A list of the most recent deficiencies for Focused Care at Pasadena. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-12 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-12 | 2023-11-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-13 | 2023-10-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-13 | 2023-10-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-13 | 2023-10-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-13 | 2023-10-27 | 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 | 2023-10-13 | 2023-10-27 | 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 | 2023-10-13 | 2023-10-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-13 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-10-27 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-10-13 | 2023-10-27 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-25 | 2023-10-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-25 | 2023-10-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-15 | 2022-09-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-15 | 2022-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-15 | 2022-09-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-15 | 2022-09-20 | Y |
| 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 | 2022-08-15 | 2022-09-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-15 | 2022-09-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-21 | 2022-09-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-21 | 2022-08-22 | 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 | 2022-07-21 | 2022-08-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-21 | 2022-08-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-21 | 2022-08-18 | 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 | 2022-07-21 | 2022-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-19 | 2022-08-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-15 | 2022-06-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-29 | 2021-05-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-29 | 2021-05-26 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-04-29 | 2021-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-29 | 2021-05-26 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-04-27 | 2021-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-27 | 2021-04-28 | N |
