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F0584
E

Failure to Maintain Cleanliness and Adequate Hot Water for Resident Care

Pasadena, California Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as evidenced by direct observations and resident interviews. In one instance, a resident with severe cognitive impairment and high dependence for activities of daily living was found in a room with visible trash, including crushed crackers, a used plastic glove, dried brown smears by the commode, and brown clumps under the bed. Both the DON and an LVN confirmed that such conditions were unsanitary and not conducive to residents' well-being, and that housekeeping should have been notified immediately to address the issue. Additionally, multiple residents reported a lack of hot water in their rooms and shower areas, which persisted for at least a week. Residents described being unable to shower or perform personal hygiene tasks comfortably due to the absence of hot water, with some stating they had to use cold water for bathing and incontinence care. Observations confirmed that water temperatures in various rooms and showers were significantly below the facility's policy requirements, with readings as low as 71.6 to 85 degrees Fahrenheit, far below the expected minimum of 110 degrees Fahrenheit. Facility policies reviewed indicated a requirement to provide a safe, clean, and homelike environment, including maintaining water temperatures suitable for residents' needs. Despite these policies, the facility did not ensure that resident rooms were kept clean or that water temperatures were adequate for daily living activities, directly impacting the comfort and hygiene of several residents with varying degrees of cognitive and physical impairment.

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