Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Suites Pasadena during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, PEG-tube dependence, and no history or orders for diabetes or insulin received approximately 0.5 units of insulin when an RN, newly employed at the facility, failed to correctly identify the resident and confused him with his insulin-dependent roommate. The resident’s active orders and MDS contained no insulin or diabetes diagnosis, and facility policy required verification of the MAR and the five rights of medication administration, including correct resident identification. The error was discovered after the family reviewed video surveillance, and documentation showed a blood glucose of 132 mg/dL at the time of the event, confirming that insulin had been administered without a physician order.
Unsecured construction area accessible to residents: Surveyors found unlocked doors leading from resident areas into an active construction zone with exposed framing, hanging electrical wiring, nails, and wires. A resident was observed entering the dining area unsupervised, and staff said the only barrier was a do not enter sign. The interim administrator stated there were no plans in place to prevent residents from entering the restricted area, while the facility census included many residents with dementia/Alzheimer's disease and several who ambulated independently.
Medications in several medication carts were found without open dates, including morphine sulphate oral solution, levetiracetam solution, lactulose, magnesia solution, multiple topical creams, chlorhexidine oral rinse, Lantus insulin, and other ophthalmic and vaginal products. MA J stated she had not opened the medications and had been off duty, while the DON confirmed that all medications must be dated when opened per CMS regulations and facility policy. The facility policy required medications and biologicals to be labeled in accordance with current state and federal regulations.
The facility failed to complete comprehensive MDS assessments within the required 14 days of admission for three newly admitted residents with complex medical conditions, including CHF, diabetes, chronic respiratory failure with hypoxia, pressure ulcers, dementia, and significant musculoskeletal and neurologic disorders. Record reviews showed incomplete or in‑progress admission and entry MDS assessments that remained unfinished well past the required timeframe, while interviews with the MDS coordinator and regional MDS staff revealed that a recent CHOW, lack of an on‑site MDS coordinator prior to hiring the current one, and the new coordinator’s limited training contributed to delays. The facility’s assessment policy addressed accuracy and professional responsibilities but did not include requirements for MDS completion timing.
A resident with multiple chronic diagnoses, including DM, schizophrenia, seizures, asthma, HTN, and breast cancer, did not have a quarterly MDS completed on time. The DON confirmed the assessment was past due, while MDS staff reported they were behind during a CHOW and that one coordinator was responsible for completing many assessments, resulting in delayed care plan updates.
A resident with severe cognitive impairment, ID, dementia, and multiple medical diagnoses was PASRR positive, but the facility did not incorporate PASRR recommendations into the assessment, care plan, or transition of care. The PASRR office made repeated attempts to process the NFSS form, but the facility did not respond to calls or email, and staff reported confusion about the PASRR process and repeated form rejections related to a physician signature mismatch.
Incomplete Comprehensive Care Plan for a Resident with Multiple Diagnoses: A resident with DM, schizophrenia, breast cancer, asthma, seizures, and HTN had a comprehensive care plan that only addressed seizure-related neurological impairment and possible adverse effects from antianxiety meds. The MDS also showed active DM, schizophrenia, and breast cancer diagnoses and use of diuretic, antiplatelet, and hypoglycemic meds, but these were not reflected in the care plan. The MDS nurse coordinator was still in training, and the DON stated care plans and assessments were created and updated by that staff member.
Failure to enter RD recommendations into active orders for a resident with moderate protein-calorie nutrition. The resident’s care plan called for RD evaluation and diet changes as needed, and the RD recommended sugar free shakes BID, weekly weights, zinc sulfate, vitamin C, and a daily MVI. Those recommendations were not reflected in the active orders when reviewed, and the DON and ADON stated the issue was related to an email/process breakdown after a change of ownership.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required. The care provided was not consistent with the established plan or the resident's expressed wishes.
A CNA failed to provide privacy for a male resident requiring substantial assistance with ADLs and incontinence care, resulting in the resident's exposed buttocks being visible through a window to a surveyor. The CNA did not draw the privacy curtain due to it being stuck, contrary to facility policy and training. The resident, who was cognitively intact, was unaware of the exposure.
A resident with multiple sclerosis and a compromised immune system requested staff to wear masks before entering her room, as indicated by a sign on her door. Despite this, staff members entered without masks, and the resident felt disrespected and that her request was not honored. Interviews revealed inconsistencies in staff understanding and adherence to the resident's preference, highlighting a failure to respect her rights and dignity.
