The Suites Pasadena

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were free of any significant medication error for 1 of 3 residents (Resident #1) reviewed for medication errors. The facility failed to ensure Resident #1 did not receive insulin without a physician order. The facility failed to ensure the RN adherence to the five rights of medication administration, including resident rights when administering medications to Resident #1. These failures could place residents at risk decline in health, adverse reactions, and hospitalization. Record review of Resident #1's face sheet revealed he is a [AGE] year-old male admitted [DATE], with an original admission date of 11/26/25. The patient has Parkinson's disease (a movement disorder affecting balance and stiffness), dysphagia (trouble swallowing), muscle weakness, and difficulty walking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 33 of 33 residents reviewed for accidents, hazard and supervision. The facility failed to ensure adequate supervision of residents to prevent them from entering the construction area that had exposed wooden framing and loose life hanging electrical wiring. This failure places residents, staff and visitors at risk of accidents, electrical shock and fire hazards.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions in accordance with professional standards for 3 of 4 medication carts reviewed for medication storage in that: Medication Carts #1, 3, and 4 contained medications that did not have an open date written on the bottles. The failure to date opened medications placed residents at risk for receiving expired, contaminated, or ineffective medications which could result in medication errors, infection, delayed treatment or adverse drug outcome. Observation on 01/13/2026 at 10:15 a.m., of the Medication Carts #1, # 3, and #4 with DON and ADON, revealed the following medications that did not have an opened date written on them. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for 3 (Residents #12, #14, #30) of 12 residents reviewed for comprehensive assessment accuracy and timing. The facility failed to complete Residents #12, #14 and #30's admission comprehensive MDS assessments within 14 days following admissions to the facility. This deficient practice could result in newly admitted residents 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 assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 (Resident # 23) of 6 residents reviewed for quarterly assessments. Resident #23's most recent quarterly assessment was completed on 9/29/2025. As of 1/14/2026 at 3:30 pm, the quarterly assessment that was due on 12/30/2025 was not completed. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #20) of 4 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within recommended time frame after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in healthFindings included: Record review of Resident #20's face sheet dated 01\13\26 revealed a [AGE] year-old female, admitted to the facility on 06\03\25 and readmitted on 11\25\25. Her diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise the person-centered comprehensive care plan for 1 (Resident #23) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #23's care plan to reflect the interventions needed to address Resident #23's medical, nursing, and psychosocial needs. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need.

Inspectors wroteBased on interview and record review, the facility failed to provide services that meet professional standards of quality as outlined by the comprehensive care plan for 1 (Resident #17) of 6 residents reviewed for services. The facility failed to ensure recommendations made by the registered dietician were followed as indicated in Resident #17's comprehensive care plan and the active physician orders. This failure could place residents at risk of not having their individual needs met and not receiving adequate nutritional and medical intervention to maintain their health and prevent worsening health conditions

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent the development of pressure ulcers for 1 of 7 (Resident #7) residents reviewed for pressure ulcers. - The facility failed to prevent Resident #7 from acquiring DTIs to both of her heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels. Resident #7 required hospitalization for the treatment of the injuries to her heels. An Immediate Jeopardy (IJ) was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:55pm. [...]

Inspectors wroteBased on observations, interviews and record reviews, 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 5 of 33 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6) reviewed for quality of care. The facility failed to perform weekly skin assessments on the residents for several weeks. This failure could place residents at risk for skin breakdown and/or wounds without receiving treatment or worsening of skin breakdown or wounds.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident's personal privacy during personal care for 1 (Resident #5) of 7 residents reviewed for privacy.- CNA I failed to provide privacy during incontinence care for Resident #5 whose naked buttocks were completely exposed and seen through the window by Surveyor walking by. This failure places residents at risk for embarrassment and a lack of privacy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed for resident rights. -The facility failed to honor Resident #1's request of wearing a mask before entering her room on 02/21/25. This failure could place residents at risk for a lack of self-determination and quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #1) of 4 residents reviewed for dietary services. -The facility failed to honor Resident #1's food preference according to her meal ticket by serving her pork, which her meal ticket reflected she disliked. This failure could place residents at risk for possible weight loss, and a diminished interest in meals and quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 for 1 kitchen. Food item was not sealed in the facility pantry . This deficient practice could place 25 residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #19) reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication, Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG, administered to Resident #19. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (CR #236) reviewed for PASRR. The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the CR #236 This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #132) reviewed for significant medication errors. The facility failed to ensure Metoprolol Tartrate (a blood pressure (BP) medication given to lower (high blood pressure) and treat heart failure) was administered on 10/28/2024 and 10/29/2024 to Resident #132 as ordered on 10/25/2024 by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for two residents (Resident# 14 and Resident #18) of five residents reviewed for pharmacy services. -The office of the ADON was open and accessible to staff and residents. There were two blister pack cards of controlled medications. Staff were within sight of the open door. The deficient practice placed the facility at risk for drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience for one (Resident #1) of five residents reviewed for chemical restraints. 1. The DON changed the medication order from Seroquel Oral Tab 100 MG to be administered at bedtime to be administered in the morning. Resident #1 slept all day until 7-8pm for 3 days. 2. The DON failed to attain verbal consent from a physician or Resident #1, who was her own responsible party. This failure could place 21 residents who receive medications at the facility at risk for adverse medication effects and potential harm.

