Focused Care at Pasadena

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident status for 1 (Resident #1) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment dated [DATE] for having verbal behavioral symptoms directed toward others. This failure could place residents at risk of inadequate care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to review and revise the comprehensive care plan for 1 (Resident #2) of 8 residents whose care plans were reviewed for care plan revision. The facility failed to develop a comprehensive care plan with objectives and interventions to address Resident 2's refusal to reposition and failed to provide education to the family regarding positioning, resulting in a care plan that did not reflect the resident's current status or needs. This failure could place residents at risk for decreased quality of care and preventable injury. Record review of Resident #2's face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received medications that were free of significant medication errors for 2 of 5 residents (Resident #1 and #2) reviewed for medications. -The facility failed to ensure that Resident #1's blood pressure medication Metoprolol was held when the blood pressure was low.-The facility failed to ensure Resident #2 blood pressure medication Midodrine was held when the blood pressure was out of the parameter it should be held. These failures could place residents with high or low blood pressure at risk of fainting or stroke due to not getting their blood pressure medication as ordered by their physician. Record review of Resident #1's admission face sheet dated 3/17/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to maintain a complete and accurate MAR for Resident #2. This failure could place residents at risk of an incomplete medical record and possibly not being given medication and treatment as ordered by their physician. Record review of Resident #2's admission face sheet dated 3/18/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, records review and interview, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 (Resident # 2 #10, #11, 21, and #52) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident # 2's MDS assessment accurately reflected discontinuation of G-tube and falls. The facility failed to ensure Resident #10's quarterly MDS assessments accurately reflected her impairment to her upper extremity on one side. Resident #11's annual comprehensive MDS assessment did not reflect his lack of natural teeth in his oral cavity. Resident #21's comprehensive significant change MDS assessment did not reflect his use of upper denture. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level II residents with mental illness were provided with an accurate PASRR Level I for II (Resident #21 and Resident #52) of 5 Residents reviewed for PASRR screening. -Resident #21 did not have an accurate and updated PASRR Level II assessment reflecting a diagnosis of mental illness. -Resident #52 did not have an accurate and updated PASRR Level II assessment reflecting a diagnosis of mental illness. These failures could place residents with mental illness at risk of not receiving a PASRR Evaluation for individualized care, or special services to meet their needs

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 19.35% based on 6 out of 31 opportunities which involved 1 of 5 residents (Resident #19) and 1 of 3 staff (MA B) observed for medication administration errors. MA B administered Acetaminophen (a drug that is used to treat moderate pain and is a fever reducer), Amlodipine Besylate (a drug used to treated elevated blood pressure), Keppra (a drug used to treat seizures), Clobazam (a drug used to treat seizures), Pregabalin (a drug used for pain), and Cyclobenzaprine (a drug used for muscle pain) 2 hours and 52 minutes after the scheduled time to Resident #19 on 2/11/2026 at 10:53 am. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs with the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 18 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's comprehensive care plan included information about her Spanish speaking status. This failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 2 staff (RN B) and 1 of 4 residents (Resident#4) reviewed for infection control. The facility failed to ensure RN B used PPE (Personal Protective Equipment) appropriately while providing care to Resident #4 who was on EBP (Enhanced Barrier Precautions). These failures could place residents at risk for cross contamination, infection and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to ensure that the grill above the oven was free of grease. 2. The facility failed to keep one of one commercial can opener in the kitchen clean. 3. The facility failed to label, and date left over food items stored in the walk-in cooler. 4. The facility failed to ensure that expired food items were not stored in the walk-in cooler. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination.

Inspectors wroteBased on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced significant change in the resident's physical status (a deterioration in health status either life-threatening conditions or clinical complications) for 1 of 6 residents (Resident #5) reviewed for a change of condition, in that: -The facility failed to notify the doctor when there was a change of condition with Resident #5's urine which had turned purple. -On 9/30/2024, Resident #5 was diagnosed with a urinary tract infection. Resident #5's change of condition was recognized by the nurses at the facility, on 10/5/2024. Resident #5 was not given antibiotics to treat her UTI until 10/8/2024. She was not sent to the hospital until 10/9/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 6 residents (Resident #5) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received treatment without delays for change in condition related to black, purple, and bloody urine in her Foley catheter . 2. The facility failed to follow the doctor's order regarding the size of the catheter that was supposed to be used and the indication for changing the Foley catheter . 3. The facility failed to provide care to Resident #5 in a timely manner after the family repeatedly requested Resident #5 be sent to the emergency room for evaluation of her purple urine and decline which caused a delay in care . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure gloves were worn by staff during food preparation. These failures placed all residents who ate food served by the kitchen at risk of a food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure waste were properly contained in dumpster and covered, in 2 of 2 kitchen and outside dumpster: -The facility failed close the lid to the dumpster. -The facility failed to provide lids to two trash cans that were placed inside of the kitchen. This failure placed residents at risk for infection and a decreased quality of life due to having an exterior environment which could attract flying pests, rodents, and other animals.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR#1) of five residents reviewed for quality of care. The facility failed to immediately assess and treat CR #1 and contact the doctor from [DATE]- [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:31 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR#1) of five residents reviewed for quality of care. The facility failed to immediately assess and treat CR #1 and contact the doctor from [DATE]- [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:31 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were treated respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #2) of five residents reviewed for dignity. The facility failed to ensure Resident #2 was not referred to as a feeder. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth .

