Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Pasadena during CMS and state inspections, most recent first.
Two residents with complex medical histories, including hypertension and hypotension, had physician orders for Metoprolol and Midodrine that included specific BP and HR hold parameters, but staff failed to document holding these medications when vital signs were outside the ordered ranges. Medication Administration Records contained blanks with no indication that doses were held, refused, or that residents were out of the building. Interviews with LVNs, a med aide, and the DON confirmed that blanks on the MAR indicate medications were not given and that all administration decisions, including holds per parameters, should be documented in accordance with facility policy.
A resident with multiple chronic conditions and moderate cognitive impairment had a physician order for Midodrine HCL 10 mg to be given orally three times daily, with parameters to hold the dose based on SBP and heart rate. Review of the MAR showed that one scheduled evening dose was left blank, with no documentation that the medication was given, held, or refused, and no vital signs recorded at that time. In interviews, LVNs, a med aide, and the DON all stated that there should be no blanks on the MAR, that all medications must be signed out or documented as refused or not given, and that undocumented medications are considered not done, which conflicted with the facility’s own charting and documentation policy requiring complete and accurate records.
Inaccurate MDS assessments were completed for multiple residents. One resident with left-sided hemiplegia had quarterly GG coding that did not match observed upper and lower extremity limitations, another resident's annual MDS did not accurately reflect oral/dental status, and two residents had MDS fall history sections left blank despite documented falls in their care plans. Another resident's quarterly MDS failed to reflect a discontinued G-tube and a fall between assessments. Staff interviews confirmed several of the coding errors.
Two residents with MI had inaccurate or incomplete PASRR documentation. One resident with schizoaffective disorder, psychotic disturbance, mood disturbance, and major depressive disorder had a PASRR that listed dementia as the primary diagnosis and left the Level II section blank, with no evidence of a Level II eval in the record. Another resident with dementia, anxiety, depression, schizoaffective disorder, and bipolar disorder also had no evidence of PASRR I or Level II evaluation despite active psychiatric diagnoses and related care planning.
A medication aide administered several scheduled meds to a resident with epilepsy, HTN, pain, and vascular dementia nearly 3 hours late, resulting in a medication error rate of 19.35%. The aide said she was covering another hall first and did not notify the RN about the delay; the ADON and DON were unaware the meds were late. The MAR showed the meds were due at 7:00 a.m. but were given at 10:53 a.m., and the facility policy and state rule cited required responsible medication administration.
A resident with dementia, dysphagia, and other chronic conditions was coded on the MDS as Spanish-speaking and needing an interpreter, but her care plan initially did not include her language or communication needs. Staff observed that she spoke Spanish only and used mobile translator apps to communicate with her, yet the undated care plan had no language/communication focus until a later printed copy showed interpretation and translation needs. The MDS Nurse acknowledged the omission was an oversight, and the DON, Administrator, and SW stated the missing or inaccurate care plan could affect communication and continuity of care.
Failure to Use EBP PPE During G-Tube Care: An RN provided g-tube feeding care to a resident with a g-tube and severe cognitive impairment without wearing the required gown while the room had an EBP sign posted. The RN stated she did not notice the sign and later acknowledged she should have worn PPE. The IP and DON stated staff were expected to follow EBP for residents with invasive devices such as a g-tube.
The facility's kitchen operations were found deficient in food safety standards, with issues such as grease accumulation on the vent hood, a dirty commercial can opener, and unlabeled, undated, and expired food items in the walk-in cooler. The Dietary Manager, new to the role, acknowledged these issues, and the acting Administrator noted the department's new staff. The facility's policy requires proper labeling, dating, and cleanliness in food storage.
A resident with a history of chronic kidney disease and other conditions experienced a significant change in physical status due to a UTI, resulting in purple urine. The facility failed to notify the physician and the resident's family promptly, delaying treatment and hospital transfer. Despite the family's request for hospital transfer, the DON canceled it, opting for IV fluids instead. This communication breakdown led to a delay in addressing the resident's medical needs.
