioning and decline to perform self-feeding skills.

Findings:

A review of Resident 22's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including but not limited to aphasia (loss of ability to understand or express speech, caused by brain damage) following cerebral infarction (stroke, a loss of blood flow to part of the brain), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting right dominant side.

A review of Resident 22's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 5/1/2024, indicated Resident 22's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated Resident 22 required partial/moderate assistance (helper does less than half the effort) with eating. It also indicated Resident 22 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting, upper body dressing, and personal hygiene. Resident 22 was dependent to staff with shower, lower body dressing and putting on/taking off footwear.

A review of the Resident 22's Order Summary Report, dated 6/14/2024, indicated the following Physician's Order for kitchen to provide:

Plastisol coated big grips spoon for resident to perform self-feeding task, ordered on 2/14/2024.

Divided section plate for resident to perform self-feeding task.

A review of Resident 22's Care Plan titled, At risk for further decline in activities of daily living (ADLs), revised

on 1/17/2024, indicated staff intervention to encourage to continue participating in performing ADLs within his capability including but not limited to washing face, combing hair, feeding self. raising arm during care, dressing, and bathing.

During a lunch observation in the dining room on 6/11/2024 at 12:35 PM, Resident 22 was eating lunch with his left hand, without using the utensils that were on the resident's tray. Resident 22's meal tray was observed to have a plate guard and weighted utensils (spoon, fork, and knife).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0810 During a lunch observation in the dining room on 6/12/2024 at 12:34 PM, Resident 22 was eating lunch without using the weighted spoon. that was on the resident's tray. Resident 22's meal tray was observed to Level of Harm - Minimal harm or have a plate guard and weighted utensils (spoon, fork, and knife) which were placed on the right side of the potential for actual harm resident's plate.

Residents Affected - Few During a concurrent observation in the dining room and interview with Director of Rehabilitation (DOR) on 6/13/2024 at 12:40 PM, Resident 22's meal tray was observed to have a plate guard and weighted utensils (spoon, fork, and knife). Resident 22 was eating a bowl of dessert using his left hand and not the weighted utensil that was provided. DOR stated that Resident 22 has right side weakness, and only able to move with his left hand. DOR verified that Resident 22 was eating with his hand, and the weighted utensils were set up

on the right side of the plate. DOR stated that utensils should have been placed where Resident 22 could easily reach them, which was on his left side. DOR stated Resident 22 should be checked periodically during meals to make sure that he was eating properly and using the spoon and plate guard.

During an interview on 6/14/2024 at 11:25 AM, Treatment Nurse (TN) stated that Resident 22 was able to feed himself using his left hand only because he has right sided weakness. TN stated Resident 22 should be reminded and redirected during mealtimes to use the weighted utensils and utilize the plate guard.

During an interview on 6/14/2024 at 1:57 PM, Registered Nurse 1 (RN 1) stated Resident 22 requires assistance with feeding, wherein staff should set up the plate, drinks, utensils. RN 2 stated the staff should provide instructions and ensure for the resident to use the weighted spoon while eating. RN 1 also stated staff should remind the resident to use the spoon if he goes back on using his hand. RN 1 stated assistive devices are to aid residents with eating and utensils should be placed on the resident's strongest side. RN 1 stated this will ensure resident will have an easier access to the assistive devices, be able to properly eat, promote independence, and prevent weight loss.

During a concurrent record review of Resident 22's medical records and interview with DOR on 6/14/2024 at 3:20 PM, DOR stated Resident 22 did not and should have a care plan on the use of assistive devices/ weighted utensils and plate guard.

A review of facility's Policy and Procedure titled, Assistive Eating Devices, revised on 12/2014, indicated assistive eating devices will be provided for those residents for whom it would be beneficial.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44636

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow proper food handling practices

in accordance with its policy and procedure by failing to:

a. Label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) or open date.

b. Discard expired food in the kitchen.

c. Store dishes in the kitchen in a sanitary manner.

d. Ensure water filter line had an air gap and did not touch the drain on the floor.

e. Ensure plunger was stored in accordance with professional standards.

These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization .

Findings:

During a concurrent observation in the kitchen and interview with the Dietary Supervisor (DS) on [DATE REDACTED] at 8:36 AM, the following were observed:

a. resident's personal container with a used napkin on top of the Beef Base seasoning

b. opened and undated [NAME] spray.

DS stated the resident's dishes were not supposed to be on the shelf with the food seasoning. The DS stated

the [NAME] spray was opened but was not and should have been labeled with the open or use by date. The DS stated when an item is opened, staff were supposed to date it with open and use by date.

During a concurrent observation in the dry storage of the kitchen and interview on [DATE REDACTED] at 8:40 AM with

the DS, an opened pack of bread was observed on the shelf. The DS stated the bread was not and should have been dated with open and used by date.

During a concurrent observation in the kitchen and interview on [DATE REDACTED] at 8:46 AM with the DS, the following were observed:

a. a bowl on the floor under the dish washing machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0812 b. water line filter touched the drain on the floor and went inside the floor drain (plumbing fixture installed in

the floor designed to direct water to a sewer or municipal storm drain so floor stays dry, and rooms do not Level of Harm - Minimal harm or flood). potential for actual harm c. bathroom plunger under the receiving station next to the dish washing machine. Residents Affected - Some

The DS stated dishes should not be kept on the floor since it was unsanitary. The DS stated the water line filter should not touch or go inside the drain on the kitchen floor. The DS she was unaware there was a plunger in the kitchen and stated the plunger was not supposed to be inside the kitchen.

During a concurrent observation in the kitchen's refrigerator and interview on [DATE REDACTED] at 8:55 AM with the DS, turkey was placed inside a clear container with use by date [DATE REDACTED]. The DS stated the turkey was expired and should have been discarded.