Inspectors wroteBased on interviews and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. 1. The DON falsified documentation that wound care was given to Resident #1 on 03/15/24 and 03/18/24. 2. LVN B failed to provide wound care services to Resident #2 everyday per physician orders. These failures could place 2 residents who receive wound care at risk for infections, healing regression, and pain.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for one (Resident #2) of two residents reviewed for wound care. Licensed Vocational Nurse (LVN B) failed to properly wash or sanitize her hands in between glove changes when providing wound care to Resident #2. This deficient practice could place 2 residents who received wound care at risk for cross contamination and/or spread of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident had a right to be free from abuse and neglect for 2 (Resident #1 and Resident #2) of six residents reviewed for abuse and neglect. -The DON caused emotional abuse to Resident #1 who was diagnosed with bipolar disorder and still had menstrual cycles when she cursed at Resident #1 and stated she could not have any more than 8 adult briefs for 2 days. -The DON caused emotional abuse to Resident #2 when she stated that Resident #2 got on her nerves when she used her call light multiple times.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent elopement.for 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended and was missing for 2 hours on 2/08/24 around 8:00 PM, until hospital staff contacted the facility. This failure could affect residents with diagnose of dementia at risk of elopement thus placing themselves at risk of physical harm, pain and mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 2/16/24 at 1:00 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 2/16/24 at 1:00 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to ensure LVN B properly assess CR#1 when he gave medication on [DATE] at 9:00am when CR#1 vomited, aspirated and later died. The facility failed to ensure that CR#1 was checked on every two hours and was not laying in her vomit from 7:15 am until 11:15am on [DATE]. The facility failed to ensure that CNAs report to the charge nurse when they found CR#1 in her own vomit. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for two (Resident #2, CR#1) of three residents observed for gastrostomy tube feedings. The facility failed to ensure that LVN B turned off Resident #2's feeding as ordered by the physician. The facility failed to ensure that CNAs notified the nurses to turn off CR#1's feeding pump when providing care. These failures could place residents at risk for aspiration, and abdominal discomfort.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 Residents (Resident #2 and, Resident #3) reviewed for medical records accuracy, in that: Resident #2's and Resident #3's January 2024 Medication Administration Record (MAR) did not reflect documentation for medications given or not given. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings Included: Resident #2 Record review of Resident #2's admission face sheet revealed he was [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage and maintain a system that assures a full, complete, and separate accounting, according to accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf, for 1 of 1 facility reviewed for management of resident funds. --facility failed to have a complete accounting of resident's trust fund activity for 2 months, failed to maintain adequate funds in the petty cash account, or have adequate management of facility funds for 2 months. These failures placed residents whose funds were managed by the facility at risk of losing their Medicaid insurance benefits and placed residents' funds at risk of being misappropriated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who is incontinent of bladder received appropriate sized absorbent product for 1 of the 5 (Resident #7103) residents. The facility failed to provide reasonable accommodation of size 5X bariatric briefs for bariatric Resident #7103. This deficient practice placed residents at risk for not having their needs met.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (CR #105) reviewed for treatment and services to prevent and heal pressure ulcers. 1. CR #105 was not provided wound care from 6/2/2023 through 6/10/2023 although the wound was identified as present prior to his admission on [DATE] . 2. CR #105 was not identified with wounds upon admission; skin assessments were not completed upon admission/re-admission. [...]

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population. The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis. This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 2 of 35 residents (Resident #27 and Resident #31) reviewed for residents' administration. -LVN A failed to properly check Resident #27's gastrostomy tube placement as ordered prior to administration of any medications. -LVN A attempted to administer Resident #27's medications by plunger pushing them into his gastrostomy tube instead of administering to gravity. -LVN A failed to check Resident #27 for residual prior to administering medications. -The facility failed to ensure Resident #31's gastrostomy tube did not become dislodged twice after the discontinuation of his order for an abdominal binder. [...]

Inspectors wroteBased on 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 14 of 18 residents (Residents #6, #9, #12, #14, #18, #22, #28, #31, #86, #87, #88, #89, #90 and #91) reviewed for infection control and prevention. - The facility failed to track, observe trends, and/or monitor infectious diseases in the facility including pneumonia. This failure could place residents at risk of becoming infected with a preventable infections disease, becoming ill, and death.

