Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Californian Pasadena Healthcare during CMS and state inspections, most recent first.
A resident admitted with a PICC line and multiple complex diagnoses did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident required significant assistance with daily activities and had moderately impaired cognition. Facility staff confirmed that no baseline care plan was created to address the PICC line care, including dressing changes and infection monitoring, resulting in a lack of appropriate care and assessment for this critical area.
A resident with a PICC line did not have their dressing changed and documented according to facility policy, as required every seven days. The DON and ADON confirmed that the dressing change was either not performed or not documented, resulting in a failure to follow professional standards for central line care.
A facility area contained accident hazards and lacked adequate staff supervision to prevent accidents, as observed by surveyors. This deficiency was identified through direct observation and review of facility practices.
A resident with dementia and a history of falls was left unattended in a shower room by a CNA, resulting in a fall and head injury. The resident required maximal assistance for showering, as indicated in their care plan, but was left without adequate supervision. This led to the resident being hospitalized with multiple rib fractures.
The facility failed to maintain the dignity of two residents by not providing a dignity bag for a resident with an indwelling catheter and not assisting another resident with eating, leading to food crumbs on her clothing. These actions were contrary to the facility's policy on dignity, which aims to prevent demeaning practices.
The facility failed to develop discharge care plans for two residents, both of whom had complex medical conditions and were scheduled for discharge with home health services. The Social Service Director admitted responsibility for the oversight, and the Director of Nursing highlighted the importance of discharge care plans to prevent readmissions. The facility's policy requires individualized post-discharge plans, which were not provided for these residents.
The facility failed to document communication records for two residents receiving hemodialysis, missing crucial documentation for multiple sessions. Despite physician orders, there was no evidence of dialysis sessions being recorded, which is essential for monitoring residents' conditions and ensuring appropriate post-dialysis care. The facility's policy requires documented collaboration with the dialysis unit, which was not maintained.
The facility failed to label dry food items with use by dates and discard expired refrigerated foods, as observed by the Dietary Supervisor. Unlabeled sugar-free beverage crystals, expired whole grain bread, and unlabeled jars of jelly were found. Additionally, expired frozen bread and crab cakes without a use by date were identified, contrary to the facility's food storage policy.
The facility failed to properly dispose of garbage, as observed with two uncovered dumpsters, one of which was overflowing. The Infection Prevention Nurse and Administrator acknowledged the risk of pest attraction and infection spread due to this oversight. Facility policy requires garbage containers to have tight-fitting lids and be covered when not in use.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident with pneumonia and COPD struggled to reach a call light on the floor, while another with metabolic encephalopathy and heart disease had a call light under the bed. Staff confirmed the importance of accessible call lights, aligning with facility policies.
A facility failed to maintain the required head elevation for a resident with a gastrostomy tube during feeding, as per physician's orders and facility policy. The resident, who was dependent on staff for positioning and lacked decision-making capacity, had their head of bed elevated at only 20 degrees instead of the required 30 to 45 degrees, increasing the risk of aspiration.
A resident with atrial fibrillation and a history of myocardial infarction did not receive Apixaban for five days due to it being out of stock. The resident expressed concern, and the facility's staff confirmed the omission, noting that the physician was not notified to find an alternative. Facility policies require timely medication administration, which was not followed.
A facility failed to ensure a physician addressed a medication regimen review for a resident on Seroquel, as recommended by a consultant pharmacist. Despite the absence of psychosis indicators, the resident continued on the same dosage without a documented gradual dose reduction (GDR) or clinical rationale for not attempting one. The Assistant Director of Nursing confirmed the lack of physician response, which was required by facility policy.
A facility failed to perform a gradual dose reduction (GDR) for a resident on Seroquel or document a clinical rationale for why a GDR was contraindicated. Despite a consultant pharmacist's recommendation for a dose review, the facility did not ensure a physician's response or any change in dosage. The resident, with Alzheimer's and psychosis, showed no episodes of psychosis for several months, yet remained on the same medication dose, contrary to the facility's policy on medication tapering.
