Pasadena Post Acute

Inspectors wroteBased on observations, interviews and record review, the facility failed to adequately allow residents to call for staff assistance from their bedside for four (Resident #1, Resident #5, Resident #9 and Resident #14) out of twenty-five residents for review of resident call systems. The facility failed to ensure call lights were accessible to Resident #1, Resident #5, Resident #9 and Resident #14 while in their beds on 05/12/2026 and 05/13/2026. This failure could place residents at risk of delays in care and emergency assistance.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure the resident (Resident #14) environment remained as free of accident hazards as is possible over three out of four days to prevent accidents. The facility failed to follow Resident #14's care plan interventions for falls. The failure could place residents at risk of injury, reduced mobility and hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to prepare food in a form designed to meet individual needs for 5 residents (Resident # 59, 51,88, 23, and 4) reviewed for puree diet. -On 5/13/26 and 5/14/26 the protein puree (A puree diet consists of foods that are blended into a smooth, pudding-like consistency to make eating and swallowing easier for people with chewing or swallowing difficulties) portions of lunch were not the correct texture. This failure had the potential to cause residents on a puree diet to aspirate, choke, or cause weight-loss due to difficulty in consuming meals. Record review of the facility therapeutic diet roster dated 5/12/26 revealed that Resident #'s 59, 51, 88, 23 and 4 required a puree diet. Record review of the menu dated 5/13/26 revealed baked chicken would be served. [...]

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 7 residents (Resident #36) reviewed for infection control. Staff failed to ensure Resident #36's indwelling urinary catheter drainage spout was not touching the floor in the main dining room during lunchtime meal service. This failure could place residents at risk for cross contamination, infection and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 1 of 8 residents (Resident #1) reviewed for resident assessment. The facility failed to ensure Resident #1's PASRR Level I screening reflected her mental illness diagnosis. This failure could place residents at risk of not receiving specialized services for their mental illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician when the resident experienced a change in condition for 1 of 8 residents (Resident #55) reviewed for a change in condition. The facility failed to notify the physician when Resident #55 was pocketing Oxycodone pills on [DATE]. Resident #55 was found unresponsive and was sent to the local hospital on [DATE] for respiratory distress. The local hospital sent her to an inpatient behavioral hospital where she was admitted due to worsening of mood and suicidal attempt by drug overdose. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to put behavioral interventions in place for Resident #55 when she returned from the behavioral hospital on [DATE] after being treated for drug overdose and suicidal idealation into the care plan. An immediate jeopardy (IJ) was identified on [DATE] at 9:45am. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #55) reviewed for supervision. -The facility failed to put interventions in place to prevent overdose of medications when Resident #55 was first noticed by the staff on [DATE] pocketing medications including narcotics. Resident #55 was found unresponsive and was sent to the hospital on [DATE] for respiratory distress with a hospital discharge diagnosis of drug overdose/suicidal attempt. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. While the IJ was lowered on [DATE] at 2:33 p.m., the facility remained out of compliance at a severity level of more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for six (Resident #44, #27, #82, #84, #309, #99) of six residents reviewed for receiving enteral feeding via a pump. -The facility failed to clean enteral feeding pumps and poles, which were dirty on 01/09/24, 01/10/24, and 01/11/24 for Residents #44, #27, #82, #84, #309, and #99. This failure could affect the residents who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination, and possible infection.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles, including the expiration date for 2 out of 5 residents (Residents #73 and #53) and 1 out of 3 Med Carts (100 Hall Nursing Cart) reviewed for pharmaceutical services. The facility failed to ensure the 100 Hall Nursing Cart did not contain: -20 tabs of Hydroxyzine 10mg (for anxiety or itching from allergic response), that expired on 9/1/23 for Resident #73. -½ a bottle of NPH insulin 100u/ml (used to bring blood sugar down), that expired on 1/8/24 for Resident #53. -½ of a multi-use bottle of Ibuprofen 200mg tabs, that expired on 10/31/23. These failures could place residents at risk of not receiving therapeutic benefits of the medication, adverse reactions to medications, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pharmacist's medication regimen review recommendations were reviewed by the resident's attending physician, were documented in the medical record, and what, if any, action had been taken to address them, for 6 of 12 months (February, March, April, May, June, and August 2023) reviewed for pharmacy services. -The facility failed to provide Drug Regimen Review forms that were noted by the MD, for the months of February, March, April, May, June, and August of 2023. The DRR forms were either blank or missing all together. This failure could place residents at risk of adverse reactions to medications, continued used of inappropriate medications, or harm including hospitalization if the MD did not review the DRR forms. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 (Dryer #1 and Dryer #3) of 3 dryers reviewed for equipment in safe operating condition. -The facility failed to check and clean the lint filters at appropriate times. The facility failed to clean the lint filter in Dryer #1 from 7 a.m. to 1 p.m., which caused a buildup of lint. The facility failed to clean the excess lint in Dryer #3, which caused a build up of lint under the machine. These failures could cause a fire or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 3 out of 7 residents (Residents #305, #28, and #89), reviewed for care plans. The facility failed to: -Update Resident #305's care plan to indicate she communicated with pen/paper due to not being able to speak. -Update Resident #28's care plan to indicate she no longer had a PICC line. -Update Resident #89's care plan to indicate she no longer was on a pureed diet. These failures could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing.

Inspectors wroteBased on observation, record review, and interview, the facility failed to serve food in accordance with professional standards for food service safety for two out of two Resident reviewed for food service, in that; -The facility failed to follow proper hand hygiene, sanitation, and food handling practices. This failure could place residents at risk of foodborne illnesses.