Pasadena Park Healthcare and Wellness Center

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate one (1) of two (2) sampled residents (Resident 1) by failing to ensure the residents call light (device used by residents to call staff) was within reach. This deficient practice has the potential to delay in the necessary care and services and/or needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for one of two sample residents (Resident 1) when transferring from chair/bed to chair transfer. This deficient practice has the potential to cause injury and/or fall to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary respiratory care services for 2 (two) of 3 (three) sampled residents (Resident 1 and 3) by: 1. Failing to administer oxygen according to physician's order to Resident 1 when resident's oxygen saturation level (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage; normal range 95%-100%) was below 92%. 2. Failing to ensure the oxygen via nasal cannula (NC, a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered according to physician's order for Resident 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) by staff for one (1) of three (3) sampled residents (Resident 1), in accordance with the with the facility's abuse prevention policy. This failure had the potential for Resident 1 to feel powerless and unprotected and had the potential to place Resident 1 at risk for further abuse, which could affect the resident's emotional and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed report a verbal abuse (use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) to the State Survey Agency (the Department of Public Health [DPH]) in accordance with State law within two (2) hours after the verbal abuse incident for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse, and/or under reporting from the facility.

Inspectors wroteBased on observation, interview and record review, the facility nursing staff failed to provide pharmaceutical services for two (2) out of 3 (three) sampled residents (Resident 2 and 3) in accordance with their policies and procedure by: 1. Failing to administer Resident 2 ' s routine 9 AM medications (total of 6 medication) as ordered. 2. Failing to administer Resident 3 ' s potassium (a mineral that is found in many foods and is needed for several functions of your body, especially the beating of your heart) and Paxlovid (Nirmatrelvir Ritonavir [medicine for the treatment of mild-to-moderate COVID-19 that is administered as three tablets {two tablets of nirmatrelvir and one tablet of ritonavir} taken together orally twice daily for five days]) as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for four (4) of seven (7) sampled residents (Residents 3, 51, 15, and 62) by failing to ensure: 1. Resident 3's personal property was protected from loss as indicated on the facility's personal property policy. This deficient practice resulted to multiple personal items unaccounted for during an inventory of Resident 3's belongings list. 2. Resident 51's shared restroom for Room A and B was clean and free from dried brown smear on the wall. 3. Resident 62's wallpaper around the resident's call light panel was not stripping off. 4. Resident 15's wall behind her head of bed was in good repair and free of long scratched up and chipped paint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement intervention to prevent pressure ulcer (wound that occurs as a result of prolonged pressure on a specific area of the body) for two (2) of three (3) sampled Residents (Residents 17 and 54) by failing to ensure the residents' low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress and distribute the resident's body weight over a broad surface area and help prevent skin breakdown) mattress was set according to the residents' weight. This deficient practice had the potential for Residents 17 and 54 to develop pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policies and procedures on safe food storage by not: 1. Labeling four (4) gallons of milk in the kitchen refrigerator with an open and/or use by date. 2. Labeling food items in the resident's fridge with a date and/or resident's name. 3. Ensuring Kitchen Staff 1 (KS 1) performed hand hygiene and changed gloves after washing dishes in the sink and went from the dirty area to the clean area. This failure had the potential for residents to be at risk of a food-borne illness (illness caused by food contaminated with bacteria).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three outside garbage cans were covered and closed per facility policy and procedure (P&P). This failure had the potential to attract pests (any living thing - a plant, an animal or a microorganism that has a negative effect on humans such as insects and insects to the facility and its residents.