The facility failed to follow infection control practices for two residents. A resident's used urinal was left next to uncovered food, and another resident's catheter drainage bag was touching the floor. Both situations were acknowledged by staff as violations of the facility's infection prevention policies, posing potential infection risks.
A facility failed to implement its norovirus prevention policy by not cohorting staff assignments after a resident tested positive for norovirus. This oversight placed other residents, staff, and visitors at risk of exposure. Despite the policy requiring staff to care for one resident cohort and not move between cohorts, staff assignments included both symptomatic and asymptomatic residents, increasing the risk of spreading the virus.
A resident with multiple health conditions requiring substantial assistance was left unattended on a bedside commode for about 40 minutes in an LTC facility. Despite the care plan indicating a risk for falls and the need for timely response to call lights, the resident's call for assistance went unanswered. The CNA who assisted the resident initially informed the charge nurse but failed to ensure the assigned CNA was aware, leading to a lack of supervision and potential risk for accidents.
A resident with dementia and aphasia reported being fondled by a male CNA during the night. The facility failed to investigate the allegation or suspend the CNA, contrary to its abuse policy, which requires thorough investigation and suspension of accused staff. The DON and Administrator acknowledged the oversight.
A CNA failed to wear an isolation gown when entering a COVID-19 positive resident's room, despite clear precaution signs. The resident had a history of Klebsiella Pneumoniae and required contact and droplet precautions. Staff interviews revealed a lack of communication and awareness of infection control protocols, with the DON and Administrator stressing the need for proper PPE use and staff education.
The facility failed to administer medications safely and timely for two residents. One resident received expired Tobramycin-Dexamethasone and was not given the prescribed Timolol Maleate for glaucoma. Another resident was given Tylenol for pain levels that did not meet the physician's order. These actions were confirmed by the LVN and QA nurse, highlighting a failure to follow medication administration policies.
A facility failed to follow infection prevention procedures during medication administration for a resident. An LVN did not wash hands before administering oral medications and did not perform hand hygiene before wearing gloves and administering eye drops. The resident had multiple medical conditions, and the LVN admitted to not performing hand hygiene as required by the facility's policy.
A resident's call light was repeatedly ignored by staff, including an LVN, CNA, and RN, despite being visible and audible. The resident, admitted with mobility issues, reported waiting up to an hour for assistance, contrary to the facility's policy requiring immediate response.
The facility failed to update care plans and reassess fall risks for two high fall risk residents after falls, leading to repeated incidents and hospital transfers. Despite being identified as high risk, the care plans for these residents were not reviewed or updated with new interventions, and no investigations were conducted following the falls, contrary to facility policies.
Failure to Develop Baseline Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with a peripherally inserted central catheter (PICC line). The resident's admission record indicated diagnoses of obstructive hydrocephalus, type 2 diabetes mellitus without complications, and malignant neoplasm of the brain. Upon admission, the resident had a right antecubital PICC line, which was intact and showed no signs of infection. The Minimum Data Set (MDS) assessment documented that the resident had moderately impaired cognitive skills and required substantial to maximal assistance with daily activities, and was dependent for several self-care tasks. The MDS also confirmed the presence of a central line (PICC) on admission. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that a baseline care plan addressing the resident's PICC line care, including dressing changes, site monitoring for infection, and assessment, was not created within the required 48-hour timeframe. The facility's policy and procedure required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in the resident's case. The absence of a baseline care plan resulted in the resident not receiving appropriate care, monitoring, and assessment specific to the PICC line.
Failure to Document and Perform Timely PICC Line Dressing Change
Penalty
Summary
A deficiency occurred when the facility failed to provide care and dressing changes for a peripherally inserted central catheter (PICC line) in accordance with professional standards and the facility's own policy for one resident. The resident, who had diagnoses including obstructive hydrocephalus, type 2 diabetes mellitus, and malignant neoplasm of the brain, was admitted with a right antecubital PICC line. The facility's policy required that the PICC line dressing be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. However, there was no documentation that the dressing was changed on or before the required date. During interviews and record reviews, the DON confirmed that it was the responsibility of the Treatment Nurse or RN Supervisor to change the dressing and document the procedure. The Assistant DON stated she had changed the dressing but could not recall the date and admitted she did not document the change in the medical record. The DON acknowledged that if the dressing change was not documented, it was considered not done, and confirmed that the facility's policy was not followed in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight by staff to mitigate these risks. The deficiency was identified based on direct observation and review of facility practices related to accident prevention.
