Deficiency Records for Pasadena Park Healthcare and Wellness Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Pasadena Park Healthcare and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-22 | 2024-01-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-22 | 2023-12-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-24 | 2023-06-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-13 | 2023-05-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-13 | 2023-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-13 | 2023-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-13 | 2023-05-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-13 | 2023-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-13 | 2023-05-18 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-13 | 2023-05-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-13 | 2023-05-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-13 | 2023-05-18 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-13 | 2023-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-04-17 | 2023-05-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-25 | 2022-11-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-24 | 2020-02-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-24 | 2020-02-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-24 | 2020-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-24 | 2020-02-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide appropriate foot care. | Health | 2020-01-24 | 2020-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-24 | 2020-02-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-24 | 2020-02-20 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-01-24 | 2020-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-24 | 2020-02-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-23 | 2020-02-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-23 | 2020-02-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-23 | 2020-02-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-23 | 2020-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-23 | 2020-02-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-11 | 2019-02-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-11 | 2019-02-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-11 | 2019-02-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-11 | 2019-02-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-11 | 2019-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-11 | 2019-02-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-11 | 2019-02-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-11 | 2019-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-11 | 2019-02-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-14 | 2019-02-11 | N |