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 received supervision during her meals in accordance with her care plan. This failure could place residents at risk of not having their needs met and decreased nutritional intake.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good nutrition for 1 of 6 residents reviewed for ADLs (Residents #1.) The facility failed to ensure Resident #1 received supervision and assistance during her meals. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be free from abuse for 1 resident (CR#1) of 10 reviewed for neglect. -The facility failed to ensure CR#1 was free from neglect when she had multiple falls with serious injuries. -The facility failed to complete assessments, assess her pain, and implement adequate interventions to address CR#1's repeated falls with injuries. CR#1 died on [DATE] at the hospital after a fall, sustaining a head injury on [DATE]. -The facility failed to adequately assess CR#1 when she cried out in pain saying her leg was broken on [DATE] when she re-admitted to the facility at 2:14 p.m. and no order was given for Stat x-ray until [DATE] at 9:47 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls and major injuries causing her to be hospitalized several times with major injuries for 1 (CR#1) of ten residents reviewed for accidents, hazards, and supervision. -The facility failed to provide adequate assistive devices for CR#1 who was on anticoagulants had a history of major falls with injury on [DATE] (unwitnessed fall-fractured nose and femur), [DATE] (unwitnessed fall), [DATE] (unwitnessed fall found face down), [DATE] (unwitnessed fall cerebral hemorrhage and neck pain). -The facility failed to conduct a thorough assessment and manage pain after CR#1's fall on [DATE] and left CR#1 unattended. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote care for resident in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 3 residents reviewed for dignity in that: The facility failed to provide dignity and respect for Resident #1 by leaving the resident on the floor face down with his buttocks exposed. This failure could place residents at risk for embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was free from abuse, neglect, and exploitation for 1 (Resident #1) of 3 residents reviewed for abuse in that: The facility photographed Resident #1 exposed buttock. This failure could place residents at risk for embarrassment.

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 12 residents (Resident #1) reviewed for resident rights. -The facility failed to notify Resident #1's physician on 11/05/2023 when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents. Resident #1 asked for a knife so he could kill himself. An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 11:38AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 of 12 residents (Resident #1) reviewed for accidents. -The facility failed to place Resident #1 immediately on 1 on 1 supervision on 11/05/2023 when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents. Resident #1 asked for a knife so he could kill himself. An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 11:38AM. While the IJ was removed on 11/12/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on suicide ideations and one on one supervision. This failure placed other residents in the NF with psych behaviors at risk for harm or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 16 residents (Resident #22 and Resident #84) reviewed for resident assessments. 1. The facility failed to ensure Resident #22's admission MDS Assessment accurately reflected his oral cavity 2. The facility failed to ensure Resident #86's admission MDS Assessment accurately reflected mental status, oral cavity, and functioning limitation. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives an accurate assessment reflecting the resident's status for 1 of 16 residents reviewed for assessment accuracy (Resident #85). Resident #85 was discharged to home, but the Discharge MDS was coded as discharged to acute hospital. This failure placed residents at risk of having inaccurate assessments and receiving improper care and services at time of discharge

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were updated and revised for 1 of 16 residents reviewed for care plan revision (Resident # 72). --Resident #72 was care planned for antibiotics which were discontinued 7/19/23 and infection which was resolved on 7/19/23 --Resident # 72 was care planned for bolus tube feeding of Nepro 4 times a day, and bolus tube feeding of Glucerna 5 times a day, when orders were for Nepro 4 times a day via bolus feeding These failures placed residents at risk of not receiving appropriate person-centered care according to their current condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 17 of 93 days (May 2023 - June 2023) reviewed for registered nursing coverage. The facility failed to ensure a RN was present in the facility for at least eight consecutive hours per day and seven days per week on 17 separate occasions in the months of May 2023 - June 2023. This failure could place residents at risk of assessments, interventions, care, and treatment requiring the advanced education, skills and judgement of an RN and leaving staff without supervisory coverage for coordination of events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 2 meals reviewed for food palatability. The facility failed to provide palatable and appetizing food to the residents. This failure could result in residents losing weight, becoming ill, and having a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with established food preparation practices and safety techniques, in 1 of 1 kitchen reviewed for food storage, in that:. Facility failed to ensure food were labeled and dated properly. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on record review and interview the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed. The facility, licensed for 125 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the state agency, a death in facility for 1 of 5 closed record (CR) residents (CR #84) reviewed for abuse and neglect in that: The facility failed to report Closed Record Resident #84's death in facility. CR #84 passed away suddenly at the facility on [DATE]. This failure could affect residents and place them at risk for changes in condition, deaths or other incidents of possible abuse and neglect, not being investigated thoroughly or reported. Findings Include: Record review of CR #84's admission sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered baseline care plan within 48 hours of admission for 1 Resident of 12 residents (Resident #38) reviewed for baseline care plans in that: - Resident #38 did not have a baseline care plan that addressed her PASRR (Preadmission Screening and Resident Review) status, completed within 48 hours of admission. This failure placed newly admitted residents at risk of not receiving comprehensive person-centered care and services to meet their needs. Findings Include: [...]