During an interview on [DATE REDACTED] at 9:01 AM with the DS, the DS stated the resident's personal container containing a used napkin was not supposed to be stored with clean kitchen seasoning supplies. The DS stated improper storage could result in cross contamination (the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods) and infection especially since the resident's container had a used napkin inside. The DS stated food items were supposed to be discarded after use by date to avoid serving to residents which could result in food poisoning. The DS stated used dishes should be placed in the dirty sink area and not placed on the floor to avoid contamination. The DS stated the water filter line that entered and touched the drain could be contaminated and could also result

in backflow (dirty water flowing back into a clean water supply line) into the water system. The DS also stated

the plunger could also cause cross contamination. The DS stated she did not know if the plunger was used prior. The DS stated plungers were usually used in the bathroom to unclog the toilet.

A review of the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Foods, dated 2020, indicated newly opened food items will need to be closed and labeled with an open date and used by date.

A review of the facility's P&P titled, Storage of Food and Supplies, dated 2020, indicated food and supplies will be stored properly and in a safe manner. The policy indicated items and other cleaning supplies should be store in entirely separate and specific areas. The policy also indicated no food will be kept longer than the expiration date on the product.

A review of the facility's P&P titled, Refrigerators and Freezers, revised ,d+[DATE REDACTED], indicated use by dated will be completed with expiration dates on all prepared food in refrigerators. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.

A review of the facility's P&P titled, Accident Prevention - Safety Precautions, revised ,d+[DATE REDACTED], indicated if

a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. An air gap between the water supply inlet (drainpipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44636 potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy to monitor the Residents Affected - Some refrigerator and freezer's temperature containing residents' food brought from home to ensure that it was within acceptable temperatures for four of five sampled residents (Residents 18, 31, 47, and 50).

This deficient practice had the potential to result in food-borne illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever, other serious medical complications, and hospitalization .

Findings:

A review of Resident 18's Admission Record indicated Resident 18 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses of malignant (cancerous) neoplasm (abnormal growth of cells in the body) of unspecified site of right female breast.

A review of Resident 31's Admission Record indicated Resident 31 was initially admitted to the facility on [DATE REDACTED], with diagnosis of Type 2 Diabetes Mellitus (a disease that occurs when there is a problem in the way

the body regulates and uses sugar as fuel) with hyperglycemia (high blood sugar).

A review of Resident 47's Admission Record indicated Resident 47 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses of urinary tract infection (UTI, an infection of the bladder and urinary system) and Type 2 Diabetes Mellitus with hyperglycemia.

A review of Resident 51's Admission Record indicated Resident 51 was initially admitted to the facility on [DATE REDACTED], with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area) affecting the left non-dominant side.

During on observation on 6/11/2024 at 11:59 AM of the facility's residents' refrigerator, a log titled, Break Room dated 6/2024 was posted in front of the refrigerator door. The sign indicated the refrigerator's temperature should be at of 35 degrees ( ) Fahrenheit (F) to 40 for refrigerators and 0 F or less for freezers.

The log included the date, recorded by, time, temperature for the refrigerator and freezer, and comments section to be completed by staff. The staff's first name or initials were entered in the log for 7 AM from 6/1/2024 to 6/11/2024, but the section for temperature of the refrigerator and freezer, and comments sections were left blank.

During the same observation on 6/11/2024 at 11:59 AM of the facility's residents' refrigerator and freezer, an undated signage titled, Refrigerator Temperature Guide, indicated as follows:

-Above 40 : Any temperature above 40 F may allow bacteria to multiply rapidly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0813 -At 40 : The U.S. Food and Drug Administration (FDA, responsible for protecting the public health by ensuring the safety of the nation's food supply and assumes primary responsibility for preventing foodborne Level of Harm - Minimal harm or illness) indicated the recommended refrigerator temperature is below 40 F. potential for actual harm -Between 35 and 38 : The ideal refrigerator temperature is between 35 F, below the safety threshold outlined Residents Affected - Some by the FDA and above freezing. It's not uncommon for refrigerators to be a few degrees off the mark you set, so err on the side of too cold to avoid food spoiling more quickly or potential food safety issues.

-At 32 : At 32 F and below, the food in your refrigerator will start to freeze. Keep your refrigerator temperature above 32 F to avoid this, and if you want anything frozen, put it in the freezer, which should be kept below 0 F.

During a concurrent observation and interview on 6/13/2024 at 2:39 PM with the Dietary Supervisor (DS), the DS stated the housekeepers were in charge of checking the residents' food items in the residents' refrigerator. The DS stated the housekeeper did not record any temperatures for the refrigerator or freezer from 6/1/2024 to 6/11/2024. The DS stated the monitoring of temperatures ensured the residents' foods were stored at a safe temperature. The DS stated the residents' refrigerator and freezer contained resident food items brought by residents' families and visitors. The DS stated the current refrigerator temperature was at 50 F. The DS stated the residents' refrigerator temperature was in the danger zone since the temperature was above 40 F. The DS stated it was unsafe for the residents to consume food stored at 50 F. The DS stated food kept at a temperature of 50 F could cause food poisoning to the residents.

A review of the facility's Policy and Procedure titled, Refrigerators and Freezers, revised 4/2024, indicated monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily. Acceptable temperatures should be 35 F to 41 F for refrigerators.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 48152 potential for actual harm Based on interview and record review, facility failed to ensure the arbitration agreement (a contract in which Residents Affected - Some the right to bring certain claims to court for resolution is given up) included for the selection of a venue that is convenient (a location in which to carry out arbitration proceedings which should be agreed upon and suitable to both parties (facility and residents) for two of three sampled residents (Resident 3 and 21).

This failure resulted in violation of Residents 3 and 21's right to be informed of all information related to an arbitration agreement.

