Average — CMS composite of the measures below.
The next survey window likely opens around April 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 The Courtyards At Pasadena during CMS and state inspections, most recent first.
Failure to prime insulin and GLP-1 injection pens and to hold the pen in place long enough during administration led to incomplete medication delivery for two residents with Type 2 DM. An LVN administered Humalog without priming, and an RN administered Humalog and liraglutide without priming either pen; the RN also removed the Humalog pen immediately, with insulin seen running down the resident's abdomen. The DON and facility reference materials confirmed the required priming and hold-time instructions.
Unsafe food handling and temping occurred during lunch meal service when a dietary employee used a paper towel instead of sanitizing wipes to clean a thermometer between food temps, changed gloves without washing hands, and prepared grilled cheese sandwiches that were never temped. An LTC dietary manager was also observed with a hair net that did not fully cover her hair and later touched trash and the trashcan lid before returning to the serving area with unwashed hands.
Staff failed to follow infection control practices during glucose checks, incontinence care, and catheter care. An LVN and RN did not consistently perform hand hygiene between glove changes and resident contact, a glucometer was not allowed the full disinfectant contact time, and CNAs and an RN did not use required EBP PPE or hand hygiene during high-contact care tasks.
A resident with HTN, DM2, dementia, and non-traumatic brain dysfunction had a BIMS of 12 and required O2 at 4 L/min via NC per orders, but the care plan did not include oxygen therapy as a care area. During observation, the resident was asleep with O2 in place, the concentrator was set at 4 L/min, and the NC tubing was not dated. The MDS nurse, ADON, and DON stated care plans were to be updated for new orders and that oxygen therapy should be care planned according to the MD order.
Failure to provide nail care and grooming assistance for a resident with DM, CVA with hemiplegia, HTN, and HF. The resident required partial/moderate help with personal hygiene, but was observed with long, dirty fingernails and stated she wanted them trimmed and cleaned. CNA I said the nails needed care, and the ADON and DON stated CNAs and nurses were responsible for routine grooming and nail care, including for residents with DM.
A resident who required O2 had tubing and a humidifier bottle that were not dated or changed per the MD order for weekly replacement. Observation showed the resident on 4 L/min via NC, with the tubing undated and the humidifier bottle carrying an older date; an LVN and the DON confirmed the expected weekly dating and replacement process, and the facility policy required tubing and humidifier labeling with date, time, and RC practitioner initials.
The facility's kitchen failed to meet food service safety standards, with observations of unclean conditions such as dark grease in the deep fryer, baked-on grease in the stove, and grease dripping from the rails above the stove. The Dietary Manager, new to the facility, acknowledged the need for cleaning and was responsible for ensuring kitchen cleanliness, as per the facility's revised sanitation policy.
The facility failed to ensure accurate assessments for three residents, leading to potential risks of inadequate care. A resident's admission MDS inaccurately reflected her hearing ability and oral dental needs. Another resident's quarterly MDS did not capture functional limitations in his extremities despite a history of stroke. A third resident's discharge MDS failed to document a fall, which was later corrected by the MDS Coordinator.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the absence of proper signage and PPE usage for two residents on enhanced barrier precautions. Staff members demonstrated a lack of knowledge regarding the protocol, leading to improper infection control practices. The DON acknowledged the oversight in ensuring proper signage and PPE availability, as required by the facility's policies.
The facility failed to complete discharge summaries for two residents, one who passed away and another discharged unexpectedly. The SW was not trained to handle unplanned discharges, leading to incomplete records. The facility's policy required the SW to initiate discharge summaries for all discharges, but a lack of training and misunderstanding of responsibilities resulted in this deficiency.
A resident with dementia and anxiety disorder did not receive a psychiatric consultation despite a physician's order. The facility failed to follow up on the order, and staff interviews revealed a lack of awareness and documentation regarding the resident's need for psychiatric services. This oversight could risk the resident's mental health and quality of life.
A facility failed to perform ordered blood glucose checks for a resident with Type 2 Diabetes Mellitus, due to an error in entering the order into the electronic medical record. The order was not included in the 24-hour report or progress notes, leading to a lack of awareness among nursing staff. The resident did not experience adverse effects from the missed checks.