Resident Fall Due to Inadequate Supervision in Shower
Penalty
Summary
The facility failed to ensure that a resident, who was assessed at risk for falls and had a diagnosis of dementia, was free from falls and injury in accordance with their care plan. On the day of the incident, a Certified Nurse Assistant (CNA) left the resident unattended in the shower room while turning away to grab a clean towel and chucks. This action resulted in the resident leaning forward and falling from the shower chair, striking her head and sustaining a hematoma. The resident, who had a history of falls and was assessed to require maximal assistance for showering, was left without adequate supervision. The CNA, who was assisted by a student, did not ensure another CNA was present to help, despite the resident's known fall risk and need for constant supervision. The resident's care plan and evaluations by occupational and physical therapists indicated the necessity for maximal assistance and continuous supervision during showers, which was not adhered to during the incident. The fall resulted in the resident being transferred to a hospital, where she was found to have multiple rib fractures and was admitted to the Intensive Care Unit. The Director of Nursing confirmed that the facility's policy on fall risk management was not followed, as the resident was left unattended in a wet environment, increasing the risk of falls. The CNA's failure to maintain supervision directly contributed to the resident's fall and subsequent injuries.
Failure to Maintain Resident Dignity and Provide Necessary Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity according to the facility's policy. Resident 222, who was admitted with diagnoses including pneumonia, COPD, and neurogenic bladder, had an indwelling catheter without a dignity bag to cover the urine drainage bag. This oversight was observed during an interview with the resident, who expressed discomfort at seeing the drains and urine, stating it made him feel weak. A Certified Nursing Assistant confirmed the absence of a dignity bag and acknowledged the importance of using one to promote respect and dignity for residents. Resident 11, admitted with conditions such as cerebrovascular disease, Parkinson's disease, and quadriplegia, was observed in the dining room with food crumbs on her shirt and table while eating without assistance. Despite needing supervision and assistance with eating due to her tremors and difficulty holding a spoon, no staff was present to help her. A Restorative Nursing Assistant confirmed the resident's need for assistance and noted that the presence of food crumbs could affect the resident's dignity and discourage her from eating. The facility's policy on dignity prohibits practices that compromise resident dignity, such as failing to assist residents in maintaining cleanliness and covering urinary catheter bags.
Failure to Develop Discharge Care Plans for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 70 and Resident 71, had a discharge care plan in place, which is a requirement for effective transition to post-discharge care. Resident 70 was admitted with multiple diagnoses, including type 2 diabetes mellitus, muscle weakness, and cognitive communication deficit, and was scheduled for discharge with home health services. Similarly, Resident 71, who had a history of fractures, muscle weakness, and dementia, was also set to be discharged with home health services. However, upon review, it was found that neither resident had a discharge care plan documented, which is essential for outlining their goals and needs post-discharge. The Social Service Director (SSD) acknowledged the absence of discharge care plans for both residents, admitting responsibility for this oversight. The Director of Nursing (DON) emphasized the importance of having discharge care plans to inform residents of their goals and to help meet their needs, thereby preventing potential readmissions. The facility's policy mandates that every resident should have an individualized post-discharge plan, which should be re-evaluated based on any changes in the resident's condition or needs prior to discharge. This policy was not adhered to in the cases of Resident 70 and Resident 71, leading to the identified deficiency.