Findings:

A review of an Arbitration Agreement signed by Resident 3 on 3/25/2019, failed to indicate information to address the selection of a venue convenient to both parties.

A review of an Arbitration Agreement signed by Resident 21 on 5/29/2024, failed to indicate information to address the selection of a venue convenient to both parties.

During a concurrent record review of the facility's Resident - Facility Arbitration Agreement and interview on 6/13/2024 at 11:48 AM with the Admissions Coordinator (AC), AC stated the agreement failed to indicate any mentions or providence of a convenient location for any arbitrations. The AC stated the agreement does not indicate the selection of a convenient venue to use for arbitrations. The AC stated her role was to present the arbitration agreement to residents (or family) and only present what was listed on the arbitration agreement when explaining it to the residents (or family). The AC stated she does not make mention of the selection of

a venue that is convenient to both parties. AC stated she does not know when residents would be made aware of the right to a convenient location to be used for arbitration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Some Based on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for three of three sampled residents (Residents 61, 52, and 64) in accordance with the facility's hospice policy and hospice agreement by failing to ensure:

1. Hospice staff visited Resident 61 per Hospice calendar.

2. and 3. Residents 52 and 64 had a hospice comprehensive assessment to include the frequency of hospice staff visits

This deficient practice had the potential for Resident's 61, 52, and 64 not to receive the hospice care and services necessary to promote comfort and quality of life.

Findings:

1. A review of Resident 61's Admission Record indicated Resident 61 was originally admitted to the facility

on [DATE REDACTED]. Resident 61's diagnoses included end stage heart failure (heart's inability to pump an adequate supply of blood), hypertension (chronic elevated blood pressure), and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness).

A review of Resident 61's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 5/16/2024, indicated Resident 61 was severely impaired with cognitive skills [ability to think, understand, and reason]) for daily decision making. The MDS indicated Resident 61 required partial assistance (helper does less than half the effort) with eating, upper body dressing and personal hygiene. It also indicated that Resident 61 required substantial assistance (helper does more than half the effort) with oral hygiene, lower body dressing and putting on/taking off footwear. Resident 61 was dependent to staff with toileting hygiene and shower.

A review of Resident 61's Order Summary Report, dated 6/14/02024, indicated Resident 61 was under hospice, ordered on 5/3/2024.

A review of Resident 61's Hospice Care Plan, initiated on 5/3/2024, indicated a goal that Resident 61's choice for desired level of care will be honored daily. Interventions were as follows:

Certified Home Health Aide (CHHA) visits twice a week, initiated on 5/3/2024 and revised on 5/6/2024.

Hospice Nurse visits twice a week, initiated on 5/3/2024 and revised on 5/6/2024.

Social Worker visit one to two times a month, initiated on 5/3/2024 and revised on 5/6/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 Pastoral counseling visit, frequency of visit was left blank, initiated on 5/3/2024.

Level of Harm - Minimal harm or A review of Resident 61's hospice binder indicated the following: potential for actual harm a. Hospice plan of care (POC, a written care plan established, maintained, reviewed and revised as Residents Affected - Some necessary, to intervals established by the Hospice Interdisciplinary Team [Hospice employees]) summary dated 5/10/2024, indicated hospice staff nurse frequency of visit of twice a week with a start date of 5/14/2024, hospice CHHA visit frequency of once a week after admission and twice a week on succeeding weeks for Activity of Daily Living (ADL's) and personal care with start date of 4/27/2024, hospice social worker frequency of once a month and as needed with start date of 4/27/2024.

b. Hospice calendar of visit starting 5/5/2024 to 6/7/2024 indicated that there should be five (5) hospice Registered Nurse (RN) visits, eight (8) hospice Licensed Vocational Nurse (LVN) visits, 10 hospice CHHA visits, and one (1) hospice staff visit for spiritual support, prayers, and counseling.

c. Patient Calendar for the month of May 2024 indicated 12 signatures from hospice staff.

d. Hospice flow sheet from 5/5/2024 to 6/6/2024 indicated 14 hospice staff visits.

During a concurrent record review of Resident 61's hospice binder and interview with Hospice LVN (HLVN)

on 6/14/2024 at 10 AM, HLVN stated that resident on hospice has their hospice binder, which contains all the Resident's hospice records. HLVN stated that having a hospice binder was important for the facility staff because it was where they check hospice nurses' visits and documentation. HLVN stated they communicate with the facility staff and would document resident visit under flow sheet. HLVN stated that hospice CHHA has no documentation of visits, nor a signature from hospice CHHA was documented in the patient calendar. HLVN added hospice CHHA visit should be documented for the facility to know which ADL's and hygiene was provided to Resident 61. HLVN stated that they are required to document in hospice flow sheet regarding their visit. HLVN added that all hospice staff including Doctor, Nurse Practitioner, RN, LVN, CHHA, Social worker, and Pastor should document in the hospice flow sheet and patient calendar.

During a concurrent record review of Resident 61's hospice binder and interview with Registered Nurse 1 (RN 1) on 6/14/2024 at 2:50 PM, RN 1 stated hospice calendar of visit starting 5/5/2024 to 6/7/2024 indicated that there should be 5 hospice RN visits, 8 hospice LVN visits, 10 hospice CHHA visits, and 1 hospice staff visit for spiritual support, prayers, and counseling. RN 1 stated that there should have been total of 24 hospice staff visits from 5/5/2024 to 6/7/2024. RN 1 confirmed that not all hospice staff that was indicated in the hospice calendar from 5/5/2024 to 6/7/2024 has a documentation in the hospice flow sheet and resident calendar. RN 1 stated that facility staff has no documentation in electronic nurse's notes whenever hospice staff visited in the past. RN 1 stated that hospice staff should communicate with the facility staff when they plan to visit or have visited a resident. RN1 stated that hospice flow sheet was important so facility would know what hospice staff did during their visit to Resident 61. RN 1 stated that hospice binder has the Hospice plan of care summary that indicated hospice staff nurse frequency of visit of twice a week, hospice CHHA visit frequency of once a week after admission and twice a week on succeeding weeks for ADL's and personal care, and hospice social worker frequency of once a month and as needed. RN 1 stated