Inspectors wroteBased on observation, interview and record review, facility failed to follow its policy on infection control for five (5) of 5 sampled Residents (Resident 25, 81, 294, 11, and 84) by failing to ensure: 1. Resident 25's humidifier bottle (bottle of water that adds moisture to oxygen therapy) was labeled with the oxygen tubing connected to it. Facility also failed to store Resident 25's Bilevel positive airway pressure (BiPAP, a mechanical breathing device with a mask that is used to help breathing) mask in a plastic bag. 2. Contact isolation (interventions used and intended to prevent spreading of infectious agents by direct or indirect contact) was initiated and implemented for Resident 81 while resident had Methicillin-resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to several antibiotics) infection. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary environment by failing to: 1. Empty the sharps container (made of rigid puncture resistant plastic which is used to ensure safe containment and disposal of items such as needles, scalpels, and other sharp medical instruments and prevent needlestick injuries) located in residents' restroom per facility policy. This failure resulted in unsafe conditions putting residents and staff at risk for injury. 2. Ensure unused toilet tissue rolls were clean, unopened, and stored in a sanitary manner. This failure resulted in unsanitary conditions putting residents at risk for urinary tract infection (UTI, an infection in any part of the urinary tract, the system of organs that makes urine) with the use of contaminated toilet tissue.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a Foley catheter (or urinary catheter is a flexible tube that is inserted into the bladder to empty it and collect urine in a drainage bag) care plan for one (1) of 1 sampled resident (Resident 84) by not updating Resident 84's Foley catheter care plan to include the resident's behavior of placing the resident's Foley catheter drainage bag on the floor. This failure resulted in the facility staff not implementing interventions to prevent Resident 84 from placing his urinary catheter drainage bag on the floor and placed Resident 84 at risk for infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure two (2) of 20 sampled residents (Residents 44 and 290) were provided care and services by failing to provide: 1. A communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) to Resident 44 that was readily accessible with the language the resident was able to understand in accordance with the facility policy. This failure had the potential to result in Residents 44 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the resident. 2. A shower to Resident 290 as scheduled and as requested. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents Coban wrap (a self-adherent elastic wrap that provides a reliable hold while maintaining mild compression) and Unna boot dressing (medicated moist gauze with zinc oxide) was applied to the resident's bilateral lower extremities (BLE, both legs) as indicated on the physician's order for one (1) of two (2) sampled residents (Resident 20). These deficient practices had the potential for unresolved and worsening edema (swelling caused by fluids trapped in the body's tissues) to Resident 20's BLE affecting the resident's physical comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care service for one (1) of five sampled residents (Residents 34) in accordance with the facility's policy and procedure when an oxygen humidifier (a device designed to increase the moisture in the air and avoid dryness of the nasal passage [nose to lungs]) being used was empty and did not have sterile water (water that is free of any microbes [tiny living things that are found all around us and are too small to be seen by a naked eye], used to prevent growth of organisms and bacteria in the water). This deficient practice had the potential to create discomfort and dryness to Resident 34's nasal passages which can lead to serious complications.

Inspectors wroteBased on interview and record review, the facility failed to accurately record and implement the food preferences for one of four sampled Residents (Resident 25). This failure resulted in a violation of Resident 25's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for two (2) out of 20 sampled residents (Residents 18 and 34) as indicated on the facility's communication-call system policy. This deficient practice had the potential for Residents 18 and 34 not being able to call the facility's staff for help or assistance especially during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Nurse Staffing Information posted was accurate and complete in accordance with the facility's policy and procedure by failing to: 1. Remove the 4/26/2024 Nurse Staffing Information posted on 4/29/2024 and post the Nurse Staffing Information for 4/29/2024. 2. Reflect the correct total number and actual hours of unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential for the Nurse Staffing Information not to be available to the residents and visitors at any given time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) of 44 resident bedrooms (Rooms 12, 14, 35, and 37) met the requirements of 80 square feet (sq. ft.) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 2 sampled residents (Resident 1 and 3) in accordance with the facility ' s policy and procedure when: 1. Resident 1 ' s oxygen humidifier (a device used to make supplemental oxygen moist) was not dated to indicate it was changed every 7 days. 2. 2. Resident 3 ' s oxygen humidifier was found sitting on the floor instead of on top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). These deficient practices had the potential for residents ' medical devices to be contaminated and placing residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccine (prevents infection by Streptococcus (bacterium that causes one of the most common and severe forms of pneumonia) to one (1) of six (6) sampled residents (Resident 2) in accordance with the facility ' s policy and procedure. This deficient practice placed Resident 2 at a higher risk of acquiring and experiencing complications from pneumococcal pneumonia disease (bacterial lung disease) including transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to meet resident's need of medications upon admission for one of three sampled residents (Resident 1). The facility did not administer Resident 1's seven (7) medications due to be given on 1/26/2024 at night (usually scheduled at 9 PM). This deficient practice had a potential of causing a decline in resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light (device to call for assistance from staff) for one of three sampled residents (Resident 1) as indicated in the Call System Communication facility policy. This failure had the potential to result in Resident 1 not being able to call the facility staff for assistance, which could result in a fall, injury or delayed provision of care.