Failure to Document Dialysis Communication Records
Penalty
Summary
The facility failed to ensure proper communication and documentation for two residents receiving hemodialysis treatment. Resident 122, admitted with chronic kidney disease and other related conditions, did not have Communication Records for Dialysis Residents (CRDR) forms for multiple dialysis sessions. Despite having physician orders for dialysis on specific days, there was no documentation indicating that Resident 122 received dialysis on those dates. The Director of Nursing (DON) confirmed the absence of these records, which are crucial for monitoring the resident's condition and ensuring appropriate post-dialysis care. Similarly, Resident 22, who also depended on renal dialysis, lacked CRDR forms for certain dialysis sessions. The Licensed Vocational Nurse (LVN) acknowledged the missing documentation, which is necessary for communicating the resident's condition and monitoring potential side effects and complications from dialysis. The facility's policy requires documented evidence of collaboration and communication between the facility and the dialysis unit, which was not maintained in these cases. The DON emphasized the importance of having these communication forms to check for new orders, medications, and to document post-dialysis vital signs and complications.
Deficiency in Food Labeling and Expiration Management
Penalty
Summary
The facility failed to ensure that dry food items removed from their original packaging were labeled with a use by date, and refrigerated foods that had expired were discarded. During an observation in the facility's kitchen, the Dietary Supervisor (DS) identified a package of assorted sugar-free beverage crystals that was not labeled with a use by date, indicating it was no longer suitable for human consumption. The DS acknowledged that the package should have been labeled by the staff responsible for labeling packages with delivery, open, and expiration dates. Additionally, a loaf of whole grain bread was found past its expiration date, which the DS stated should have been discarded to prevent potential gastrointestinal issues for residents. Further observations revealed two jars of pear honey and ginger jelly in the dry storage room without a use by date label. In the kitchen, a box of frozen bread with an expired use by date was found in the freezer, which the DS confirmed should have been discarded. Additionally, a box of frozen crab cakes in the freezer lacked a use by date, and the DS was uncertain about its safety for consumption. The facility's policy on food receiving and storage mandates that dry foods stored in bins be labeled and dated with a use by date, and all refrigerated or frozen foods be covered, labeled, and monitored to ensure they are used by their use by date or discarded.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per its policy, which led to a deficiency. During an observation and interview with the Infection Prevention Nurse (IPN), it was noted that two dumpsters located outside the facility by the parking lot were not covered. One dumpster was overflowing with garbage, and both lacked proper covering. The IPN acknowledged that the dumpsters should be covered to prevent the attraction of pests, which could lead to the spread of infection affecting both staff and residents. In a subsequent interview with the Administrator (ADM), it was confirmed that maintaining cleanliness in the garbage area is the responsibility of the maintenance and kitchen staff. The ADM stated that dumpster covers should remain closed and not be filled beyond the full line to prevent pest infestation, which could impact the health of residents and staff. A review of the facility's policies and procedures indicated that all garbage containers should have tight-fitting lids and be kept covered when not in use, especially those containing food waste, to make them inaccessible to pests.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, which is essential for residents to request assistance. Resident 222, who was admitted with pneumonia, COPD, and neurogenic bladder, was observed struggling to reach his call light, which was found on the floor. Certified Nursing Assistant 4 confirmed that the call light should have been on the bed and within reach, emphasizing the importance of accessibility for residents to call for help. The Director of Nursing also stated that call lights on the floor are unacceptable as they prevent residents from reaching out for assistance. Similarly, Resident 126, admitted with metabolic encephalopathy, hypertensive heart disease, atrial fibrillation, and chronic kidney disease, was found unable to reach his call light, which was under the bed. Certified Nursing Assistant 1 acknowledged that the call light was not within reach and should be accessible to ensure timely assistance, especially during emergencies. The facility's policies on accommodating needs and answering call lights both indicate that call lights should be easily accessible to residents at all times.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 54, had the head of their bed elevated at a minimum of 30 degrees during tube feeding infusion, as per the facility's policy and physician's orders. Resident 54 was admitted with a diagnosis of dysphagia and had a gastrostomy tube for nutrition. The resident was dependent on staff for various activities, including positioning, and did not have the capacity to make decisions. The physician's order required the head of the bed to be elevated between 30 to 45 degrees during and one hour after enteral feeding. During an observation, it was noted that the resident's head of bed was elevated at approximately 20 degrees while the tube feeding was infusing, which was below the required minimum. Licensed Vocational Nurse 4 confirmed the inadequate elevation and acknowledged the risk of aspiration due to the resident's need for assistance in turning. The Director of Nursing emphasized the importance of following physician's orders to prevent aspiration, aligning with the facility's policy that mandates a minimum 30-degree elevation during and after feeding.