The facility failed to maintain an infection prevention and control program, as evidenced by two CNAs' improper handling of used wipes and clean gloves during incontinent care for a resident. These actions, despite prior training, did not adhere to proper infection control practices and placed residents at risk for cross-contamination and infection.
Failure to Prime and Properly Administer Diabetes Injection Pens
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquisition and administration of medications for two residents receiving diabetes-related injections. One resident, a female with Type 2 diabetes and an order for insulin lispro 4 units subcutaneously three times daily before meals, was observed receiving an insulin pen injection from an LVN who attached the needle, dialed the dose, and administered the medication without priming the pen first. The LVN stated she was not aware she had to prime the insulin pen and had not read the manufacturer's instructions for administration. A second resident, a male with Type 2 diabetes, had orders for insulin lispro 12 units before meals and liraglutide 0.6 mg daily. During observation, an RN obtained the resident's blood sugar, reviewed the orders, and then prepared both pens without priming either one. The RN injected the Humalog into the resident's abdomen and immediately removed the pen, with insulin observed running down the resident's abdomen. She then administered liraglutide and held that pen against the skin for about 6 seconds. The RN stated she was not aware she had to prime the insulin pens or liraglutide and acknowledged she did not hold the Humalog pen in place long enough. The DON stated the insulin pen was to be primed with 2 units before each injection to ensure air was out of the pen and to confirm it was working correctly, and that failure to do so could result in the resident receiving too little medication and ineffective treatment with uncontrolled blood sugars. Facility reference material and manufacturer instructions reviewed by surveyors stated that Humalog should be primed before each injection and that liraglutide should be primed for a new pen, with the needle held under the skin for at least 6 seconds to help ensure the full dose is delivered.
Unsafe Food Handling and Temperature Monitoring During Meal Service
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards in the kitchen during lunch meal service. During observation, Dietary G took temperatures of food without using sanitizing wipes between items, stating that wipes had not come in. Instead, she used a paper towel that she had held under her arm against her clothing, placed it on the counter, and wiped the thermometer with it between food temperatures. After temping the Salisbury steak, she dropped the paper towel on the floor, picked it up, and continued using it to wipe the thermometer before taking the temperature of the mixed vegetables. During the same meal service, Dietary G was observed handling food and equipment while changing gloves without washing her hands between tasks. She removed gloves after placing fresh cooked bread rolls in a tray, put on new gloves without handwashing, and continued handling food and equipment, including retrieving items from the freezer and buttering bread rolls. She later made grilled cheese sandwiches, removed her gloves, did not wash her hands, put on new gloves, and continued working. The grilled cheese sandwiches were set aside and were never temped. The Dietary Manager was also observed with a hair net that only covered her ponytail, leaving the sides and back of her head exposed, and later touched trash and the trashcan lid before returning to the serving trays with unwashed hands. During interview, Dietary G stated she realized she had forgotten to wash her hands between glove changes and acknowledged that paper towels were not an appropriate substitute for sanitizing wipes. She stated all foods should have been temped, including the grilled cheese, and that using paper towels and holding them against her clothing could cause cross contamination. The Dietary Manager and Administrator both confirmed that hand hygiene was required after glove removal, that all food should be temped before serving, that sanitizing wipes should be used between food temperatures, and that hair nets should cover all hair.