A resident with a urinary catheter experienced a urinary tract infection and purple urine syndrome due to the facility's failure to provide timely care and adhere to physician orders. Despite the family's requests for emergency evaluation, the facility delayed treatment, leading to a deterioration in the resident's condition. Communication and documentation issues among staff further contributed to the deficiency.
The facility's kitchen was found to have unsanitary conditions, with dirty floors and staff not wearing gloves during food preparation, as observed with Cook A handling turkey meat without gloves. The Dietary Manager acknowledged the importance of gloves to prevent cross-contamination, but there was a lack of soap availability, further compromising hygiene. These actions violated the facility's policy on preventing foodborne illness, putting residents at risk.
The facility failed to maintain proper waste management practices, with an open dumpster lid and lidless trash cans in the kitchen containing food particles. Staff interviews confirmed these unsanitary conditions, which contravened the facility's waste management policy.
A resident with a history of serious medical conditions experienced ongoing vomiting and distress for two days without receiving timely medical intervention. The facility staff failed to document and communicate the resident's condition changes, leading to a delay in contacting the physician. The resident was eventually sent to the hospital in critical condition and later passed away due to aspiration pneumonia.
A resident with multiple health issues experienced ongoing vomiting and distress, but the facility failed to assess and treat him promptly or notify the doctor. Staff did not document or communicate the resident's condition changes, leading to his hospitalization with severe complications. This resulted in an Immediate Jeopardy situation due to the facility's inadequate response and communication.
A resident with severe cognitive impairment was referred to as a 'feeder' by a CNA, compromising her dignity. The CNA, new to the job, was unsure if she had been trained on resident rights and dignity. The DON acknowledged the term was inappropriate, and the Administrator confirmed that residents should be referred to as 'Red Napkin Program assisted dining residents'. This incident highlights a deficiency in the facility's adherence to its policy on treating residents with respect and dignity.
A resident with hemiplegia and vascular dementia did not receive the required supervision during meals, as outlined in her care plan. Despite her difficulty eating independently due to hand weakness, staff failed to provide necessary assistance, leading to decreased food intake. Interviews revealed staff were unaware of the care plan requirements, resulting in a lack of adherence to the facility's policy on individualized care plans.
A resident with hemiplegia and muscle weakness did not receive the required supervision and assistance during meals, as outlined in her care plan. Despite her difficulty eating independently due to hand tremors, staff failed to provide the necessary support, resulting in inadequate food intake and weight loss. Observations and interviews revealed a lack of awareness among staff regarding the resident's care plan requirements.
Failure to Follow BP Medication Hold Parameters and Document Administration
Penalty
Summary
Surveyors identified a deficiency in medication administration related to blood pressure medications for two residents. For the first resident, an older female with multiple diagnoses including cerebral infarction, peripheral vascular disease, hypertension, heart failure, chronic kidney disease, atrial fibrillation, chronic embolism/thrombosis, and COPD, the physician’s order dated 9/8/2025 directed Metoprolol Tartrate 25 mg by mouth twice daily for hypertension, to be held if systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) less than 60, or heart rate less than 60. Review of the March 2026 MAR showed that on 3/9/2026, when her blood pressure was 106/70, Metoprolol 25 mg was not documented as held, and there was no code indicating refusal or that the resident was not in the facility. For the second resident, an older female with diagnoses including depression, anemia, hyperlipidemia, cerebral infarction, hypotension, acute respiratory failure, and type 2 diabetes, a physician’s order dated 2/27/2026 directed Midodrine HCL 10 mg by mouth three times a day, to be held if SBP was greater than 120 or heart rate was greater than 60. Review of her March 2026 MAR showed that Midodrine 10 mg was not documented as held on multiple occasions when her vital signs were outside the ordered parameters: on 3/2/2026 with BP 137/73 and HR 75, on 3/3/2026 with BP 133/63 and HR 78 at 9:00 p.m., and on 3/5/2026 at 3:00 p.m. with BP 124/76 and HR 85. Multiple staff interviews, including LVNs, a med aide, and the DON, confirmed that there should be no blanks on the MARs and that if medications were given or not given, including refusals or residents being out of the building, this must be documented. Staff stated that blanks on the MAR indicate medications were not given and that blood pressure medications should be held or administered according to physician-ordered parameters. The facility’s Charting and Documentation policy dated July 2017 stated that all services and treatments, including whether a resident refused a procedure or treatment, must be documented in the medical record, with the signature and title of the individual documenting. Despite these expectations and policies, the MARs for both residents contained blanks and lacked documentation that the ordered hold parameters for Metoprolol and Midodrine were followed.