A resident with multiple sclerosis and bipolar disorder was repeatedly served pork, despite it being listed as a dislike on her meal ticket due to religious reasons. Staff interviews revealed a lack of adherence to meal verification processes, with reliance on memory leading to errors. The facility administrator acknowledged the issue, noting that staff were not properly checking meal tickets.
The facility failed to properly store food in the kitchen, as observed with an open container of brown sugar, risking contamination. The Dietary Manager and a staff member acknowledged the oversight, noting potential contamination from insects. The Administrator confirmed the lapse in following storage protocols.
A resident with bipolar disorder was administered Wellbutrin XL without informed consent, violating resident rights. The medication was given for several days before the resident, who was capable of understanding his treatment, discovered the oversight and informed the DON, leading to its discontinuation. Staff interviews revealed a lapse in the process of obtaining necessary consents.
A facility failed to coordinate assessments with the PASRR program for a resident with Major Depressive Disorder, resulting in the denial of specialized services. The necessary NFSS request was not submitted by the deadline, and the resident did not receive eligible therapies and equipment. Interviews revealed confusion among staff about responsibility for PASRR documentation, with the MDS Coordinator unaware of why the follow-up request was not submitted.
A resident with hypertension and heart failure did not receive Metoprolol Tartrate as prescribed due to a medication aide's misinterpretation of the administration parameters. The medication was held on two occasions despite the resident's vital signs being within the prescribed limits. The facility's policy requires medications to be administered as ordered, which was not followed in this case.
The facility failed to secure controlled medications properly, leaving them accessible in an open office. Two blister pack cards containing Acetaminophen with Codeine and Norco were left unattended in the ADON's office, which was open and accessible to staff and residents. The DON acknowledged the oversight, noting that the medications should have been locked up, as per facility policy.
A resident in an LTC facility experienced excessive daytime sleepiness after the DON changed her Seroquel administration time from bedtime to morning without consent. The resident, who was cognitively intact, was not informed of the change, leading to anger and confusion. The DON's actions were unauthorized and not documented, resulting in her termination.
A facility failed to provide adequate wound care for two residents, leading to potential risks. The DON falsified records for one resident, claiming wound care was provided despite being restricted from the resident's room. Another resident did not receive daily wound care as ordered, with the responsible LVN citing overwhelming duties. The facility's documentation policy was not followed, resulting in incomplete and inaccurate records.
A facility failed to maintain proper infection control during wound care for a resident with multiple health conditions. An LVN did not sanitize her hands between glove changes, as observed during a wound care procedure. The resident had missed several wound care services, and the LVN expressed difficulty in managing her expanded duties. The facility's policy required handwashing between glove changes, which was not followed.
Two residents experienced emotional abuse and neglect by the DON. One resident, with bipolar disorder and multiple sclerosis, was denied sufficient adult briefs, causing distress. Another resident, with bipolar disorder and cognitive impairment, was told by the DON that she was getting on her nerves, leading to emotional upset. Staff and residents described the DON's communication as rude and bullying.
Insulin Administered Without Order Due to Resident Misidentification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically the administration of insulin without a physician’s order. The resident was an older male with Parkinson’s disease, dysphagia, muscle weakness, difficulty walking, metabolic encephalopathy, emphysema, COPD, GERD, hyperlipidemia, and a contracted right wrist, and was PEG-tube dependent for nutrition and medications. His admission MDS and care plan did not identify diabetes or insulin dependence, and his active physician orders did not include any insulin. Instead, his orders included medications such as laxatives, carbidopa-levodopa, entacapone, ibuprofen, ondansetron, acetaminophen, cetirizine, esomeprazole, and ipratropium-albuterol, all to be administered via PEG tube or other specified routes. Despite the absence of an insulin order, the resident received approximately 0.5 units of insulin. The RN involved reported that he had been employed at the facility for three days and that he failed to correctly match the resident’s face with the intended recipient of the insulin, confusing the resident with his roommate who required insulin. This error occurred around the scheduled medication time in the morning. The facility’s own medication administration policy required staff to review the MAR to identify the medication to be administered and to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time, as well as to adhere to resident rights, but this verification process was not followed. The incident was discovered after the resident’s family, using video camera surveillance, observed that the resident had been given insulin despite having no such order. Documentation showed a blood glucose value of 132 mg/dL at the time of the event, and the complaint/grievance report confirmed that the wrong medication had been administered. Interviews with facility leadership and clinical staff confirmed that the resident was normally given medications through his PEG tube, that there were no active insulin orders, and that the RN acknowledged failing to verify the resident’s identity before administering the insulin. The facility’s resident rights policy stated that residents have the right to receive services and items included in the plan of care, which in this case did not include insulin therapy.