Infection Control Failures During Glucose Monitoring, Incontinence Care, and EBP Procedures
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program during multiple observed care events involving residents with diabetes, incontinence, catheter care, and Enhanced Barrier Precautions. During blood sugar monitoring for one resident with type 2 diabetes, an LVN did not perform hand hygiene after glove removal, did not wait the full 2-minute contact time for the glucometer disinfectant wipe before using the device on another resident, and then continued medication administration without hand hygiene between tasks. The LVN later stated she knew hand hygiene was required after glove changes and that she had not waited the full disinfection time for the glucometer. During another blood sugar check for a resident with type 2 diabetes, an RN sanitized the glucometer, removed gloves, and did not perform hand hygiene before entering the resident’s room. After obtaining the fingerstick blood sugar, the RN again removed gloves and did not perform hand hygiene before checking the computer and retrieving insulin and liraglutide pens. The RN then attached needles, dialed the doses, sanitized her hands, and administered the injections. The RN stated she should have performed hand hygiene after sanitizing the glucometer, after obtaining the fingerstick blood sugar, and after returning to the medication cart. The facility also failed during incontinence and catheter care. Two CNAs providing incontinence care to one resident did not perform hand hygiene when moving from dirty to clean tasks and continued care while wearing contaminated gloves. For another resident on Enhanced Barrier Precautions, two CNAs entered the room for catheter and incontinence care without gowns, used double gloves, and did not perform hand hygiene when changing gloves or moving between care tasks. For a resident with a suprapubic catheter who was also on Enhanced Barrier Precautions, an RN performed catheter care without a gown and changed gloves during the procedure without hand hygiene. The DON stated that staff were required to wear gown and gloves for high-contact activities on residents on Enhanced Barrier Precautions and that staff were to change gloves and perform hand hygiene when moving from dirty to clean tasks.
Missing Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident that included measurable objectives and time frames to meet medical, nursing, mental, and psychosocial needs. Resident #129 had diagnoses including hypertension, type 2 diabetes mellitus, Non-Alzheimer's Dementia, and Non-Traumatic Brain Dysfunction, and the Quarterly MDS dated 04/23/26 showed a BIMS score of 12, indicating moderate cognitive impairment. Section O-C1 reflected that the resident required oxygen while in the facility, and the Order Summary Report dated 06/30/25 showed oxygen at 4 liters per minute via nasal cannula with instructions to change the oxygen tubing, nasal cannula, mask, and humidification system weekly. Record review of the care plan dated 04/09/26 did not show oxygen therapy as a care area or problem. During observation on 05/12/26 at 10:12 a.m., the resident was asleep in the room with oxygen in place via nasal cannula, the concentrator was set at 4 liters per minute, the nasal cannula tubing was not dated, and the solution bottle on the concentrator was dated 04/28/26. In interviews, the MDS Nurse stated he was responsible for care plans and that charge nurses were also responsible for updating them when there was a new order or change in condition; he said updates were done quarterly during the IDT meeting. The ADON stated she had been reviewing and updating care plans over the prior three months but had not yet gotten to this resident's care plan, and the DON stated residents' oxygen therapy should be care planned according to doctor's orders.
Failure to Provide Nail Care and Grooming Assistance
Penalty
Summary
The facility failed to provide the necessary services for a resident who was unable to carry out activities of daily living to maintain good grooming and personal hygiene. Resident #86, a female with diagnoses including hypertension, type 2 diabetes mellitus, cerebral vascular accident with hemiplegia, and heart failure, had a quarterly MDS dated 04/08/26 showing a BIMS score of 14/15 and requiring partial/moderate assistance for personal hygiene. Her care plan, revised on 04/22/26, reflected partial/moderate assistance with ADLs and included interventions to encourage and provide positive feedback for any effort. On 05/12/26, the resident was observed lying in bed with long fingernails on both hands, approximately 0.4 cm beyond the fingertips, with tan discoloration and dark brown residue under the nails. The resident stated she wanted her fingernails trimmed and cleaned. During later observation and interview, CNA I stated the nails needed to be trimmed and cleaned and said nurses and CNAs were responsible for nail care, with nurses responsible for residents with diabetes. The ADON stated nail care should be done on shower days and as needed, and the DON stated CNAs were responsible for checking residents each shift and providing appropriate grooming, with nurses also responsible for ensuring needs were met.