Incomplete MAR Documentation for Ordered Midodrine Dose
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not fully documenting medication administration on the Medication Administration Record (MAR). The resident was an older female admitted with multiple diagnoses including anemia, depression, hyperlipidemia, cerebral infarction, hypotension, acute respiratory failure, and type 2 diabetes, and had a BIMS score of 09 indicating moderate cognitive impairment. A physician’s order dated 2/27/2026 directed that Midodrine HCL 10 mg be given orally three times a day, with instructions to hold the dose if systolic blood pressure was greater than 120 or heart rate greater than 60. The corresponding March 2026 MAR reflected this order, but the entry for the 9:00 p.m. dose on 3/12/2026 was left blank, with no documentation that the medication was given, held, or refused, and no vital signs recorded for that administration time. Multiple staff interviews confirmed that there should be no blanks on the MAR and that all medications must be signed when given or documented if refused or if the resident is not present. LVNs and a med aide consistently stated that if it is not documented, it is considered not done, and that blanks on the MAR could indicate a medication error or that the medication was not given. The DON also stated that there should be no blanks on the MAR and that nurses are expected to follow physician orders and document when medications are given, reiterating that if it is not documented, it was not done. Review of the facility’s Charting and Documentation policy indicated that all services and treatments, including whether a resident refused a procedure or treatment, must be documented in a complete and accurate manner in the medical record, underscoring that the blank MAR entry for this ordered medication was inconsistent with facility policy.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of residents' functional capacity for 5 of 18 residents reviewed. The deficiencies involved inaccurate MDS coding for Resident #2, Resident #10, Resident #11, Resident #21, and Resident #52. The report states these inaccurate assessments could place residents at risk of receiving inadequate care and services due to inaccurate assessments. For Resident #10, the record showed diagnoses including left-sided hemiplegia and hemiparesis, seizures, left shoulder pain, and a prior left fibula fracture. Two quarterly MDS assessments coded impairment on one side in section GG for upper extremities, but the resident was observed lying in bed with her left arm bent upward toward her chest and her left ankle positioned inward. During interview, she stated she could move her arm but could not straighten her left arm. The DOR confirmed she had left-sided upper and lower body limitations after stroke, and the MDS nurse later stated the resident had left-sided impairments and that the assessments were coded incorrectly. For Resident #11, the annual comprehensive MDS did not reflect his lack of natural teeth in the oral cavity. The assessment section for oral/dental indicated obvious or likely cavities or broken natural teeth, and the care plan identified him as at risk for altered oral/dental health problems related to obvious or likely cavity or broken natural teeth. However, during observation and interview, he said his dentures were in his nightstand, that he did not wear them because they did not fit right, and his meal was untouched at the bedside while he requested pudding. For Resident #21 and Resident #52, the significant change and quarterly MDS assessments left the fall history section blank despite documented falls in the care plans. Resident #21 had multiple falls documented in the care plan, and the MDS assessments reviewed did not capture fall history. Resident #52 also had multiple documented falls in the care plan, yet the significant change and annual MDS assessments left fall history blank. In addition, Resident #52 was observed in bed receiving G-tube feeding, and the record showed he had a history of frequent falls and had been transported to the hospital after hitting his head. For Resident #2, the quarterly MDS did not reflect that the feeding tube had been discontinued on physician order and did not capture a fall that occurred between assessments. The MDS nurse and DON acknowledged the feeding tube removal and fall should have been coded on the appropriate MDS assessments.