the frequency of hospice staff visits was not reflected on the hospice flow sheet, and not the same to the hospice care plan on resident's facility chart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 A review of facility's Policy and Procedure (P&P) titled, Hospice, revised in 4/2024, indicated the facility shall maintain documentation in the patient's health record that will demonstrate the patient terminal status and Level of Harm - Minimal harm or the coordination of hospice service to the patient by the interdisciplinary team (IDT). The hospice staff is an potential for actual harm integral part of the facility's IDT. It also indicated the various Hospice staff shall wire progress notes and entries during each visit to the patient. Residents Affected - Some

A review of the Hospice Agreement dated 5/3/2024, duties and obligations of the facility indicated facility and Hospice shall prepare and maintain complete medical records for Hospice Clients receiving facility services

in accordance with this agreement and shall include all treatments, progress note, authorizations, Physician orders and other patient's information. Copies of all documents of services provided by Hospice at Hospice office, Facility and Hospice shall each have access to the Hospice Client's records maintained by the other party for verification of patient care and financial information pertinent to the Agreement. Access to Hospice Clients' records shall be provided during routine hours of business and each party shall give reasonable notice to the other of its intent to review such records. It also indicated duties and obligations of Hospice to maintain a complete and timely clinical record on each Hospice Client relating to all service rendered. Alt records of service and treatment are part of the Hospice record.

44636

2. A review of the Resident 52's Admission Record indicated Resident 52 was admitted to the facility on [DATE REDACTED], with diagnoses of schizoaffective disorder (a mental illness that causes loss of contact with reality) bipolar type (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), anxiety disorder (persistent and excessive worry that interferes with daily activities), and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area) affecting the left non-dominant side.

A review of the MDS, dated [DATE REDACTED], indicated Resident 52's cognitive patterns were intact. The MDS indicated Resident 52 had an impairment in the upper extremity (shoulder, elbow, wrist, hand) and an impairment in the lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 52 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene (combing hair, shaving, washing/drying face and hands), roll left and right, sit to lying, lying to sitting, chair/bed-to-chair transfer, and tub/shower transfer. The MDS also indicated Resident 52 received hospice care.

A review of Resident 52's Care Plan, initiated 5/24/2024, indicated Resident 52 was admitted under hospice level of care. The care plan interventions were CHHA visits, hospice nurse visits, and pastoral counseling visit.

A review of Resident 52's Physician Order Summary Report, dated 5/24/2024, indicated hospice level of care with terminal diagnosis (medical prognosis illness or condition is not curable and likely to result in death) of cerebral infarction due to unspecified occlusion of stenos of right mid cerebral artery (rare but potentially devastating cause of stroke).

A review of Resident 52's Hospice Plan of Care Summary Orders indicated as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 - 5/24/2024: Frequency of Visits: Certified Home Health Aide (CHHA) visit one time a week for the first week

after admission and two times a week on succeeding weeks for activities of daily living (ADLs) and personal Level of Harm - Minimal harm or care. potential for actual harm - 5/24/2024: Frequency of Visits: Registered Nurse (RN) Supervisory visit. Residents Affected - Some -5/24/2024: Frequency of Visits: Spiritual Counselor (SC) initial and one time a month and three as needed for spiritual support, prayers, and counseling.

- 5/25/2024: Frequency of Visits: Skilled Nurse (SN) visits two times a week plus three as needed for change

in condition and symptoms management.

A review of Resident 52's Hospice Resident Calendar and Flow Sheet, dated 5/24/2024 to 5/31/2024, indicated as follows:

- RN (unknown) visit on 5/24/2024, 5/25/2024, and 5/27/2024.

- SN (unknown) visit on 5/30/2024.

There were no CHHA and SC visits and SN visits conducted two times a week for May 2024.

A review of Resident 52's Hospice Resident Calendar and Flow Sheet, dated 6/1/2024 to 6/14/2024, indicated as follows:

- SN (unknown) visit on 6/3/2024, 6/6/2024, and 6/14/2024.

- RN (unknown) visit on 6/10/2024.

- SC (unknown) visit on 6/11/2024.

There were no CHHA visits for the month of June 2024. SN visits were not done two times a week, and there was only one RN visit.

There was no hospice calendar for staff frequency of visits for the months of May and June 2024.

3. A review of Resident 64's Admission Record indicated Resident 64 was admitted to the facility 5/7/2024, with diagnoses of malignant (cancerous) neoplasm (abnormal growth of cells in the body) of unspecified part of unspecified bronchus (one of the two tubes that carry air into the lungs from the trachea) or lung, pleural effusion (fluid buildup in the space between the lung and the chest wall), and atelectasis (collapse of a lung or part of a lung due to air loss in the air sacs).

A review of Resident 64's MDS, dated [DATE REDACTED], indicated Resident 64's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 64 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for sit to stand and chair/bed-to-chair transfer.

The MDS indicated Resident 64 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for toilet hygiene, shower/bathe self, roll left and right, sit to lying, and lying to sitting on side of bed. The MDS also indicated Resident 64 received hospice care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 A review of Resident 64's Care Plan, initiated 5/7/2024, indicated Resident 64 required comfort care/hospice care. The care plan interventions were Resident 64 was under the hospice care, CHHA visits as ordered, Level of Harm - Minimal harm or hospice nurse visits, and pastoral counseling visit. potential for actual harm

A review of Resident 64's Physician Order Summary Report, dated 5/8/2024, indicated admit hospice level of Residents Affected - Some care with terminal diagnosis of malignant neoplasm of unspecified bronchus or lung cancer.