Failure to Administer Prescribed Anticoagulant
Penalty
Summary
The facility failed to ensure that a resident received Apixaban, a medication prescribed to prevent blood clots, as indicated on the physician's order. The resident, who was admitted with a diagnosis of atrial fibrillation and a history of myocardial infarction, did not receive the medication for five consecutive days due to it being out of stock. This lapse was confirmed during an interview with the resident, who expressed concern about not receiving the medication necessary for her heart condition. The resident's medical records indicated a need for anticoagulant therapy to manage her condition. Licensed Vocational Nurse 3 confirmed that the resident did not receive Apixaban on the specified dates and acknowledged that there was no documentation of the facility physician being notified about the medication's unavailability. The Director of Nursing verified the omission and stated that the licensed nurses should have informed the physician to find an alternative medication. The facility's policies on pharmacy services and medication administration emphasize the importance of having a sufficient supply of prescribed medications and the need for timely administration, which were not adhered to in this case.
Failure to Address Medication Regimen Review for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a physician addressed the medication regimen review (MRR) for a resident, specifically regarding the use of Seroquel, a medication used to treat psychosis. The consultant pharmacist recommended a gradual dose reduction (GDR) for the resident's Seroquel dosage, but there was no documentation indicating that the physician responded to this recommendation or provided a clinical rationale for not attempting a GDR. This oversight was identified during a review of the resident's clinical records and interviews with facility staff. The resident in question, identified as Resident 52, was admitted to the facility with diagnoses including Alzheimer's disease and psychosis. The Minimum Data Set (MDS) for the resident indicated that they had been taking an antipsychotic medication routinely and that a GDR had not been attempted or documented as clinically contraindicated. Despite the absence of psychosis indicators or mood and behavioral symptoms, the resident continued to receive the same dosage of Seroquel since March 2024. Interviews with the Assistant Director of Nursing (ADON) confirmed that the facility did not ensure a physician's response to the pharmacist's recommendation for a GDR. The ADON acknowledged that the physician should have responded within one to two days of the pharmacist's report. The facility's policies and procedures require medication regimen reviews upon admission and at least monthly, with physician responses maintained as part of the permanent medical record. However, in this case, the facility did not adhere to these policies, increasing the risk of adverse effects for the resident.
Failure to Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) for a resident using Seroquel, a medication for treating psychosis, or document a clinical rationale for why a GDR was contraindicated. The resident, who was admitted with Alzheimer's disease and psychosis, had been on a routine dose of Seroquel without any attempts at dose reduction or documentation of contraindications. The Minimum Data Set (MDS) indicated that the resident had severe cognitive impairment but no mood or behavioral symptoms, and no episodes of psychosis were recorded for several months. The Assistant Director of Nursing (ADON) confirmed that the facility did not ensure the physician responded to a consultant pharmacist's recommendation to consider a dose change for the resident's Seroquel. The pharmacist's recommendation, dated several months prior, noted the need for a psychotropic drug regimen review and evaluation for dose reduction. Despite this, there was no documentation of any response from the physician or any change in the medication dosage since March of the same year. The facility's policy on tapering medication and gradual drug dose reduction requires periodic review of medication necessity and appropriate tapering when conditions improve or stabilize. However, the facility did not adhere to this policy, as evidenced by the lack of documentation or action regarding the resident's Seroquel dosage. This oversight increased the risk of adverse effects for the resident, as noted by the ADON during an interview.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to standard infection prevention control practices for two residents, leading to potential infection risks. For Resident 126, a used urinal containing urine was placed next to an uncovered cup of water and a cup of oatmeal on the bedside table. This was observed during an interview with the resident, who mentioned that the CNA was asked to empty the urinal earlier. Both the LVN and the DON confirmed that the urinal should not have been left near the resident's food, as it violates the facility's infection prevention policy, which mandates maintaining hygiene and preventing contamination. For Resident 273, the facility did not ensure proper catheter care, as the resident's urinary catheter drainage bag was observed touching the floor. This was noted during an observation with an RN, who acknowledged that the bag should not be in contact with the floor due to the risk of infection. The DON confirmed that the facility's catheter care policy requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Both instances demonstrate a failure to follow the facility's infection control policies, placing residents at risk for potential infections.
