A list of the most recent deficiencies for South Pasadena Care 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-01 | 2023-09-12 | 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 | 2023-09-01 | 2023-09-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-01 | 2023-09-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-01 | 2023-09-12 | 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 | 2023-08-28 | 2023-09-12 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-09 | 2023-06-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-27 | 2023-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2022-12-29 | 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 | 2022-11-08 | 2022-11-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-18 | 2022-11-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-03 | 2022-01-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-23 | 2021-09-07 | 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 | 2021-07-23 | 2021-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-23 | 2021-09-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-23 | 2021-09-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-23 | 2021-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-23 | 2021-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-23 | 2021-09-07 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-07-23 | 2021-09-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-23 | 2021-09-07 | 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 | 2021-07-23 | 2021-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-23 | 2021-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-23 | 2021-09-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-23 | 2021-09-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-23 | 2021-09-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-22 | 2021-09-03 | 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 | 2021-07-22 | 2021-09-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-07-22 | 2021-09-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-22 | 2021-09-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-22 | 2021-09-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-27 | 2021-09-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-05 | 2021-03-23 | 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 | 2021-03-05 | 2021-03-23 | Y |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-02-14 | 2020-03-05 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-02-07 | 2020-03-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-07 | 2020-03-03 | 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 | 2020-02-07 | 2020-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-07 | 2020-03-03 | 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 | 2020-02-07 | 2020-03-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-07 | 2020-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-07 | 2020-03-03 | 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 | 2020-02-07 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-07 | 2020-03-03 | 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 | 2020-02-07 | 2020-03-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-07 | 2020-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-07 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-03-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-07 | 2020-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-14 | 2019-03-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-14 | 2019-03-13 | 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 | 2019-02-14 | 2019-03-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-14 | 2019-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-14 | 2019-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-14 | 2019-03-13 | N |