Inaccurate PASRR Assessments for Two Residents With Mental Illness
Penalty
Summary
The facility failed to ensure that two residents with mental illness had accurate and updated PASRR Level II assessments. Resident #21 had diagnoses including schizoaffective disorder, psychotic disturbance, mood disturbance, and major depressive disorder that were present on admission, but the PASRR evaluation dated 11/19/24 checked dementia as the primary diagnosis and marked the mental illness and IDD sections as no. A significant change MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition, and the Level II PASRR screening section was left blank. The resident’s clinical record contained no evidence of a PASRR Level II evaluation. Resident #52 had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, depression, schizoaffective disorder, and bipolar disorder. A comprehensive significant change MDS showed a BIMS score of 15 out of 15, and the active diagnoses section was checked for anxiety disorder, depression, bipolar disorder, and schizophrenia. The care plan addressed impaired decision-making abilities, dementia, schizoaffective disorder, and bipolar disorder, but the clinical record contained no evidence of PASRR I or Level II evaluation. During interview, the MDS coordinator stated she was responsible for ensuring residents with MI, IDD, and related diagnoses had PASRR Level I assessments on admission and were referred for Level II evaluation, and she said she would complete a 1012 form for Residents #21 and #52.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure medication administration error rates remained below 5 percent. Survey observation and record review showed a medication error rate of 19.35%, based on 6 errors out of 31 opportunities involving one resident and one medication aide observed during medication administration. The cited deficiency involved a medication aide administering multiple scheduled medications 2 hours and 52 minutes after the ordered time. Resident #19 was an older female with diagnoses including transient cerebral ischemic attack, epilepsy, essential hypertension, rheumatoid arthritis, and vascular dementia. Her quarterly MDS showed a BIMS score of 13, indicating intact cognitive function. Her physician orders included Tylenol for right leg pain, Amlodipine for elevated blood pressure, Keppra and Clobazam for seizures, Pregabalin for pain, and Cyclobenzaprine for muscle pain. The MAR showed these medications were scheduled for 7:00 a.m., but on the day of observation they were administered at 10:53 a.m. During observation, the medication aide obtained the resident’s blood pressure and heart rate, performed hand hygiene, gathered the medications, and administered them late. In interview, the medication aide stated she was supposed to give medications in another hall first and said she could not be in two places at one time. She also stated she had not yet notified the nurse caring for the resident about the delayed administration. The ADON and DON stated they were not aware the medications had been given late, and the RN overseeing the resident stated the medication aide did not notify her about the delay. The facility policy required review of the 5 rights during medication administration, and the state rule cited that a medication aide may not neglect to administer appropriate medications as prescribed in a responsible manner.
Missing Communication Care Plan for Spanish-Speaking Resident
Penalty
Summary
Resident #3 did not have a comprehensive person-centered care plan that included her Spanish-speaking status and communication needs. She was admitted and readmitted with diagnoses including chronic peripheral venous insufficiency, dysphagia, dementia, gastrostomy status, and mood disorder. Her annual MDS coded her preferred language as Spanish and indicated that she needed or wanted an interpreter to communicate with staff, and she had a BIMS score of 7 out of 15, indicating severe cognitive impairment. The MDS also identified communication as a triggered care area with a care planning decision dated 12/12/2025. During observation, Resident #3 was noted to be Spanish speaking only, with Spanish-speaking signs posted above her bed. Staff including the ADON, DON, and RN used mobile device translator applications as needed to communicate with her. However, record review of her undated care plan showed no care plan for language or communication and no information about her Spanish-speaking status. When asked, the MDS Nurse stated that Resident #3 should have had a communication/Spanish-speaking care plan and acknowledged that it had been an oversight on her part, since she was responsible for annual and quarterly updates to resident care plans. A printed copy of the care plan obtained later on 02/13/2026 showed a newly added focus date and statements that Resident #3 had an interpretation need, would communicate via an interpreter, had Spanish as her preferred language, and had translation needs. The MDS Nurse, SW, DON, and Administrator stated that inaccurate or missing care plans could affect communication and continuity of care. The facility policy stated that every resident would have an individualized interdisciplinary plan of care developed in conjunction with the MDS and CAA process and revised quarterly, with significant changes, annually, or as the resident's condition changed.