Unsecured construction area accessible to residents
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision to prevent residents from entering an active construction area. Survey observations showed that parts of hall 100 and the end of hall 300 had signage stating do not enter, but the construction area on halls 100 and 200 remained accessible through unlocked doors. The area contained exposed wooden framing, hanging electrical wiring, nails, and wires, and the dining room was located next to the construction area with approximately 20 residents eating lunch nearby. During observations, a resident was seen walking unsupervised into the dining area to get a snack. The patio door to the courtyard was open, and the patio area contained six beds with electrical cords hanging from them; two beds had mattresses and four had exposed bed springs. Additional observations showed multiple doors between the construction area, dining room, therapy room, and patio were unlocked, allowing access from resident areas into the construction site. Staff interviews indicated that the only barrier initially relied upon was the do not enter sign, and the interim administrator stated there were no plans in place to prevent residents from entering the restricted area. Interviews with staff showed that monitoring was inconsistent and depended on staff sitting by doors to keep residents, staff, and visitors out of the construction area. The DON stated residents were on other halls, while the interim administrator acknowledged the construction area was accessible and that residents could have been injured by the exposure to construction. The resident matrix showed 26 residents with dementia/Alzheimer's disease, and the facility assessment showed 19 residents ambulated independently. The emergency evacuation plan dated 4/22/2025 did not include changes related to the construction.
Medications Left Undated After Opening
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles because multiple medications in Medication Carts #1, #3, and #4 did not have an open date written on the containers. On 01/13/2026 at 10:15 a.m., the DON and ADON observed Medication Cart #1 with morphine sulphate oral solution 100 mg per 5 ml that lacked an opened date. Medication Cart #3 contained three bottles of levetiracetam 100 mg/ml solution, one bottle of magnesia solution, and one bottle of lactulose 10 gm/15 ml solution without open dates. Medication Cart #4 contained triamcinolone/acetonide cream, hydrocortisone cream maximum strength, ketoconazole cream 2%, nystatin and triamcinolone acetonide cream USP, one bottle of lactulose 10 gm/15 ml solution, one bottle of chlorhexidine gluconate oral rinse USP 0.12%, zinc oxide ointment, latanoprost ophthalmic solution 0.005%, Premarin vaginal cream, magnesium citrate saline laxative solution, olopatadine hydrochloride ophthalmic solution USP 0.1%, Lantus insulin 100 units/ml, two nystatin creams, two Voltaren topical gels, and morphine sulphate oral solution 100 mg per 5 ml, all without open dates. During interview, MA J stated she had not opened the medications and had been off duty, but observed them in that condition when she returned to work. She acknowledged that medications must be dated upon opening according to facility policy and safe medication administration practices, and stated that without an open date staff would not be able to determine when the medication expired. The DON confirmed that all medications are required to be dated upon opening in accordance with CMS regulations and facility policy, and acknowledged the facility failed to meet this requirement. Review of the facility policy titled Medication Labeling and Storage, revised 5/16/2025, stated that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medication.