Failure to Cohort Staff During Norovirus Outbreak
Penalty
Summary
The facility failed to implement its policy and procedure for norovirus prevention and control, which resulted in a deficiency. The issue arose when the facility did not cohort staff assignments after receiving a positive norovirus result for a resident. This failure to cohort staff placed all other residents, staff, and visitors at risk of exposure to norovirus. The facility's policy required that staff care for one resident cohort on their unit and not move between resident cohorts, which was not followed. The report details the cases of three residents who exhibited symptoms consistent with norovirus, such as diarrhea, vomiting, and nausea. One resident tested positive for norovirus, while the other two showed symptoms but were not confirmed. Despite the positive test result and symptomatic residents, the facility did not assign separate staff to care for these residents, leading to mixed cohorts of symptomatic and asymptomatic residents. Interviews with facility staff, including the Infection Preventionist, Director of Staff Development, and Assistant Director of Nursing, confirmed that the facility did not follow its policy to cohort staff assignments. The staff acknowledged that the failure to cohort assignments increased the risk of spreading the virus. The facility's policy clearly stated that during an outbreak, staff should care for one resident cohort and not move between cohorts, which was not adhered to in this case.
Resident Left Unattended on Bedside Commode
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was left unattended on a bedside commode for an extended period. The resident, who had been admitted with conditions including acquired deformities of the left lower leg, enterocolitis due to Clostridium difficile, abnormal gait and mobility, and severe protein-calorie malnutrition, required substantial assistance for activities of daily living. Despite being assessed as low risk for falls, the resident's care plan indicated a risk for falls due to medication use and required timely response to call lights and assessment of toileting needs. On the day of the incident, a CNA assisted the resident to the bedside commode and instructed the resident's daughter to use the call light when assistance was needed. However, the CNA left the room and did not return to assist the resident, who was left on the commode for approximately 40 minutes. The resident's daughter eventually had to assist the resident back to bed after the call light went unanswered for an extended period. Interviews with facility staff revealed a lack of communication and follow-up, as the CNA informed the charge nurse but did not ensure the resident's assigned CNA was aware of the situation. The facility's policy on activities of daily living and fall risk management emphasized the need for appropriate support and assistance for residents unable to carry out ADLs independently. However, the failure to provide timely assistance and supervision placed the resident at risk for accidents, such as falls, due to the prolonged period on the commode without staff supervision. The incident highlights a breakdown in communication and adherence to established care protocols within the facility.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure for a resident by not thoroughly investigating an allegation of sexual abuse. The resident, who was admitted with diagnoses of dementia and aphasia, reported being fondled by a male staff member during the nighttime or early morning hours. The facility's records indicated that a male Certified Nursing Assistant (CNA) was assigned to the resident during the relevant shift. However, the facility did not take appropriate action to investigate the allegation or suspend the staff member involved. The Director of Nursing and the Administrator both acknowledged that the facility should have reviewed the staffing records for the shift in question and suspended the CNA pending further investigation. The facility's policy requires that all allegations of abuse be thoroughly investigated and that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow these procedures placed the resident at risk for elder abuse.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, as evidenced by a Certified Nursing Assistant (CNA 3) not wearing an isolation gown while entering the room of a resident who tested positive for COVID-19. The resident, admitted with a diagnosis of Klebsiella Pneumoniae and resistance to multiple antimicrobial drugs, required contact and droplet precautions due to their COVID-19 status. Despite the presence of a precaution sign outside the resident's room, CNA 3 entered without the necessary protective equipment, stating unawareness of the resident's COVID-19 status and neglecting to read the precaution sign. Interviews with staff revealed a lack of communication and awareness regarding the infection control protocols. The Licensed Vocational Nurse (LVN 2) acknowledged the need to inform CNA 3 about residents' COVID-19 status, while the Director of Nursing (DON) emphasized the importance of