Oxygen tubing and humidifier bottle not dated or changed per order
Penalty
Summary
Resident #129, a [AGE]-year-old female with diagnoses including hypertension, type 2 diabetes mellitus, Non-Alzheimer’s Dementia, and Non-Traumatic Brain Dysfunction, required oxygen while at the facility and had a BIMS score of 12 indicating moderate cognitive impairment. Her care plan dated 04/09/26 did not include oxygen therapy, although her order summary directed oxygen at 4 liters per minute via nasal cannula and required the oxygen tubing, nasal cannula, mask, and humidification system to be changed weekly on Thursdays. On 05/12/26, observation of the resident showed she was asleep with oxygen in place via nasal cannula, the concentrator was set at 4 liters per minute, the nasal cannula tubing was not dated, and the humidifier bottle on the concentrator was dated 04/28/26. During interview, an LVN stated the tubing was not dated and that she would change the bottle because of the old date, and said nurses were responsible for checking oxygen tubing each shift and night shift nurses were responsible for changing the tubing and solution bottle weekly. The DON stated nurses were expected to change and date the oxygen tubing weekly and change and date the solution bottle weekly, and the facility policy required tubing and humidifier to be labeled with date, time, and RC practitioner initials.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain food service safety standards in its only kitchen, as observed during a survey. The deep fryer contained dark grease with brown floating substances, indicating it had not been changed as required. The Dietary Manager admitted uncertainty about the last time the grease was changed, suggesting it was supposed to be done weekly. Additionally, one of the stoves had baked-on grease inside the oven, and the grease trap rails above the stove were observed to have grease dripping along them. The Dietary Manager acknowledged the need for cleaning and stated that all kitchen employees were responsible for maintaining cleanliness, although she was ultimately responsible for ensuring the kitchen's cleanliness. The facility's Dietitian noted that the Dietary Manager was new, having been at the facility for about three weeks, and had made efforts to clean the kitchen. The facility's policy on kitchen sanitation, revised in June 2023, assigns the Certified Dietary Manager the responsibility for food safety and sanitation. However, the observations during the survey indicated lapses in adhering to these standards, potentially placing residents at risk for food-borne illnesses due to the unclean conditions in the kitchen.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to potential risks of inadequate care. Resident #9's admission MDS inaccurately reflected her hearing ability and oral dental needs. Despite her cognitive intactness, she reported difficulty hearing and issues with her dentures, which were not captured in the MDS. The MDS Coordinator was not responsible for the oral dental section, which was handled by the speech therapist, who only assessed swallowing difficulties. Resident #43's quarterly MDS did not accurately reflect his functional limitations in the range of motion of his extremities. Despite having a history of stroke with right-sided deficits and severe cognitive deficits, the MDS did not capture any limitations. Observations and interviews confirmed that the resident had contractures and weakness, which were not documented in the MDS. The MDS Coordinator acknowledged the resident's weakness but did not recognize the contractures that limited his range of motion. Resident #380's discharge MDS failed to document a fall that occurred on 2/8/25. The resident, who had moderate cognitive impairment, was found on the floor, but this incident was not initially recorded in the MDS. The MDS Coordinator admitted to missing the fall and later corrected the MDS. Interviews with staff confirmed the fall, but the initial oversight in documentation could have impacted the resident's care plan.
Inadequate Infection Control Practices and Signage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of proper signage and personal protective equipment (PPE) usage for residents on enhanced barrier precautions. Specifically, two residents, a female with end-stage renal disease and a male with a nontraumatic intracerebral hemorrhage, were not properly identified with signage indicating their need for enhanced barrier precautions. Observations on multiple occasions revealed the absence of such signage on their doors, which is a critical component of the facility's infection control policy. Additionally, staff members, including CNAs, demonstrated a lack of knowledge and adherence to the enhanced barrier precautions protocol. Interviews with CNAs revealed confusion and incorrect understanding of which residents required enhanced barrier precautions and the appropriate PPE to use. For instance, one CNA incorrectly stated that a resident was not on precautions and admitted to not wearing a gown while providing care, despite the resident's care plan indicating the need for enhanced barrier precautions. The Director of Nursing (DON) acknowledged the oversight in ensuring proper signage and PPE availability, as well as the need for enhanced barrier precautions for residents with specific medical conditions such as wounds, feeding tubes, and catheters. The facility's infection prevention and control policies require clear signage and the use of gowns and gloves during high-contact resident care activities, which were not consistently implemented, potentially exposing residents to infectious diseases.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for two residents, which included a recapitulation of their stay and their final status at discharge. For one resident, a 77-year-old male with diagnoses including brain cancer, dementia, repeated falls, pain, and seizures, there was no discharge summary completed after he passed away at the facility. The Social Worker (SW) was unaware of their responsibility to complete discharge summaries for residents who died, believing that charge nurses were responsible for unplanned discharges. This misunderstanding was due to a lack of training on completing discharge summaries for unplanned discharges, as the SW had only been trained on planned discharges. Another resident, a male with end-stage renal failure, hypertensive chronic kidney disease, anemia, hypothyroidism, dysphasia, and pain, was discharged from the facility without a discharge summary. The SW did not complete the discharge summary because the resident was part of a special program that discharged him. The facility's policy stated that the SW was responsible for initiating discharge summaries for all discharges, but the SW was not trained on how to complete summaries for unplanned discharges or after a resident was discharged from the electronic medical record system. This lack of training and misunderstanding of responsibilities led to the deficiency.