Failure to Complete Timely Comprehensive MDS Assessments After Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive MDS assessments within 14 calendar days of admission for three residents. For one male resident in his eighties with multiple complex diagnoses including congestive heart failure, diabetes, chronic kidney disease, anemia, hyperlipidemia, tracheostomy care, and generalized muscle weakness, record review showed a 20‑day entry MDS assessment dated on his admission date that was not completed. This failure occurred despite his extensive medical needs documented in the clinical record. A female resident with acute and chronic respiratory failure with hypoxia, chronic pain, a left heel pressure ulcer, skin infection, hypertension, protein‑calorie malnutrition, heart disease, type 2 diabetes with neuropathy, insomnia, depression, prior cerebral infarction with dysphagia, cerebrovascular disease, dementia, psychotic disturbance, mood disturbance, and anxiety was also affected. Her clinical record showed a 5‑day entry MDS dated on the day of admission with only section A completed. Her admission MDS, dated six days after admission, remained incomplete more than two weeks later, well beyond the 14‑day requirement. Another female resident with a history of ankylosing spondylitis of the lumbosacral region, displaced intertrochanteric fracture of the right femur, prior falls, senile degeneration of the brain, osteoarthritis, right artificial knee joint, wedge compression fracture of the second lumbar vertebra, major depressive disorder, dementia, psychotic disturbance, mood disturbance, and anxiety also lacked a timely comprehensive assessment. Her record showed the last completed quarterly MDS several months earlier and an admission MDS dated late in the year that remained in progress and incomplete. Interviews with the on‑site MDS coordinator and the regional MDS coordinator confirmed that the facility was behind on required MDS assessments, that the on‑site coordinator was new and still in training, that there had been a CHOW with discharge of all residents, and that one regional staff member was handling all MDSs. The facility’s written policy on conducting accurate resident assessments did not address required MDS timing.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete Resident #23’s quarterly MDS assessment within the required 3-month timeframe. Resident #23 was a female admitted to the facility with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, malignant neoplasm of the left breast, asthma, paranoid schizophrenia, other seizures, and essential hypertension. Her most recent quarterly MDS was completed on 9/29/2025, and the next quarterly assessment due on 12/30/2025 had not been completed as of 1/14/2026 at 3:30 pm. Interview with the DON on 1/14/2026 at 4:45 pm confirmed that comprehensive care plans and assessments are created and updated by MDS A, and the DON acknowledged that Resident #23’s quarterly MDS was past due and should have been completed in December 2025. Interview with MDS B on 1/14/2026 at 1:12 pm revealed the facility was in the middle of a CHOW, resulting in the discharge of all residents, and that she was the only staff member responsible for completing many MDS assessments. MDS B stated the assessments were being completed as quickly as possible but were behind, and that delayed completion could result in incomplete, inaccurate, or delayed care plans. Interview with MDS A on 1/15/2026 at 1:26 pm confirmed she was still in training and aware that Resident #23’s quarterly MDS was past due.
PASRR recommendations not incorporated into resident assessment and care planning
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into Resident #20’s assessment, care plan, and transition of care. Resident #20 was a female admitted on 06/03/25 and readmitted on 11/25/25 with diagnoses including neurocognitive disorder with Lewy bodies, generalized anxiety disorder, unspecified intellectual disabilities, dementia with psychotic disturbance and mood disturbance, cognitive communication deficit, difficulty walking, chronic respiratory failure, stage 4 sacral pressure ulcer, and chronic kidney disease. Her annual MDS dated 11/23/25 showed a BIMS score of 4, indicating severe cognitive impairment. Her care plan identified her as PASRR positive for intellectual disability and stated she would receive specialized services/equipment/habilitative therapies as deemed necessary during her stay. The resident’s Individualized PASRR Care Plan dated 06/26/25 to 06/26/26 indicated recommendations for habilitative services, speech therapy, and occupational services. Record review showed multiple attempts by the PASRR office to send the NFSS form for processing, including a phone call to the facility on 09/15/25 with no answer and an email to the Administrator on 09/24/25 with no response. During interviews, the Resource Manager stated the facility did not currently have an Administrator, and the Rehab Manager said she was new to the facility and did not know how the PASRR process worked. She also stated she sent NFSS forms that were returned several times, including one returned because the physician signature did not match due to a change within the agency. She stated the resident continued to receive the recommended services.
Incomplete Comprehensive Care Plan for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan for Resident #23, a [AGE]-year-old female admitted on [DATE] with diagnoses including Type 2 diabetes mellitus with diabetic polyneuropathy, malignant neoplasm of the left female breast, unspecified asthma, paranoid schizophrenia, other seizures, and essential hypertension. Her care plan, initiated on 12/1/2025, addressed only impaired neurological function related to a seizure disorder and the potential for adverse effects related to antianxiety medications, and did not include other identified conditions or focus areas. Record review showed the MDS identified active diagnoses of diabetes mellitus, schizophrenia, and malignant neoplasm of the left breast, and also indicated that Resident #23 was taking diuretic, antiplatelet, and hypoglycemic medications. During interview, MDS A stated she began working at the end of October 2025 and was still in training for her role as MDS nurse coordinator, and that there was not an MDS nurse coordinator at the facility when she was hired. The DON stated that all comprehensive care plans and assessments are created and updated by MDS A, and that inaccurate care plans place residents at risk by not receiving needed services or can delay needed services.
