A list of the most recent deficiencies for Pasadena Nursing 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-01 | 2024-03-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-26 | 2024-01-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-26 | 2024-01-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-12-26 | 2024-01-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-26 | 2024-01-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-26 | 2024-01-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-26 | 2024-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-02 | 2024-01-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-25 | 2023-11-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-25 | 2023-11-14 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-09-19 | 2023-10-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-06-14 | 2023-07-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-18 | 2023-06-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-23 | 2023-03-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-04 | 2023-03-21 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-04 | 2023-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-03-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-09-21 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-07-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-07-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-19 | 2022-06-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-19 | 2022-06-22 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-02-17 | 2022-04-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-25 | 2022-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-18 | 2022-02-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-19 | 2022-02-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-11 | 2022-02-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-02-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-23 | 2022-01-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-07 | 2021-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-02 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-08-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-09 | 2021-08-05 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-07-09 | 2021-08-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-07-09 | 2021-08-05 | N |
| 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 | 2021-07-09 | 2021-08-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-09 | 2021-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-09 | 2021-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-09 | 2021-08-05 | 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 | 2021-07-09 | 2021-08-05 | 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 | 2021-07-09 | 2021-08-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-09 | 2021-08-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-09 | 2021-08-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-09 | 2021-08-05 | 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 | 2021-07-09 | 2021-08-05 | 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 | 2021-07-09 | 2021-08-05 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-07-09 | 2021-08-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-09 | 2021-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-09 | 2021-08-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-09 | 2021-08-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-09 | 2021-08-05 | 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 | 2021-07-02 | 2021-07-16 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-05-19 | 2021-05-25 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-08 | 2019-09-17 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-08 | 2019-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-08 | 2019-09-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-08 | 2019-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-08 | 2019-09-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-08 | 2019-09-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-08-08 | 2019-09-17 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-08-08 | 2019-09-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-08 | 2019-09-17 | 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 | 2019-08-08 | 2019-09-17 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-08-08 | 2019-09-17 | 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 | 2019-08-08 | 2019-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-08 | 2019-09-16 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-08-08 | 2019-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-08 | 2019-09-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-08 | 2019-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-08 | 2019-09-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-20 | 2018-09-26 | 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 | 2018-08-20 | 2018-09-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-08-20 | 2018-09-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-18 | 2018-09-12 | 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 | 2018-08-18 | 2018-09-12 | N |
| 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 | 2018-08-18 | 2018-09-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-18 | 2018-09-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-18 | 2018-09-12 | 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 | 2018-08-18 | 2018-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-18 | 2018-09-12 | 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 | 2018-08-18 | 2018-09-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-18 | 2018-09-12 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-18 | 2018-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-18 | 2018-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-18 | 2018-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-18 | 2018-09-12 | 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 | 2018-08-18 | 2018-09-12 | 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 | 2018-08-18 | 2018-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-18 | 2018-09-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-18 | 2018-09-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-08-18 | 2018-09-12 | N |