A review of Resident 64's Hospice Plan of Care Summary Orders indicated as follows:

- 5/7/2024: Frequency of Visits: CHHA two times a week for the first week after admission and two times a week on succeeding weeks for ADLs and personal care.

- 5/7/2024: Frequency of Visits: RN Supervisory visit.

-5/7/2024: Frequency of Visits: SC initial and one time a month and three as needed for spiritual support, prayers, and counseling.

- 5/12/2024: Frequency of Visits: SN visits two times a week plus three as needed for change in condition and symptoms management.

A review of Resident 64's Hospice Resident Calendar and Flow Sheet, dated 5/7/2024 to 5/31/2024, indicated as follows:

- RN (unknown) visit on 5/7/2024, 5/9/2024, 5/12/2024, 5/16/2024, 5/23/2024, 5/27/2024, and 5/31/2024.

- SN (unknown) visit on 5/8/2024, 5/15/2024, and 5/30/2024.

There were no CHHA and SC visits and SN visits were not done two times a week for May 2024.

A review of Resident 64's Hospice Resident Calendar and Flow Sheet, dated 6/1/2024 to 6/14/2024, indicated as follows:

- RN (unknown) visit on 6/5/2024, 6/7/2024, and 6/10/2024.

- SN (unknown) visit on 6/3/2024, 6/4/2024, and 6/6/2024.

- SC (unknown) visit on 6/11/2024.

There were no CHHA visits and SN visits conducted two times a week for the month of June 2024.

There was no hospice calendar for staff frequency of visits for the months of May and June 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0849 During a concurrent review of Residents 52 and 64's Hospice Plan of Care Summary Orders an interview on 6/14/2024 at 9:06 AM with RN 2, RN 2 stated the order for Hospice RN did not specify the frequency of RN Level of Harm - Minimal harm or visits. RN 2 stated RN 2 was unaware of how often hospice RNs were supposed to visit Residents 52 and potential for actual harm 64. RN 2 stated RN 2 relied on the hospice calendar to coordinate Residents 52 and 64's care with hospice staff. RN 2 stated hospice usually provide a calendar indicating hospice staff visit frequency and days. RN 2 Residents Affected - Some stated based on the hospice calendar, RN 2 could follow up with hospice if hospice staff were scheduled and did not show up. RN 2 stated RN 2 did not know which hospice staff was scheduled to visit or when the specific hospice staff were supposed to visit Residents 52 and 64. RN 2 stated the importance of having a hospice calendar was to ensure a collaboration of care between hospice and the facility. RN 2 also stated

the absence of the hospice calendar could result in Residents 52 and 64's to not receive the care that was supposed to be provided from hospice.

During an interview on 6/14/2024 at 9:49 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the hospice RN was scheduled to visit every two weeks for stable residents but can come more often when the resident was unstable.

During an interview on 6/14/2024 at 3:17 PM with the Director of Nursing (DON), the DON stated the hospice binder was the communication between the hospice staff and facility staff. The DON stated the hospice staff's communication of care was documented in the binder. The DON stated the hospice staff should sign

in legibly so the licensed nurses could see who came to visit the hospice resident. The DON stated a hospice calendar should be included in the hospice binder to ensure continuity of care. The DON stated the hospice calendar would show when the CHHA, SN, and RN were scheduled to visit. The DON stated without a hospice calendar, the facility was unaware of the hospice staff schedule. The DON stated if the hospice staff did not visit per schedule and the facility staff were unaware of the hospice schedule and did not follow up

this would result in neglect of the hospice residents.

A review of the facility's Policy and Procedure titled, Hospice, revised 4/2024, indicated the Hospice Team shall be responsible for providing the following documentation in the patient's health record: the various Hospice staff shall wire progress notes and entries during each visit to the patient.

A review of the Hospice and Nursing Facility Services Letter of Agreement, updated 3/24/2023, the agreement indicated Hospice shall assess the individual's need for care and services upon admission and on

an ongoing basis. Hospice shall be responsible for the professional management and coordination of the plan of care. Hospice shall collaborate with facility on a coordinated plan of care developed jointly between hospice and facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 48152 potential for actual harm Based on interview and record review, facility failed to conduct a monthly Quality Assessment and Residents Affected - Few Assurance (QAA, process to evaluate activities under the Quality Assurance and Performance Improvement [QAPI, process used to ensure services are meeting quality standards and assuring care reaches a certain level) program, such as identifying issues with respect to which QAA activities, including PI projects required under the QAPI program, are necessary) meeting as indicated in the facility policy and procedure (P&P).

This failure had the potential to result in inadequate, incomplete provision of care and services provided to residents throughout the facility, decreasing their quality of life.

Findings:

During an interview on 6/14/2024 at 5:47 PM with Infection Preventionist Nurse (IPN), IPN stated every department in the facility makes a report to identify what needs to be improved and the QAPI meetings are for all departments to come together to present what areas need to be improved and to discuss solutions that can be implemented after the meeting. IPN stated QAPI has not had consistent monthly meetings but should. IPN stated QAPI improves the care of the residents, which means better quality care with the possibility of better and faster solutions to concerns and residents can be negatively affected by having a slower outcome to solutions.

During a concurrent record review and interview on 6/14/2024 at 5:57 PM with the Director of Nursing (DON), the facility's QAPI binder was reviewed. The binder did not have any QAPI meeting conducted for the months of 10/2023, 11/2023, 12/2023, 1/2024, 2/2024, 3/2024, and 5/2024. The DON stated, the most recent QAPI meetings held were on 4/25/2024 and 9/28/2023. The DON stated the purpose of QAPI is to ensure residents receive quality healing care and their needs are being attended to. The DON also stated residents benefit from QAPI meetings because staff can evaluate if the approaches (to resident's care) are effective, and if QAPI meetings are not being done per policy, the residents [health, condition] will decline.