Failure to Enter RD Recommendations Into Active Orders
Penalty
Summary
The nursing facility failed to ensure that Registered Dietician recommendations were followed for Resident #17, a female admitted on 5/21/2021 with a diagnosis of moderate protein-calorie nutrition. Her active physician order dated 9/29/2025 stated that she may follow Registered Dietician recommendations, and her care plan initiated on 12/8/2025 included an intervention for the Registered Dietician to evaluate and make diet change recommendations as needed and provide and serve supplements as ordered. A Registered Dietician progress note dated 1/2/2026 documented recommendations for sugar free shakes twice daily, weekly weights for 4 weeks, zinc sulfate 220 mg twice daily, vitamin C 500 mg twice daily, and a daily multivitamin. Review of the active physician orders on 1/12/2026 did not reflect those recommendations. The Registered Dietician stated she emailed the recommendations to the DON, ADON, and Dietary Manager, and the DON stated the recommendations were not entered as orders because of a system email issue after a change of ownership. The ADON stated she did not realize her email account was not receiving emails timely and that entering the recommendations was part of her duties.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse was observed during the survey process, but the report does not specify the number of residents affected, their medical histories, or their conditions at the time of the deficiency.
Failure to Provide Privacy During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to provide adequate privacy during incontinence care for a male resident with a history of atherosclerotic heart disease, cognitive communication deficit, lack of coordination, muscle weakness, and impairments in both upper and lower extremities. The resident required substantial assistance with all activities of daily living and was incontinent of bowel and bladder. During the provision of incontinence care, the CNA did not draw the privacy curtain, resulting in the resident's naked buttocks being visible through the window to a surveyor passing by. The CNA stated that the privacy curtain was stuck and admitted she should have tried harder to pull it around before proceeding with care. The resident, who was cognitively intact, was unaware of his exposure during the incident and reported that the CNA typically pulled the privacy curtain during care. Facility policy required staff to provide privacy by pulling the curtain or closing the door during personal care, and the administrator confirmed that this was the expected practice. The failure to ensure privacy during personal care was observed directly by the surveyor and was inconsistent with both facility policy and staff training.
Failure to Honor Resident's Mask Request
Penalty
Summary
The facility failed to honor a resident's request for staff to wear masks before entering her room, which compromised her right to a dignified existence and self-determination. The resident, who was cognitively intact and had a history of multiple sclerosis and bipolar disorder, had a sign posted on her door requesting that masks be worn by anyone entering her room. Despite this, observations revealed that staff members, including a nurse and a medication aide, entered her room without wearing masks. Interviews with the resident indicated that she felt disrespected and that her request was not being honored, as staff members entered her room without masks and did not ask for her permission. The resident expressed that she should not have to remind staff to wear masks, as the sign on her door clearly communicated her preference. The resident's concern was rooted in her compromised immune system and the facility's history of COVID-19 cases. Staff interviews revealed inconsistencies in understanding and honoring the resident's request. While some staff members claimed the resident allowed them to enter without masks, the resident consistently stated that her request was not being respected. The Director of Nursing acknowledged the expectation for staff to meet residents' requests and recognized the potential psychological impact of not doing so. The facility's policy on residents' rights emphasized the importance of treating residents with respect and honoring their preferences.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's dietary preferences, specifically serving pork to a resident who had explicitly indicated a dislike for it due to religious reasons. The resident, a cognitively intact female with multiple sclerosis and bipolar disorder, was served pork despite her meal ticket clearly listing it as a dislike. This incident was confirmed through observations, interviews, and record reviews, revealing that the resident had been served pork on multiple occasions, leading to dissatisfaction and refusal to eat. Interviews with staff, including a nurse, CNA, and dietary aide, highlighted a lack of adherence to meal tickets and verification processes. The CNA admitted to not checking under the food cap cover, resulting in the resident being served pork. The dietary aide acknowledged the mistake and attempted to rectify it by offering alternatives, but the resident refused. The facility administrator was aware of the issue and noted that staff were not verifying meals against tickets, relying instead on memory, which led to repeated errors in meal service for the resident.