Failure to Use EBP PPE During G-Tube Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for 1 of 2 staff reviewed and 1 of 4 residents reviewed. Resident #4 was admitted with diagnoses including epilepsy, dysphagia, and cerebral infarction, and had a BIMS score of 7 out of 15 indicating severe cognitive impairment. The resident had an active order for Jevity 1.5 bolus feeding three times daily and an overnight enteral feeding order, with a gastrostomy tube in place. During observation, Resident #4’s room door had an Enhanced Barrier Precautions sign stating that staff must wear gloves and a gown for high-contact resident care activities, including device care or use such as feeding tube care. RN B was observed at the resident’s bedside administering the bolus feeding with the enteral feeding syringe connected to the gastrostomy tube and holding the Jevity carton, but RN B was not wearing a gown. RN B initially did not respond when asked about the resident’s EBP status and later stated she was not aware the resident was on EBP before the surveyor asked, and that she should have been wearing a gown. The resident stated she did not know whether staff always wore a gown or gloves when giving feedings or handling the gastrostomy tube. RN B later returned and donned and doffed PPE appropriately when administering pain medication, and stated she had been trained on infection control, including EBP and TBP, during orientation. The Infection Preventionist and DON both stated that staff should adhere to EBP and that RN B should have worn the appropriate PPE while providing care to the resident’s gastrostomy tube.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The deficiencies included a vent hood above the oven with grease accumulation, a commercial can opener with dark brown substances between the cutting blade and holder, and unlabeled and undated leftover food items in the walk-in cooler. Additionally, expired food items were found stored in the cooler. These issues were identified during an initial kitchen observation and were confirmed by the Dietary Manager, who acknowledged the presence of expired food and the need for cleaning. The Dietary Manager, who had only been working in the kitchen for three days, was interviewed and expressed an expectation that all food items in the walk-in cooler should be labeled and dated. The acting Administrator noted that the dietary department had all new staff, including the Dietary Manager, who was in the process of cleaning the entire kitchen. The facility's policy on food receiving and storage, revised in 2017, mandates that foods be received and stored in compliance with safe food handling practices, including labeling and dating all stored foods and maintaining clean storage areas.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident representative when a resident experienced a significant change in physical status. The resident, who had a history of chronic kidney disease, cognitive communication deficit, neuromuscular dysfunction of the bladder, and type 2 diabetes, was diagnosed with a urinary tract infection (UTI) on September 30, 2024. Despite the diagnosis, the resident's change in condition, specifically the discoloration of urine to a purple hue, was not reported to the physician until October 8, 2024. This delay in notification resulted in a delay in treatment, as antibiotics were not administered until October 8, 2024, and the resident was not sent to the hospital until October 9, 2024. The resident's urine had been discolored for about a month, yet the facility staff did not take immediate action to address this change. The resident's family had requested that she be sent to the hospital on October 5, 2024, but this request was not honored, and transportation was canceled by the DON after obtaining an order for IV fluids from the physician. The facility's staff failed to communicate effectively with the physician and the resident's family, leading to a lack of timely intervention for the resident's condition. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's condition. The DON and other staff members were not fully aware of the resident's urine discoloration or the family's request for hospital transfer. The facility's policy on notifying the physician and resident representatives of significant changes in condition was not followed, contributing to the delay in addressing the resident's medical needs.