A review of the facility P&P titled QAPI, revised 4/24/2024, indicated the facility is to maintain an ongoing, facility- wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents and meetings are to be monthly to review reports, evaluate data and monitor QAPI related activities and make adjustments to the plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46919 potential for actual harm Based on observation, interview and record review, the facility failed to implement appropriate infection Residents Affected - Some control practices for one of two sampled residents (Resident 62) as indicated on the facility's policy and procedure (P&P) by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident of other objects the resident has handled) room with Clostridium difficile (C. diff- a bacteria that causes diarrhea),

This deficient practice placed the residents, staff, and visitors at higher risk for cross-contamination, and increased spread of C. diff infection in the facility and the community.

Findings:

A review of resident 62's Admission Record indicated Resident 62 was admitted to the facility on [DATE REDACTED] with diagnoses that included acute (severe and sudden onset) and chronic (long lasting) respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in the body), enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium difficile not specified as recurrent, and sepsis (infection in the blood).

A review of resident 62's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/2/2024, indicated Resident 62 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills with daily decision making and was dependent (helper does all of the effort) with eating, toileting hygiene, shower/bathe self, upper/lower body dressing, and personal hygiene.

A review of Resident 62's Order Summary Report, dated 6/14/2024, indicated a physician order, with a start date of 6/10/2024, for contact isolation secondary to C. Diff colitis (inflammation of the large intestines).

A review of Resident 62's Order Summary Report, dated 6/14/2024, indicated a physician order, with a start date of 6/10/2024 fir Vancomycin HCL ( a medication to treat infection) Oral Solution Reconstituted (diluted) 25 milligrams (mg- unit of measurement)/milliliters (ml- unit of measurement), give 10 ml via G-tube (a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) four times a day for C. Diff until 6/20/2024 at 11:59 PM.

A review of Resident 62's Care Plan, dated 6/10/2024, indicated Resident 62 was on contact isolation precautions related to C. Diff colitis. Resident 62's care plan intervention indicated to implement appropriate isolation techniques by staff, resident, visitors.

During a concurrent observation of Resident 62's room and interview with Licensed Vocational Nurse 2 (LVN 2), on 6/11/2024 at 11:37 AM, LVN 2 stated Resident 62 was on contact isolation for C. Diff. LVN 2 stated Resident 62 was currently taking antibiotic (a medicine that inhibits the growth of or destroys microorganisms) for C. Diff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0880 During an interview with Housekeeping 1 (HKP 1), on 6/13/2024, at 3:17 PM, HKP 1 stated she cleaned Resident 62's room last today because it was an isolation room. HKP 1 stated she used Cleaning Solution 1 Level of Harm - Minimal harm or (CS 1) to clean Resident 62's floor. HKP 1 stated she also used CS 1 to clean the floors in the facility. HKP 1 potential for actual harm stated she did not know if CS 1 contained bleach.

Residents Affected - Some During an interview with HKP 2, on 6/14/2024, at 9:03 AM, HKP 2 stated Resident 62 was on contact isolation but did not know what type of infection Resident 62 was isolated for. HKP 2 stated she used CS 2 to clean the floor in Resident 62's room. HKP 2 stated Resident 62's room was supposed to be cleaned with bleach (a chemical used to sterilize or disinfect). HKP 2 stated she did not know if CS 2 had bleach. HKP 2 stated the infection can be on the floor and if it is not cleaned with the proper cleaning solution the infection can be spread to other areas in the facility.

During an interview with the Infection Preventionist Nurse (IPN), on 6/14/2024, at 10:37 AM, the IPN stated Resident 62 currently had active C. diff. The IPN stated a room isolated for C. diff should only be disinfected with bleach or cleaning solutions listed on the EPA's registered Antimicrobial Products Effective Against Clostridioides difficile (C. diff) Spores [List K] list. The IPN stated that according to the EPA, the cleaning solutions under List K are the only cleaning solutions than can effectively kill C. diff. The IPN stated it is important to use the proper cleaning solution in C. diff rooms to prevent the spread of C. diff to other residents.

During an interview with Registered Nurse 1 (RN 1), on 6/14/2024, at 3:41 PM, RN 1 stated Resident 62 was isolated because she had an active C. diff infection. RN 1 stated residents and facility staff can get exposed to C. diff if the room is not cleaned properly with a bleach solution. RN 1 stated residents who get infected with C. diff can get sick and possible transferred to the hospital.

During a concurrent interview and record review with the IPN, on 6/14/2024, at 5:18 PM, the IPN stated CS 1 and CS 2 were not included in the EPA's registered Antimicrobial Products Effective Against Clostridioides difficile (C. diff) Spores [List K] list.

During the same concurrent interview and record review with the IPN, on 6/14/2024, at 5:18 PM, the manufacturer's guideline for CS 1 and CS 2 were reviewed. The IPN stated CS 1 did not include bleach as

an active ingredient. The IPN stated the manufacturer's guideline for CS 1 did not indicate CS 1 was an effective cleaning solution for disinfecting C. diff. The IPN stated the manufacturer's guideline for CS 2 did not indicate CS 2 was an effective cleaning solution for disinfecting C. diff.

A review of the facility's P&P, titled, Clostridium Difficile, revised on 4/24/2024, indicated, Measures are taken to prevent the occurrence of Clostridium Difficile infections (CDI) among residents. Precautions are taken while caring for resident with C. Difficile to prevent transmission to other residents. The P&P indicated, Environmental cleaning in rooms of residents with CDI is done with a disinfecting agent recommended for C. difficile (example: household bleach and water solution or an EPA registered germicidal agent effective against C. difficile spores).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 44636

Residents Affected - Some Based on observation and interview, the facility staff failed to provide a safe environment in the kitchen by failing to:

1. Ensure the portable air conditioner unit was safely plugged into the wall outlet.

2. Ensure the wall outlet was free of tape covering the plug and outlet when the generator was plugged into

the wall outlet.