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage of food items in the kitchen. During an observation, a 13.7-quart container of brown sugar was found left open to the air in the facility pantry. This oversight was confirmed through interviews with the Dietary Manager and a staff member, who acknowledged that the brown sugar was not properly sealed. The Dietary Manager noted that leaving the brown sugar uncovered could lead to it becoming hard, going bad quickly, and being susceptible to contamination from insects or other items falling into it. The staff member involved admitted to moving quickly and forgetting to close the container, recognizing that this could lead to contamination by bugs. The Administrator was informed of the incident and confirmed that the cook had neglected to replace the lid and plastic wrapper on the container, which could allow bugs to enter and contaminate the sugar. The facility's Food Receiving and Storage Policy requires dry foods to be stored in a manner that maintains packaging integrity, and the U.S. Food and Drug Administration guidelines were referenced regarding the handling of food in sealed containers.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment, specifically regarding the administration of the antipsychotic medication Wellbutrin XL. The resident, a 61-year-old male with a diagnosis of bipolar disorder, was administered Wellbutrin XL without a signed consent form. The medication was given from September 17 to September 25, 2024, without the resident's informed consent, which is a violation of resident rights. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was capable of understanding and participating in discussions about his treatment. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the responsibility for obtaining informed consent was not fulfilled. The nurse stated that the provider is responsible for informing the resident about prescribed medications, while the nurse must ensure a signed consent is obtained before administration. The DON acknowledged the failure to obtain consent and stated that the medication was discontinued once the issue was brought to her attention by the resident. The facility was unable to provide the policy for Psychoactive Medication Informed Consent when requested.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for one of the residents reviewed. The resident, a 45-year-old female with a diagnosis of Major Depressive Disorder, was admitted to the facility and was eligible for PASRR specialized services. However, the facility did not submit the necessary Nursing Facility Specialized Services (NFSS) request by the specified deadline, resulting in the denial of the request. Consequently, the resident did not receive the specialized services she was eligible for, such as therapies and assessments, and durable medical equipment. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing and submitting PASRR documentation. The Director of Nursing (DON) indicated that the MDS Coordinator was responsible for ensuring PASRR completion, while the Administrator, new to the facility, was unaware of the responsible party. The MDS Coordinator acknowledged that the PASRR Level 1 screening was completed but did not know why the NFSS follow-up request was not submitted. The failure to submit the request was attributed to the resident being identified as Medicaid Pending, which led to the resident not receiving the necessary services.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Metoprolol Tartrate, a medication prescribed for hypertension and heart failure. The resident, an elderly female with diagnoses including hypertension, heart failure, and respiratory failure, was admitted to the facility with a physician's order for Metoprolol Tartrate to be administered daily, with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, the medication was not administered on two consecutive days, despite the resident's SBP and HR being within the prescribed parameters. The medication administration record (MAR) indicated that the medication was held due to an incorrect interpretation of the parameters by the medication aide (MA A), who believed the medication should be held due to the resident's diastolic blood pressure (DBP) being low, although no parameter was set for DBP. The Director of Nursing (DON) confirmed that the medication should not have been held and that the physician's order should have been followed. The facility's policy on administering medication emphasizes that medications should be administered as prescribed, which was not adhered to in this instance.
Failure to Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured properly, as observed during a survey. The Assistant Director of Nursing's (ADON) office was left open and accessible to staff and residents, with two blister pack cards of controlled medications visible on an over-bed table. These medications included 77 tablets of Acetaminophen with Codeine for one resident and 21 tablets of Norco for another resident. The Director of Nursing (DON) and ADON had left the office unattended, and upon their return, the DON acknowledged that the medications should have been locked up, as they were controlled substances. The DON explained that the medications were brought to her by a nurse and that she was called away, leaving the medications unsecured for approximately three minutes. The ADON was unaware of the medications' presence in her office and stated that she would have locked the door had she known. The facility's policy requires that drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. The failure to secure these medications placed the facility at risk for drug diversion, as anyone could have taken the medications during the time the office was left open.
