A list of the most recent deficiencies for Pasadena Care Center, LLC. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-05 | 2024-02-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-08 | 2024-01-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2024-01-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-07 | 2023-12-08 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-11-07 | 2023-12-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-10 | 2023-09-08 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-29 | 2023-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-07-24 | 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 | 2023-06-29 | 2023-07-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-29 | 2023-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-24 | 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 | 2023-06-29 | 2023-07-24 | 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 | 2023-06-29 | 2023-07-24 | 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 | 2023-06-29 | 2023-07-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-29 | 2023-07-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-29 | 2023-07-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-29 | 2023-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-29 | 2023-07-24 | N |
| Have policies on smoking. | Health | 2023-06-29 | 2023-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-06-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-16 | 2023-05-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-16 | 2023-05-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-16 | 2023-05-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-26 | 2022-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-26 | 2022-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-03-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-06-24 | 2021-07-21 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-08 | 2021-06-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-17 | 2019-10-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-17 | 2019-10-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-09-17 | 2019-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-17 | 2019-10-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-17 | 2019-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-08 | 2019-10-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-08 | 2019-10-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-08 | 2019-10-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-08 | 2019-10-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-08 | 2019-10-02 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-08 | 2019-10-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-08 | 2019-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-08 | 2019-10-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-08 | 2019-10-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-08 | 2019-10-02 | 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 | 2019-09-08 | 2019-10-02 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-08 | 2019-10-02 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Develop a communication plan. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-14 | 2018-11-16 | 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 | 2018-09-14 | 2018-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-14 | 2018-11-16 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-09-17 | 2018-10-09 | 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 | 2018-09-17 | 2018-10-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-17 | 2018-10-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-17 | 2018-10-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-17 | 2018-10-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-17 | 2018-10-09 | 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 | 2018-09-17 | 2018-10-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-17 | 2018-10-09 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-09-17 | 2018-10-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-17 | 2018-10-09 | 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 | 2018-09-17 | 2018-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-17 | 2018-10-09 | N |