This deficient practice had the potential to result in a fire which placed residents, staff, and visitors at risk.

Findings:

During on observation on 6/11/2024 at 8:52 AM in the kitchen, there was a double gang box switch and outlet combo (device that combines a switch and an electrical outlet in the same enclosure box) between the kitchen sink and towel dispenser. The bottom of outlet combo had an extension cable plugged in. The extension cable had a bug zapper, a phone charger, a large black portable air conditioning unit Portacool plugged in (about the height of the sink). Approximately a foot below the double gang box switch and outlet combo was a wall outlet with two outlets. The wall outlet had multiple layers of blue tape covering the bottom outlet and generator plug. The generator's orange cable was observed coming out of the blue tape from the bottom outlet. There was a sign Please do not disconnect cable from wall outlet thank you to the right of the blue tape.

During a concurrent observation and interview on 6/11/2024 at 9:22 AM of the outlets in the kitchen with the Maintenance Supervisor (MS), MS stated the black portable air conditioner was not supposed to be connected to the extension cord. The MS stated the extension cord used did not have a safety switch and could catch on fire. The MS stated the portable air conditioner needed to be directly connected to the outlet and not connected to the extension cord. The MS also stated the plug connected to the outlet covered with blue tape could catch on fire and cause a fire in the kitchen. The MS stated the generator had an orange cable which was not supposed to be used for regular outlets, but only for hospital outlets. The MS stated the generator plugged inside the kitchen was located outside of the kitchen. The MS stated the generator was temporarily being used since the facility's generator was being in serviced. The MS stated the facility building could not operate without a generator.

A review of the facility's Policy and Procedure (P&P) titled, Accident Prevention - Safety Precautions, revised 4/2024, indicated do not use equipment with frayed or ungrounded cords and plugs.

A review of the facility's P&P titled, Maintenance Service, revised 4/2024, indicated the maintenance department was responsible for maintaining equipment in a safe manner at all times. Functions of maintenance personnel include maintaining the building free from hazards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 79 555213

F-F759

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 50) in accordance with the facility policy by:

1. Failing to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024.

2. Failing to administer the following 9 AM due medications on 6/14/2024:

a. Cozaar (medication to lower blood pressure) oral tablet 50 mg

b. Lasix (medication to treat fluid retention and swelling) oral tablet 20 mg

c. Norvasc (medication to lower blood pressure) oral tablet 5 mg

d. Docusate Sodium (stool softener) oral Capsule 100 mg

e. Levetiracetam (medication to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 750 mg

f. Lidocaine Patch 4 percent (medication, a patch to relieve pain)

These deficient practices had the potential for Resident 50 to experience tachycardia (a fast heartbeat of more than 100 times per minute), high blood pressure, constipation, seizures, and pain, and decline in overall health status.

Findings:

A review of Resident 50's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnosis including angioneurotic edema (unpredictable frequent edematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system), hypertension (high blood pressure), and seizures.

A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/27/2024, indicated Resident 50 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS indicated Resident 50 required partial/moderate assistance (Helper does less than half the effort) from staff with eating. It also indicated that Resident 50 was dependent from staff with oral hygiene, toileting, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 During a concurrent observation of medication administration and interview with the Licensed Vocational Nurse 1 (LVN 1) on 6/14/2024 at 8:56 AM, LVN 1 was observed preparing the following medications for Level of Harm - Minimal harm or Resident 50: potential for actual harm 1. Dexamethasone 2 mg tablet Residents Affected - Some 2. Eliquis 5 mg tablet (prevents blood clots)

3. Senna 8.6 mg tablet, two tablets (for constipation)

4. Magnesium Citrate (used to treat constipation) 200 mg, half a tablet

5. Gabapentin (used to treat nerve pain) 300 mg capsule, one capsule

LVN 1 stated there were five total morning medications to administer for Resident 50.

During an observation on 6/14/2024 at 9:18 AM, in Resident 50's room, Resident 50 was observed taking the five medications by mouth with yogurt and fluids.

During a concurrent record review of Resident 50's Order Summary Report (a summary of all currently active physician orders) and interview on 6/14/2024 at 10:55 AM, LVN 1 stated he failed to administer the following:

1. Cozaar oral tablet 50 mg, give 1 tablet by mouth one time a day for hypertension. Hold if systolic blood pressure (SBP, the top number in a blood pressure reading) is less than120. With order date of 6/6/2024.

2. Lasix oral tablet 20 mg, give 1 tablet by mouth one time a day for edema. Hold if SBP is less than 110. With order date of 6/7/2024.

3. Norvasc oral tablet 5 mg, give 1 tablet by mouth one time a day for hypertension. Hold if SBP is less than 110. With order date of 6/6/2024.

4. Docusate Sodium oral capsule 100 m. Give 1 capsule by mouth two times a day for bowel management, hold for loose stool. With order date of 6/7/2024.

5. Levetiracetam oral tablet 750 mg. Give 2 tablet by mouth two times a day for Seizures. With order date of 6/6/2024.

6. Lidocaine patch 4 percent for pain. Apply to right hip topically (used on the outside of the body) every 12 hours. With order date of 6/7/2024.

