A list of the most recent deficiencies for Pasadena Post Acute. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-15 | 2022-12-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-06 | 2022-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-04 | 2022-10-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-04 | 2022-10-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-10-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-03 | 2021-08-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-08-03 | 2021-08-10 | 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 | 2021-08-03 | 2021-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-03 | 2021-08-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-03 | 2021-08-10 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-08-03 | 2021-08-10 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-03 | 2021-08-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-03 | 2021-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-03 | 2021-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-03 | 2021-08-10 | 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 | 2021-08-03 | 2021-08-10 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-08-03 | 2021-08-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-16 | 2021-03-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-27 | 2019-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-27 | 2019-10-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-27 | 2019-10-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-27 | 2019-10-16 | 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 | 2019-09-27 | 2019-10-16 | 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 | 2019-09-27 | 2019-10-16 | N |
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2019-09-27 | 2019-10-02 | N |
| Keep all essential equipment working safely. | Health | 2019-09-27 | 2019-10-02 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2019-09-27 | 2019-10-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-24 | 2019-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-24 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2019-09-30 | 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 | 2019-09-27 | 2019-09-28 | N |
