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? |
|---|---|---|---|---|
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-12-15 | 2023-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-18 | 2023-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-04 | 2023-09-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-05 | 2023-06-27 | Y |
| 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 | 2023-05-18 | 2023-06-18 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-02-16 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-04 | 2023-02-05 | 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 | 2022-11-07 | 2022-12-07 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-20 | 2022-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-10-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-20 | 2022-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-12 | 2022-04-08 | Y |
| 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 | 2022-03-11 | 2022-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-07 | 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 | 2022-03-11 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-07 | 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 | 2022-03-11 | 2022-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-07 | N |
| Post nurse staffing information every day. | Health | 2022-03-11 | 2022-04-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-03-23 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-02-01 | 2022-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-30 | 2021-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-30 | 2021-09-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-14 | 2021-07-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-07-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-07-30 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-07 | 2020-02-03 | 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 | 2020-01-07 | 2020-02-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-12-29 | 2020-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-29 | 2020-01-21 | 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 | 2019-12-29 | 2020-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-29 | 2020-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-29 | 2020-01-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-29 | 2020-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-29 | 2020-01-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-29 | 2020-01-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-22 | 2019-01-30 | 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 | 2018-12-22 | 2019-01-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-12-22 | 2019-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-22 | 2019-01-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-22 | 2019-01-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-22 | 2019-01-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-16 | 2019-01-15 | 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 | 2018-12-16 | 2019-01-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-16 | 2019-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-16 | 2019-01-15 | 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 | 2018-12-16 | 2019-01-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-16 | 2019-01-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-12-16 | 2019-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-16 | 2019-01-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-12-16 | 2019-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-16 | 2019-01-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-16 | 2019-01-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-12-16 | 2019-01-15 | N |