Unauthorized Medication Change Leads to Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints imposed for convenience, as evidenced by the unauthorized change in medication administration time for a resident diagnosed with bipolar disorder. The Director of Nursing (DON) altered the administration time of Seroquel, a psychotropic medication, from bedtime to morning without obtaining verbal consent from the resident or a physician. This change resulted in the resident experiencing excessive daytime sleepiness, which was not in line with her treatment plan. The resident, who was cognitively intact and her own responsible party, was not informed of the change and did not consent to it. The alteration in medication timing led to the resident sleeping throughout the day, which was contrary to her usual routine and care plan. The resident expressed anger and confusion upon discovering the change, which was confirmed by a Licensed Vocational Nurse (LVN) who investigated the resident's concerns. The DON's actions were not supported by documentation or a physician's order, as required by the facility's medication policy. Interviews with facility staff, including the Administrator and the physician, revealed that the DON did not have authorization to make such changes without proper documentation and consent. The physician could not recall authorizing the change, and the Administrator confirmed that the DON's actions were inappropriate given the resident's cognitive status. The DON was subsequently terminated due to job performance issues related to this incident and another involving a different resident.
Failure to Provide Adequate Wound Care and Falsification of Records
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice for two residents. For Resident #1, the Director of Nursing (DON) falsified documentation indicating that wound care was provided on specific dates, despite being restricted from entering the resident's room. This resident, who has multiple sclerosis and other health conditions, reported that the DON falsely claimed to have provided care, which was corroborated by the facility's administration. Resident #2, who has type 2 diabetes and other serious health conditions, did not receive daily wound care as ordered by the physician. The Licensed Vocational Nurse (LVN) responsible for this care failed to provide the necessary treatment on multiple occasions, as documented in the wound administration record. The resident reported that her wound was not being treated daily as required, and there was an odor emanating from the wound, indicating a lack of proper care. Interviews with staff revealed that the LVN felt overwhelmed by her expanded duties, which included medication administration in addition to wound care. The facility's administration acknowledged the staffing challenges but emphasized the importance of following physician orders to prevent harm to residents. The facility's documentation policy requires accurate and complete records, which were not maintained in these cases, leading to potential risks for the residents involved.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of wound care for a resident. A Licensed Vocational Nurse (LVN) did not properly sanitize her hands between glove changes while providing wound care to a resident with multiple health conditions, including type 2 diabetes, heart failure, and chronic kidney disease. This oversight was observed during a wound care procedure where the LVN did not have hand sanitizer available and proceeded to change gloves without sanitizing her hands, potentially risking cross-contamination and infection spread. The resident involved had three wound care orders, and it was noted that wound care services were not provided on several occasions in March 2024. The LVN expressed that her expanded duties, which now included medication passes, made it difficult to complete her tasks. The facility's wound care policy, revised in October 2010, clearly outlined the need for handwashing between glove changes, which was not adhered to during the observed procedure. The facility administrator acknowledged the importance of hand sanitization between glove changes to prevent the spread of infections like MRSA.
Emotional Abuse and Neglect by DON
Penalty
Summary
The facility failed to protect two residents from emotional abuse by the Director of Nursing (DON). Resident #1, who has bipolar disorder and multiple sclerosis, was subjected to emotional abuse when the DON cursed at her and restricted her access to adult briefs. The resident, who is incontinent and requires frequent changes, was left without sufficient supplies, causing distress and frustration. The DON's actions included locking up the diapers and refusing to provide more when requested, leading to Resident #1 feeling neglected and emotionally distressed. Resident #2, who has a diagnosis of bipolar disorder and moderate cognitive impairment, also experienced emotional abuse from the DON. The DON reportedly told Resident #2 that she was getting on her nerves, which made the resident feel bad and upset. This behavior was repeated on multiple occasions, contributing to the resident's emotional distress. Interviews with staff and residents revealed a pattern of the DON's inappropriate communication and neglectful behavior. The DON was described as having a bully attitude and being rude, with staff and residents expressing fear and frustration. The facility's administrator acknowledged the lack of proper documentation and training for the DON, who was new to the role. The facility's policies on abuse and neglect were not effectively implemented, leading to the deficiencies observed.
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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) |
|---|---|---|---|---|
| Hca Houston Healthcare Southeast | 0.1 mi | — | 0 | 0 |
| Baywood Crossing Rehabilitation & Healthcare Cente | 1.2 mi | ★★★★★ | 3 | 0 |
| Avir At Pasadena | 1.8 mi | ★★★★★ | 3 | 0 |
| Focused Care At Pasadena | 1.9 mi | ★★★★★ | 8 | 0 |
| Pasadena Post Acute | 2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.