Deficiency Records for Pasadena Grove Health Center
Updated as of July 01, 2018
This is not the most recent data for Pasadena Grove Health Center. For the most recent information, click here.
A list of the most recent deficiencies for Pasadena Grove Health 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? |
|---|---|---|---|---|
| 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 | 2018-04-16 | 2018-05-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-29 | 2018-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-29 | 2018-04-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-03-08 | 2018-03-15 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-11-22 | 2017-12-19 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-11-22 | 2017-12-19 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-11-22 | 2017-12-19 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-22 | 2017-12-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-11-22 | 2017-12-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-22 | 2017-12-19 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-11-22 | 2017-12-19 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-22 | 2017-12-19 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-22 | 2017-12-19 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-22 | 2017-12-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-11-22 | 2017-12-19 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2017-11-22 | 2017-12-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-11-22 | 2017-12-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-11-22 | 2017-12-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2017-11-27 | 2017-12-18 | 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 | 2017-11-27 | 2017-12-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-11-27 | 2017-12-18 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-15 | 2017-05-31 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-01-10 | 2017-02-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-01-10 | 2017-02-14 | 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 | 2017-01-10 | 2017-02-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-01-10 | 2017-02-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-01-10 | 2017-02-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-01-17 | 2017-02-13 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-01-17 | 2017-02-13 | N |
| Provide written records when a resident is transferred or discharged. | Health | 2017-01-17 | 2017-02-13 | N |
| Tell 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 | 2017-01-17 | 2017-02-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-01-17 | 2017-02-13 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-01-17 | 2017-02-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-01-17 | 2017-02-13 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-17 | 2017-02-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-01-17 | 2017-02-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-01-17 | 2017-02-13 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-01-17 | 2017-02-13 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-01-17 | 2017-02-13 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-01-17 | 2017-02-13 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-01-17 | 2017-02-13 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-01-17 | 2017-02-13 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-01-17 | 2017-02-13 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-01-17 | 2017-02-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-17 | 2017-02-13 | N |
| Dispose of garbage and refuse properly. | Health | 2017-01-17 | 2017-02-13 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-17 | 2017-02-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-17 | 2017-02-13 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-01-17 | 2017-02-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-01-17 | 2017-02-13 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2016-12-16 | 2017-01-17 | Y |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-12-16 | 2017-01-17 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-28 | 2016-12-23 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-28 | 2016-12-23 | Y |
| Maintain comfortable and safe temperature levels. | Health | 2016-06-02 | 2016-06-28 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2015-12-17 | 2016-02-04 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-12-17 | 2016-02-04 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2015-12-17 | 2016-02-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide housekeeping and maintenance services. | Health | 2015-12-17 | 2016-02-04 | N |
| Maintain comfortable and safe temperature levels. | Health | 2015-12-17 | 2016-02-04 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-12-17 | 2016-02-04 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-12-17 | 2016-02-04 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-12-17 | 2016-02-04 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-12-17 | 2016-02-04 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-12-17 | 2016-02-04 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2015-12-17 | 2016-02-04 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2015-12-17 | 2016-02-04 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-12-17 | 2016-02-04 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-12-17 | 2016-02-04 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide food in a way that meets a resident's needs. | Health | 2015-12-17 | 2016-02-04 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-12-17 | 2016-02-04 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-12-17 | 2016-02-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2015-12-17 | 2016-02-04 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2015-12-17 | 2016-02-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2015-12-17 | 2016-02-04 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-12-17 | 2016-02-04 | N |
| Fire resistant room wall surfaces. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Properly maintained smoke detectors. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-12-17 | 2016-01-15 | N |