LVN 1 stated failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization . LVN 1 confirmed that the order of dexamethasone oral tablet 2 mg, to give 1 tablet by mouth every eight (8) hours related to malignant neoplasm (abnormal cells grow, multiply and spread to other parts of your body) of brain, with order date of 6/6/2024, was given at 9:18 AM. LVN 1 stated, per physician's order, it should be given at 2 PM. Medication Administration Record indicated that 6 AM dose was already given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 During an interview with Registered Nurse 1 (RN 1) on 6/14/2024 at 2:30 PM, RN 1 confirmed LVN 1 did not give all Resident 50's medication and administered dexamethasone at wrong time. RN 1 added that Level of Harm - Minimal harm or dexamethasone administration time was scheduled at 6 AM, 2 PM and 10 PM. RN 1 stated that missed potential for actual harm blood pressure medications might lead to uncontrolled high blood pressure. RN 1 stated that Resident who was not given Levetiracetam might have seizure. Residents Affected - Some

A review of the facility`s Policy and Procedure (P&P) titled, Policy and Procedure in Medication Administration, revised in 7/2013, indicated all medications will be administered following the scheduled medication administration for routine medication unless otherwise specified by Doctor which is different from

the routine medication administration schedule.

A review of the facility`s P&P titled, Administering Medications, revised in 4/24/2024, indicated a policy that medications are administered in a safe and timely manner, and as prescribed. It also indicated that medications are administered in accordance with prescriber orders, including any required time frame.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Some Based on interview and record review, the facility failed to report to the resident's primary physician the irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) on the medication regimen

review (MRR, or Drug Regimen Review, a thorough evaluation of the medication regimen of a resident, with

the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 5/28/2024, for two (2) of five (5) sampled residents (Resident 12 and Resident 61) in accordance with the facility policy.

1. Recommendation to evaluate whether taking Vascazen (helps reduce the risk of heart disease) 1 gram (g, unit of measurement) every night and Vascepa (medicine used to reduce the risk of heart attack, and certain types of heart issues requiring hospitalization in adults with heart disease) 1 g twice a day was indicated for Resident 12.

2. Recommendation to verify the diagnosis and specific target behavior for the use of Zyprexa (medication used to treat certain mental/mood disorders) 10 milligrams (mg, unit of measurement) three times a day for Resident 61.

This deficient practice had the potential for Residents 12 and 61 to be administered unnecessary medication, which could result to serious harm.

Findings:

1. A review of Resident 12's Admission Record indicated an admission to the facility on [DATE REDACTED] with diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), presence of cardiac pacemaker (a small device used to help your heartbeat at a normal rate and rhythm), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood).

A review of Resident 12's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 5/21/2024, indicated Resident 12 was moderately impaired (decisions poor, cues/supervision required) with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 12 required supervision with eating and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) with toileting, lower body dressing, and putting on/taking off footwear and was dependent (helper does all the effort) with shower/bathing.

A review of Resident 12's Order Summary Report, dated 6/14/2024, indicated the following orders:

a. Vascazen oral capsule 1 g, give 1 capsule by mouth at bedtime related to hyperlipidemia, with order date of 2/6/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0756 b. Vascepa oral capsule 1 g, give 2 capsules by mouth two times a day related to hyperlipidemia, with order date of 3/19/2024. Level of Harm - Minimal harm or potential for actual harm A review of Consultant's Pharmacist's MRR, dated 5/28/2024, indicated a recommendation to evaluate whether taking Vascazen and Vascepa was indicated for Resident 12. Residents Affected - Some 2. A review of Resident 61's Admission Record indicated Resident 61 was originally admitted to the facility

on [DATE REDACTED]. Resident 61's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (depression, is a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep).

A review of Resident 61's MDS, dated [DATE REDACTED], indicated Resident 61 was severely impaired with cognitive skills for daily decision making. The MDS indicated Resident 61 required partial assistance with eating, upper body dressing and personal hygiene. It also indicated that Resident 61 required substantial assistance with oral hygiene, lower body dressing and putting on/taking off footwear and was dependent to staff with toileting hygiene and shower.

A review of Resident 61's Order Summary Report, dated 5/3/2024, indicated Zyprexa 10 mg tablet by mouth three times daily for mood stabilizer.

A review of Consultant's Pharmacist's MRR, dated 5/28/2024, indicated a recommendation to verify the diagnosis for Resident 61's use of Zyprexa 10 mg three times a day and to indicate the behavior manifestation in the physician's order.

During an interview with the Director of Nursing (DON) on 6/14/2024 at 4:40 PM, the DON stated that facility did not follow up the MRR for the month of May in timely manner. The DON stated that MRR was done end of May, and she only followed up to the Pharmacist Consultant (PC) on 6/10/2024. The DON stated that recommendations should be reviewed by facility and should have been reported to resident's Doctors if they agree or disagree with the recommendations. The DON stated it was important to act upon the pharmacist recommendation for Resident 12's MRR to evaluate use of Vascazen and Vascepa to make sure that Resident 12 was not taking 2 medications with the same action. The DON also stated it was important to act upon the pharmacist recommendation for Resident 61's MRR to verify the diagnosis for the use of Zyprexa and that the behavior manifestation should be indicated in the order to prevent unnecessary medication.

During a concurrent record review of Residents 12 and 61's Pharmacy Consultant's (PC) MRR, dated 5/28/2024, and interview with the PC on 6/14/2024 at 5:35 PM, the PC stated her recommendation for Resident 12 was to make sure resident was not receiving medications with the same effect. PC stated her recommendation was to verify Resident 61's order of Zyprexa to indicate the diagnosis and specific target behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0756 A review of facility's Policy and Procedure titled, Medication Regimen Reviews, revised in 1/2015, indicated that the primary purpose of the review is to help the facility maintain each resident's highest practicable level Level of Harm - Minimal harm or of functioning by helping them utilize medications appropriately and prevent or minimize adverse potential for actual harm consequences related to medication therapy to the extent possible. It also indicated that the Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed, and Residents Affected - Some dated copy of the report, listing the irregularities found and recommendations for their solutions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 79 555213 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555213 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Care Center, LLC 1640 N. Fair Oaks Avenue 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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 potential for actual harm Cross reference: