The Courtyards at Pasadena

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #37 and Resident #20) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in the required amount of Insulin to be administered to Resident #37 on 05/12/26. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility dietary staff failed to ensure temperatures were taken of grilled cheese before serving to residents during lunch meal service on 5/12/26. The facility dietary staff failed to properly sanitize the thermometer while temping each food. The facility dietary staff failed to use proper hand hygiene during lunch service on 5/12/26The facility dietary staff failed to properly wear hair nets during lunch service on 5/12/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food cross contamination. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and 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 six of eight residents (Resident #100, Resident #37, Resident #20, Resident #34, Resident #5 and Resident #13) reviewed for infection control. 1. The facility failed to ensure LVN B performed hand hygiene after obtaining a FSBS for Resident #100 and Resident # 37 on 05/12/26 and failed to allow the glucometer the full 2 minutes of contact time to ensure adequate disinfection prior to using on Resident #37 on 05/12/26. 2. [...]

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 included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 (Resident #129) of 8 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #129's oxygen therapy. This failure could affect residents by placing them at risk for not receiving necessary care and services. Record review of Resident #129's Quarterly MDS assessment, dated 04/23/26 reflected a [AGE] year-old female with an original admission date of 11/22/23 and readmission date of 05/08/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #86) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #86 had her fingernails cleaned and trimmed on 05/12/26. These failures could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life. Record review of Resident #86's quarterly MDS assessment, dated 04/08/26, reflected a [AGE] year-old female with an admission date of 09/22/25, and readmission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 (Resident #129) residents reviewed for respiratory care. The facility failed to ensure Resident #129's oxygen tubing was dated, and the humidifier bottle changed weekly per MD order on 05/12/26. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #129's Quarterly MDS assessment, dated 04/23/26 reflected a [AGE] year-old female with an original admission date of 11/22/23 and readmission date of 05/08/26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. -The facility failed to ensure that one of one deep fryer grease was clean. -The facility failed to ensure that the stove in the kitchen was kept clean. -The facility failed to ensure that the rail above the stove was free of grease. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination Kitchen observation and interview with the Dietary Manager on 03/17/25 at 8:45AM, revealed the following: The cooking area revealed the deep fryer had dark looking grease with brown floating substances on top of the grease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that assessments accurately reflected resident's status for 3 (Resident #9, Resident #43 and Resident #380) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure that Resident #9's admission MDS dated [DATE] accurately reflected her inability to hear normal conversation and her oral dental need. The facility failed to ensure that Resident #43's quarterly MDS dated [DATE] accurately reflected the resident had functional limitation in range of motion of upper and lower extremities. The facility failed to ensure that Resident #380's discharge MDS dated [DATE] accurately reflected the resident's fall that occurred on 2/8/25. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and 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 2 (Residents #73 and #119) of 6 residents and 3 of 4 staff (CNA I, CNA J, CNA K) reviewed for infection control. The facility failed to ensure that proper signage was in place for Resident #73 and Resident #119 who were on enhanced barrier precautions. The facility failed to ensure that CNA I, CNA J, and CNA K were knowledgeable and able to appropriately answer questions regarding enhanced barrier precautions. The facility failed to ensure that CNA I was wearing PPE while caring for Resident #73 who was on enhanced barrier precautions. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 2 of 3 residents (CR #127 & CR #128) reviewed for discharge summary. The facility failed to complete a discharge summary for CR #127. The facility failed to complete a discharge summary for CR #128. These failures could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who displayed or diagnosis with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1(Resident #51) of 5 residents. The facility failed to follow up to ensure Resident #51 received a psychiatric consultation after an order was written on 09/19/2024 from the physician. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: Record review of Resident #51's admission face sheet dated 05/08/2024 indicated an [AGE] year-old female. Resident #51 was admitted with a diagnose of the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services ordered by the physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws, to meet the needs for 1 (Resident #380) of 6 residents reviewed for laboratory services. The facility failed to ensure that blood glucose checks that were ordered on 3/17/25 were performed on 3/18/25 and before breakfast on 3/19/25 for Resident #380. The failure could place residents at risk of not receiving timely diagnosis or treatment, and not receiving appropriate monitoring for health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 (Residents #1) out of 3 residents reviewed for infection control, in that: The facility failed to ensure CNA B contained the dirty wipes after cleaning Resident #1; CNA B threw the used wipes across Resident #1 to the trash can located at the opposite side of the bed whilre providing incontinent care to Resident #1. The facility failed to ensure that CNA C did not put clean gloves in her scrubs pocket during incontinent care for Resident #1. These failures could increase the spread of infection and place residents living in the facility at risk of exposure to infections.

Inspectors wroteF656/3790 Based on observation, interview, and record review, the facility failed to implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 55 residents (Resident #119) reviewed for the development and implementation of comprehensive care plans. The facility failed to ensure Resident #119's refusals of showers was reflected in his comprehensive care plan. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation and interview, 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 food procurement . The facility failed to prevent the following. 1. A Plastic Container of American Cheese dated 1/27/24. 2. A Plastic Container of Mozzarella Cheese had no label and was not dated. 3. A Plastic Container of Powdered Cheese had no label was not dated. 4. A Plastic Container Cream Mexicana Sour Cream with expiration date 1/13/24 5. A Plastic Container of Hard-Boiled Eggs, no label dated 1/15/24. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/30/24 at 6:30 AM revealed that leftover foods were not discarded prior to the use by date. 1. [...]

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired and wearing a wander guard, received adequate supervision when the facility sent him to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of a building in the rain by a bystander. An immediate jeopardy (IJ) was identified on 1/26/24 at 9:40 a.m. While the IJ was removed on 1/27/24 at 3:30 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]