Failure to Provide Timely Care for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a urinary tract infection and a condition known as purple urine syndrome. The resident, who was severely cognitively impaired and dependent on staff for most activities, exhibited symptoms of a urinary tract infection, including discolored urine, which were not promptly reported to the physician. Despite the family's repeated requests for the resident to be sent to the emergency room, the facility delayed in providing necessary medical attention. The facility did not adhere to the physician's orders regarding the size and maintenance of the resident's Foley catheter. The catheter was changed multiple times without following the specified guidelines, and the resident's change in condition was not communicated effectively to the attending physician. This lack of communication and adherence to medical orders contributed to the resident's deteriorating condition. Interviews with staff revealed a breakdown in communication and documentation regarding the resident's care. The Director of Nursing and other staff members were not fully aware of the resident's condition or the family's concerns. The facility's failure to promptly address the resident's medical needs and communicate effectively with the family and medical professionals resulted in a significant deficiency in care.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed to have dirty floors with food particles and grease stains near the stove, deep fryer, and handwashing sink. Additionally, Cook A was seen preparing food without wearing gloves, specifically placing turkey meat into a grinder without proper hand protection. This lack of glove use during food preparation was acknowledged by the Dietary Manager, who confirmed that gloves are necessary to prevent cross-contamination. Interviews with staff revealed a misunderstanding or disregard for proper food handling protocols. Cook A believed gloves were only necessary when handling raw food, not when stirring or placing cooked food into equipment. The Dietary Manager admitted to issues with soap availability, which could further compromise hygiene practices. The facility's policy on preventing foodborne illness emphasizes the importance of personal hygiene and safe food handling, yet these standards were not upheld, placing residents at risk of foodborne illness.
Improper Waste Management in Kitchen and Dumpster Area
Penalty
Summary
The facility failed to ensure proper waste management practices in both the kitchen and the outside dumpster area. Observations revealed that the commercial-sized dumpster located behind the dietary department had its lid open, with trash visible inside. Additionally, two trash cans inside the kitchen were found without lids, one positioned near the stove and the other between the deep fryer and the back door, both containing food particles. These conditions were noted during an inspection, highlighting a lapse in maintaining sanitary waste disposal practices. Interviews with facility staff, including the Dietary Manager and the Regional VP of Operations, confirmed the unsanitary conditions. The Dietary Manager acknowledged that trash cans without lids should not be present in the kitchen and admitted that the trash cans had been lidless since he began working there a month prior. He also noted that the dumpster lid should have been closed to prevent attracting pests. The Regional VP of Operations concurred, stating that both the dumpster and kitchen trash cans should have been covered, as per the facility's policy on waste management. The facility's policy, dated April 20, 2022, mandates that waste containers and dumpsters must have lids when not in use and should not be overflowing, with the surrounding area kept clean and free of odors and rodents.
Failure to Provide Timely Medical Intervention for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, an elderly male with a history of rhabdomyolysis, dysphagia, Type II Diabetes, and hypertension, experienced ongoing vomiting and distress over a period of two days. Despite these symptoms, there was no immediate assessment or treatment provided, nor was the resident's doctor contacted in a timely manner. The resident was eventually transported to the hospital, where he was found to be in a critical condition. The deficiency was identified when it was discovered that the resident had been vomiting for two days without receiving appropriate medical intervention. The night nurse, LPN A, failed to document any changes in the resident's condition or notify the on-call doctor. Additionally, the resident's care plan, which included monitoring and reporting symptoms such as nausea and vomiting, was not followed. The lack of communication and documentation between the nursing staff contributed to the delay in addressing the resident's deteriorating condition. Interviews with staff revealed that the resident's condition was not adequately communicated between shifts, and there was a failure to follow the facility's policy on change in condition. The resident's symptoms, including vomiting and altered mental status, were not promptly reported to the physician, leading to a delay in necessary medical intervention. This oversight resulted in the resident being sent to the hospital in a critical state, where he was diagnosed with aspiration pneumonia and subsequently passed away.
Failure to Provide Timely Care and Communication Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to provide appropriate treatment and care to a resident, identified as CR#1, in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. CR#1, an elderly male with multiple diagnoses including rhabdomyolysis, dysphagia, Type II Diabetes, and hypertension, experienced ongoing vomiting and distress over several days. Despite these symptoms, the facility did not immediately assess and treat the resident or contact the doctor from the onset of symptoms until the resident was transported to the hospital. The deficiency was highlighted by the lack of documentation and communication among the staff. The night nurse, LPN A, failed to document any changes in CR#1's condition or inform the incoming RN A about the resident's vomiting and distress. CNA A and CNA B both reported the resident's condition to LPN A, but there was no follow-up or documentation of any medical intervention. The resident's condition deteriorated over two days, culminating in a hospital admission where he was found to be hypotensive, septic, and suffering from aspiration pneumonia. Interviews with staff revealed a breakdown in communication and adherence to protocols for reporting changes in a resident's condition. The DON was not informed of the resident's condition until the day he was sent to the hospital. The facility's failure to promptly assess and address the resident's symptoms, coupled with inadequate documentation and communication, resulted in an Immediate Jeopardy situation, indicating a serious risk to resident health and safety.