Inspectors wroteBased on interview and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity when Certified Nurse Assistant (CNA) 1 called Resident 1 fat. This deficient practice had the potential to result in psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for the use of oxygen therapy (a treatment that delivers oxygen for you to breath) or two (2) of four (4) sampled residents (Resident 4 and Resident 32) in accordance with the facility policy and procedure. This deficient practice had the potential to result in a lack of or delay in delivery of necessary care and services for Resident 4 and Resident 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident receiving enteral feeding (gastrostomy [GT] feeding) received appropriate care and services to prevent complications of enteral feeding for two of two sampled residents (Resident 55 and 30). Resident 55's gastrostomy (GT) feeding tube did not have a date and time label, in accordance with the facility's policy on Enteral Feeding. This deficient practice had the potential to cause GT associated complications such as infection to the gastrostomy site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care service for two (2) of four sampled residents (Residents 4 and 32). 1. For Resident 4, the facility failed to change the resident's oxygen humidifier (a device used to make supplemental oxygen moist) every three (3) days per physician's order. This deficient practice had the potential for the resident to develop a respiratory infection. 2. For Resident 32's oxygen tubing was not labeled according to the facility's policy and procedure. This deficient practice had the potential for Resident 32 not to receive the benefits of the supplemental oxygen ordered if the oxygen tubing was not in its optimal working condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for one of three sampled residents (Resident 55) after an increase in the dose of antidepressant drug (medication used to treat certain mental/mood conditions) dosage. This failure had the potential to violate Resident 55's rights to be informed and to choose the type of care or treatment to be received, or alternatives the resident or responsible party preferred.

Inspectors wroteBased on interview and record review the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record for one of two sampled residents (Resident 79). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of quality (means that care and services are provided according to accepted standards of clinical practice) during medical equipment sharing in between residents, by failing to clean and disinfect the sphygmomanometer (BP-equipment used to measure blood pressure) cuff and glucometer (an instrument for measuring the concentration of glucose in the blood) before and after each resident's use for four of seven sampled residents (Resident 81, 79, 57, and 192). This deficient practice had the potential to put residents at higher risk of health-care associated infections, where blood glucose monitoring equipment is shared and exposure to other infectious diseases during contaminated BP equipment sharing.

Inspectors wroteBased on interview and record review, the facility failed to prepare one of 18 sampled residents (Resident 77) for a colonoscopy procedure (examination of the inside of the colon using a colonoscope, inserted into the rectum) as indicated on the physician order. This deficient practice resulted to a rescheduled appointment to a later date, which could potentially cause a negative outcome and a delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities that included arranging and making appointments to see an eye specialist since 2/15/2023 for one of two sampled residents (Resident 63). This deficient practice had the potential to result in further decline of Resident 63's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, implement, monitor, and modify interventions, consistent with the resident's assessed needs, choices, and preferences to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 63), who was assessed at risk for fluctuation in weights and malnutrition (the condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function). This deficient practice had the potential to result in further significant weight loss, which can affect resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide pharmaceutical services to prevent consequences of medication-related adverse events for one of seven sampled residents (Resident 7) by failing to dilute GlycoLax Powder (a medication used to treat occasional constipation [difficulty emptying the bowels]) in six (6) to eight (8) ounces of water per physician's order. This deficient practice had the potential to result in ineffectively managed constipation and decrease the efficacy of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe drug storage by leaving a medication unattended on top of the medication cart for one of seven sampled residents (Resident 192) as indicated on the facility policy and procedure. This deficient practice had the potential to result in other residents having access to medications causing adverse consequences or possible hospitalization if ingested.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly provide dental services fort two of two sampled residents (Resident 63, and 56). This deficient practice had the potential to result in the inability to effectively chew foods and lead into weight loss for Resident 56 and 63.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation practices for 84 out of the 88 residents in the facility by failing to store the red sanitizing bucket (a designated container, for holding sanitizing solution used for cleaning equipment surfaces) away from clean, air-drying dishes, utensils, pots, pans, and equipment. This deficient practice has the potential to expose residents to pathogens (bacteria, viruses, or other germs which may cause disease), increasing the risk for developing foodborne illness (food poisoning); symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 171 and 173) receive the treatment and care as indicated on the care plan and facility policy. a. Resident 171 did not have a documented evidence of physician notification for reevaluation of multiple use of Norco (opioid) ordered as needed (PRN). Resident 171 received PRN Norco once to two times a day since 1/12/2020. b. Resident 173 did not have a documented evidence of physician notification for reevaluation of multiple use of Norco. Resident 173 received PRN Norco once to three times a day since 1/3/20. Resident 173 did not receive pain medication (Acetaminophen) as ordered on 1/7/2020. These deficient practices had the potential to result in unmanaged pain that can affect the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure discontinued non-narcotic medications were disposed in accordance with the facility's policy and procedures. There were multiple non-narcotic medications on multiple occasions, disposed without two licensed staff verifying the destruction of the medications, without the quantity of medication to be disposed and without a date. This deficient practice had the potential to result in medication diversion/loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were maintained for one of 19 sampled residents (Resident 40) and during an inspection of the laundry room. a. For Resident 40, a gown and used linens were observed placed in the resident's wheelchair and bathroom sink. b. Clean linens in closed and opened bags were stored on the shelves in the laundry room next to the washer. These deficient practices had the potential to result in cross contamination and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 40), wore a diaper while in bed and was not naked per her preference. This deficient practice did not maintain the resident's dignity and did not respect her preference.