Inspectors wroteBased on interview and record review the facility failed establish an infection prevention and control program (IPCP) that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. The facility did not have an antibiotic stewardship program in place until June 2023. This failure could place residents at risk of being overmedicated, and/or the facility failing to observe an outbreak of an infectious disease which antibiotics had been prescribed.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 2 of 15 residents (Resident #9 and Resident #90) reviewed for resident rights, in that: -Resident #9 did not have a signed consent for psychoactive medication Quetiapine which he received. -Resident #90 did not have a signed consent for antidepressant medication Bupropion HCI (ER) XL which she received. These failures affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 2 of 16 residents (Resident # 6, #15) reviewed for trust funds. -The facility failed to ensure that Resident #6, and #14 trust fund accounts were spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. -The facility failed to have a surety bond which would cover facility residents' trust funds. The facility's trust fund balance on 7/11/2023 was $57,003.25 and the surety bond at that time was $45,000. Resident #14 requested money from his trust fund, and it had not been provided to him timely. This failure could place residents whose funds are managed by the facility at risk of losing their Medicaid Insurance benefits and their personal funds not being accessible or mis-managed. Findings Included: [...]

Inspectors wroteBased on record review and interview, the facility failed to convey resident funds within 30 days of the resident's discharge, eviction, or death, for 8 of 10 residents (CR#96, CR#97, CR#98, CR#99, CR#101, CR#102, CR#103 and CR#104) reviewed for conveyance of funds. -The facility failed to convey CR#96, CR#97, CR#98, CR#99, CR#101, CR#102, CR#103 and CR#104 funds within the timeframe as required after discharge. This failure could affect all residents and place them at risk for not receiving funds owed to them by the facility.

Inspectors wroteBased on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility reviewed for surety bonds and security of personal funds, in that: -The facility's residents' trust fund account balance totaled $57,003.25. -The facility's Surety Bond totaled $45,000.00. This failure affected 13 residents that allow the facility to manage their funds at risk of the facility not being able to guarantee repayment to the resident. and placed any additional resident that choses to deposit funds in the facility trust fund at risk of their personal funds not being assured.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 3 of 18 (Residents #31, #32, and #89) reviewed for nutrition and hydration status and maintenance. 1. The facility failed ensure Resident #31, Resident #32, and Resident #89 did not sustain an unplanned and/or unexpected significant weight loss. 2. There was no evidence a registered Dietitian had addressed the unplanned weight loss, assessed the residents, or implemented interventions for residents that were experiencing unplanned weight loss since April 2023. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 5 residents (Resident #27, Resident #31) reviewed for tube feeding management and restore eating skills, in that: -LVN A failed to properly check Resident #27's gastrostomy tube placement as ordered prior to administration of any medications. -LVN A attempted to administer Resident #27's medications by plunger pushing them into his gastrostomy tube instead of administering to gravity. -LVN A failed to give Resident #27 (5) ml's of water between each medication as ordered. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure, based on a comprehensive assessment of a resident, residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 4 residents (Residents #11 and #28) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #11 had documentation to show GDR related to Seroquel. 2. The facility failed to ensure Resident #28 had documentation to show attempted GDR despite pharmacist recommendations. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and adverse consequences related to medication therapy. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 4 errors out of 26 opportunities which resulted in a 15% error rate involving 3 of 3 residents (Resident #6, Resident #15, and Resident #27) and 2 of 2 employees (LVN A and MA A) observed during medication administration reviewed for medication error, in that: -LVN A omitted Resident #27's oral rinse that was prescribed for him after a dental procedure. -LVN A failed to give Resident #27 the correct multivitamin (MVI). -MA A failed to give Resident #6 his Sucralfate (antacid) as directed, which was before meals. -MA A failed to give Resident #15's delayed release aspirin (ASA) as prescribed. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 16 of 18 residnets (Residents #6, #7, #9, #12, #14, #18, #22, #25, #28, #31, #86, #87, #88, #89, #90 and #91) reviewed for influenza and pneumococcal immunizations, in that - The facility failed to ensure there was documentation related to the pneumococcal immunization for Residents #6, #7, #9, #12, #14, #18, #22, #25, #28, #31, #86, #87, #88, #89, #90 and #91). - The facility failed to ensure Resident #12 received a Pneumonia vaccine after it was requested by the resident. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 of 18 (Resident #12) residents reviewed for accuracy of assessments, in that: 1. Resident #12's Annual MDS documented he was receiving dialysis treatment services although his dialysis treatment services had ended. This failure could place residents at risk of not receiving care and services needed to attain/maintain their highest practicable quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 8 residents (Resident #26) reviewed for PASRR assessments. -The facility failed to ensure Resident #26 who had a diagnosis of mood disorder, had an accurate PASSR Level I assessment or received a PASRR Level II assessment or evaluation. This failure could place residents with a serious mental illness at risk of not receiving needed care and services to meet their individual needs.

Inspectors wroteBased on interview and record review the facility failed to develop baseline admission care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care for 2 of 15 residents (Residents #89 and #91) reviewed for baseline care plans. The base line care plan was not developed within 48 hours of admission for Resident #89 and Resident #91. This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for disposing garbage and refuse properly. -The facility failed to ensure the lid and door on one dumpster was closed. This failure could place residents at risk for of infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents, and other animals.