Failure to Provide Psychiatric Consultation for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #51, who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services. Despite a physician's order written on September 19, 2024, for a psychiatric consultation with Deer Oaks for psychological and psychiatric services, the facility did not follow up to ensure the consultation occurred. This oversight was identified during a review of Resident #51's records, which showed no documentation of any referral to psychiatric services or notification to a physician or nurse practitioner regarding the need for such services. Resident #51, a female admitted on May 8, 2024, with diagnoses including unspecified dementia and anxiety disorder, had a BIMS score indicating moderate cognitive impairment. Her care plan, updated on May 24, 2024, included interventions for arranging psychiatric services due to increased signs of anxiety and aggressive behaviors. However, interviews with facility staff, including the Director of Nursing, MDS nurse, and social workers, revealed a lack of awareness or follow-up on the psychiatric consultation order. The responsible party for Resident #51 was also unaware of any orders for psychiatric services. The facility's policy on psychological services, dated June 9, 2023, outlines procedures for assessing and addressing behavioral health needs, including timely referrals for further evaluation and treatment. Despite this policy, there was no documentation to justify why Resident #51's needs were not addressed, and the failure to provide the necessary psychiatric consultation could place residents at risk for not receiving behavioral health services and a decline in quality of life.
Failure to Perform Ordered Blood Glucose Checks
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered for a resident, specifically blood glucose checks, which were not performed on the specified dates. The resident, a male with chronic conditions including Type 2 Diabetes Mellitus, had an order for blood glucose checks three times a day before meals. However, these checks were not documented or performed on the dates specified, leading to a delay in monitoring the resident's blood sugar levels. Interviews revealed that the order for blood glucose checks was entered incorrectly into the electronic medical record, causing it to be placed on the wrong flow sheet. This error resulted in the nursing staff not being aware of the new order, as it was not included in the 24-hour report or progress notes. The Director of Nursing and other staff acknowledged the oversight, and it was noted that the resident did not suffer any adverse effects from the missed checks. The facility's policies require that new orders be documented in the resident's chart and included in the 24-hour report, which was not followed in this instance.
Infection Control Deficiencies During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to a resident. CNA B was observed throwing used wipes across the resident's bed to a trash can on the opposite side, with some wipes falling on the floor. This practice could potentially spread microorganisms into the air and cause contamination. Additionally, CNA C was seen removing clean gloves from her scrubs pocket and donning them during the same care session, despite acknowledging that her pocket was not sanitized and could contaminate the gloves. Both CNAs had received training on infection control, but their actions during this incident did not reflect adherence to proper infection control practices. The resident involved was a male with multiple diagnoses, including the need for assistance with personal care, hypertension, acute respiratory failure, and cognitive communication deficit. He required extensive assistance for ADL care and one-person physical assistance. The facility's policy on infection prevention and control, dated 02/17/2021, outlined the need for proper handling of waste and supplies, as well as training for employees on hand hygiene and other infection control measures. Despite this policy, the observed deficiencies in infection control practices by the CNAs placed residents at risk for cross-contamination and infection.
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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.
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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) |
|---|---|---|---|---|
| Focused Care At Pasadena | 2.3 mi | ★★★★★ | 8 | 0 |
| Avir At Pasadena | 2.3 mi | ★★★★★ | 3 | 0 |
| Pasadena Post Acute | 2.6 mi | ★★★★★ | 6 | 0 |
| Baywood Crossing Rehabilitation & Healthcare Cente | 3 mi | ★★★★★ | 3 | 0 |
| Hca Houston Healthcare Southeast | 3 mi | — | 0 | 0 |
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