Inspectors wroteBased on interview and record review, the facility failed to: a. Ensure Advance Directive (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them ) education or information was provided and documented on the facility's Advance Directive Acknowledgement Form for Resident 59. b. Ensure Resident 60 had a Physician Orders for Life Sustaining Treatment (POLST) in the clinical record. These deficient practices had the potential for the residents' treatment wishes not to be carried out in the event the residents were unable to communicate or during an emergency.

Inspectors wroteBased on interview and record review, the facility did not have a documented evidence that a baseline care plan summary was provided to the resident or representative for two of 19 sampled residents (Resident 171 and 172). This failure had the potential for the residents or representatives to be unaware and not be able to participate in the plan of care to address specific residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for two of 19 sampled residents (Resident 34 and 121). a. Resident 34 did not have a care plan to address hearing limitations as indicated on the Minimum Data Set (MDS, standardized assessment and care screening tool). b. Resident 121 did not have a care plan to address behavior of pulling nasal cannula. This failure had the potential for the resident not to receive interventions to address resident's specific needs, which could affect quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan to include specific current interventions to address constipation (acute or chronic condition in which bowel movements occur less often than usual or consist of hard, dry stools that are painful or difficult to pass) for one of 19 sampled residents (Resident 172), as indicated on the facility policy. This deficient practice had the potential for Resident 172 not to receive specific interventions to address constipation, which can result to complications and affect Resident 172's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for two of six sampled residents (Resident 121 and 172). a. Resident 172, who was assessed as at risk for pressure ulcer was observed in bed with bilateral heels not offloaded (to suspend or take off pressure from the heels), as indicated on the care plan. This deficient practice had the potential to result in the deterioration of Resident 172's Stage 1 pressure ulcer (intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin) on bilateral heels. b. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to make the necessary podiatrist (physician whose education and training was to diagnose and treat conditions affecting the foot, ankle, and related structures of the leg) appointment for toe nail care and treatment for one of 19 sampled residents (Resident 62), as indicated on the facility policy. This deficient practice had the potential to result in discomfort and decline in the resident's functional mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accident hazards for two of six sampled residents (Resident 171 and 172). a. Resident 171, assessed as high risk for fall, was observed with only one floor mat instead of two, as indicated on the physician's order. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. b. Resident 172, assessed as high risk for fall, was observed not on a low bed as indicated on the care plan. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a bowel and bladder (B&B) reassessment after completion of the toilet schedule program and discontinuance of urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag) for one of 19 sampled residents (Resident 34), as indicated on the facility policy. This deficient practice had the potential for the resident not to receive interventions to restore or maintain continence to the extent possible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 121) received oxygen (O2, a colorless, odorless reactive gas) as prescribed by the physician. This deficient practice had the potential to cause respiratory complication to Resident 121 due to lack of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Residents 59 and 121), who were on psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) had specific indication and continuous monitoring for the side effects of the medication. a. For Resident 121, the resident did not have a specific indication for the use of Lorazepam (antianxiety medication) as needed (PRN). b. For Resident 59, the nursing staff failed to monitor the side effects of Remeron (antidepressant medication) per physician's orders. These deficient practices had the potential to place Residents 121 at risk for receiving unnecessary psychotropic medications, and placed Resident 59 at risk to experience adverse effects from the use of antidepressant without appropriate interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet (a meal plan that controls the intake of certain foods or nutrients as part of the treatment, includes diet in which the texture of a diet is altered or modified) was served per physician's order for one of two sampled residents (Resident 58). Resident 58, who was on nectar-thick liquids (liquids with nectar like consistency), received milk that was not thickened as nectar like consistency. This deficient practice had the potential to result in aspiration (liquids entering airway and into lungs), coughing, shortness of breath and pneumonia (lung infection).