Resident Dignity Compromised by Inappropriate Language
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, specifically in the case of a resident who was referred to as a 'feeder' by a Certified Nursing Assistant (CNA). This resident, a female with severe cognitive impairment and requiring total assistance with eating, was observed lying in bed with a meal tray beside her. The CNA, who was new to the job, admitted to not remembering if she had been trained on resident rights and dignity. During an interview, the Director of Nursing (DON) acknowledged that the term 'feeder' was inappropriate and could negatively impact a resident's dignity. The facility's policy on resident rights, which mandates treating all residents with kindness, respect, and dignity, was not adhered to in this instance. The Administrator confirmed that residents should be referred to as 'Red Napkin Program assisted dining residents' instead of 'feeders' and stated that staff were trained on resident rights and dignity through computer-based training. However, the incident revealed a gap in the implementation of this training, as the CNA was not aware of the appropriate language to use, indicating a deficiency in the facility's adherence to its own policies.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in the resident not receiving the necessary supervision during meals. The resident, who had a history of hemiplegia, muscle weakness, and vascular dementia, required supervision from one staff member while eating, as indicated in her care plan. However, the facility did not provide the required level of assistance during 21 out of 23 meals documented over a period of several days. During an observation, the resident was seen struggling to eat independently due to her hand shaking and weakness, which led to food and beverage spillage. Despite the resident's difficulty and her expressed need for assistance, staff did not provide the necessary supervision or physical help. The CNA responsible for the resident's care was unaware of the care plan interventions and believed the resident could eat independently, which was contrary to the care plan's requirements. Interviews with facility staff, including the DON and the Regional MDS RN, revealed a lack of awareness and adherence to the care plan. The DON acknowledged that the resident should have been assisted if needed, and the Regional MDS RN confirmed that the resident required supervision during meals. The facility's policy on comprehensive care plans emphasized the need for individualized plans, but the staff failed to follow the care plan, resulting in the resident's decreased food intake and potential nutritional risk.
Failure to Provide Meal Assistance
Penalty
Summary
The facility failed to provide necessary supervision and assistance during meals for a resident with multiple health conditions, including hemiplegia, muscle weakness, and vascular dementia. The resident's care plan required supervision by one staff member during meals, but this was not consistently provided. Observations and interviews revealed that the resident struggled to eat independently due to hand tremors and weakness, resulting in food and beverage spillage and inadequate food intake. The resident's care plan and nutritional risk assessment indicated a need for supervision and assistance during meals, yet documentation showed that the resident did not receive the required level of assistance for 21 out of 23 meals over a specified period. The resident experienced a 3.54% weight loss over a 20-day period, highlighting the impact of inadequate assistance on her nutritional status. Staff interviews revealed a lack of awareness and understanding of the resident's care plan requirements, contributing to the deficiency. During an observation, the resident was left alone to eat, and staff did not return to assist, despite the resident's visible difficulty and expressed need for help. The CNA and DON both misunderstood the level of assistance required, believing the resident could eat independently. The facility's policy on comprehensive care plans was not effectively implemented, as staff failed to follow the care plan interventions, leading to the resident's inadequate nutrition and care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Pasadena | 0.2 mi | ★★★★★ | 3 | 0 |
| Pasadena Post Acute | 0.3 mi | ★★★★★ | 6 | 0 |
| Hca Houston Healthcare Southeast | 1.9 mi | — | 0 | 0 |
| The Suites Pasadena | 1.9 mi | ★★★★★ | 24 | 2 |
| Paradigm At Faith Memorial | 2.1 mi | ★★★★★ | 18 | 0 |
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