educating staff on the use of Personal Protective Equipment (PPE). The Administrator also highlighted the necessity for staff to be knowledgeable about residents' isolation precautions and the appropriate PPE required. The facility's policy, revised prior to the incident, mandated the use of gowns for staff entering rooms of residents in isolation, which was not followed in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medication in a safe and timely manner for two residents. Resident 1 did not receive Tobramycin-Dexamethasone ophthalmic suspension within the 30-day period after opening as per the facility's policy. Additionally, Resident 1 was administered Tobramycin-Dexamethasone instead of the prescribed Timolol Maleate for glaucoma, and the medication was not found in the medication cart or refrigerator. This oversight was confirmed by the Licensed Vocational Nurse (LVN) and the Quality Assurance (QA) nurse, who emphasized the importance of verifying medication expiration dates and following physician orders to ensure resident safety and medication efficacy. Resident 2 was administered Tylenol for pain despite reporting a pain level of two to three, which did not meet the physician's order for Tylenol to be given for moderate pain levels of four to six. The LVN acknowledged the discrepancy and the potential risk of medication dependency due to inappropriate administration. The QA nurse reiterated the necessity of adhering to physician orders, including pain parameters, to ensure the efficacy of the medication and reduce the risk of addiction. The facility's policies and procedures for administering medications were reviewed and found to require that medications be administered in a safe and timely manner, as prescribed. The policies also specified that medications should be administered within one hour of their prescribed time unless otherwise specified. The deficiencies observed in the administration of medications to Residents 1 and 2 highlight a failure to comply with these policies, potentially compromising the residents' health and well-being.
Failure to Follow Infection Prevention Procedures During Medication Administration
Penalty
Summary
The facility failed to follow infection prevention procedures during medication administration for one resident. Specifically, a Licensed Vocational Nurse (LVN) did not wash hands before administering oral medications and did not perform hand hygiene before wearing gloves and administering ophthalmic medications. This was observed during a medication administration session where the LVN entered the resident's room without performing hand hygiene and administered several oral medications. The LVN also applied gloves without washing hands and attempted to administer eye drops, touching various surfaces and the resident's face without proper hand hygiene. The resident involved had a history of falling, difficulty in walking, muscle weakness, hypertension, glaucoma, hyperlipidemia, and benign prostatic hyperplasia. The resident's cognitive skills for daily decision-making were moderately impaired, but there was no impairment in the range of motion in the upper and lower extremities. The LVN admitted to not performing hand hygiene before entering the resident's room and administering eye drops. The facility's quality assurance nurse confirmed that staff should sanitize their hands before and after medication administration and wash their hands when administering eye drops, as per the facility's policy on hand hygiene.
Failure to Respond to Call Light Promptly
Penalty
Summary
The facility failed to ensure that the call light device, a critical communication tool for residents to request assistance, was answered promptly for one of the residents. On multiple occasions, staff members, including a Licensed Vocational Nurse (LVN), a Certified Nurse Assistant (CNA), and a Registered Nurse (RN), either ignored or failed to respond to the call light of a resident who had been admitted with conditions such as difficulty in walking and muscle weakness. The resident's care plan emphasized the importance of timely response to the call light to prevent falls and ensure safety. Observations revealed that the call light was left unanswered despite being visible and audible to staff members. Interviews with staff confirmed that the call light should be answered promptly to prevent accidents and maintain resident dignity. The resident reported experiencing delays of 30 minutes to an hour before receiving assistance, particularly during busy shifts, leading to feelings of discouragement. The facility's policy mandates immediate response to call lights, which was not adhered to in this instance.
Failure to Update Care Plans and Assessments for High Fall Risk Residents
Penalty
Summary
The facility failed to ensure the safety and prevent falls for two high fall risk residents, Resident 2 and Resident 3. Resident 2, admitted with diagnoses including muscle weakness and traumatic subarachnoid hemorrhage, was identified as high risk for falls. Despite this, the facility did not update Resident 2's care plan or reassess the fall risk after a fall on April 25, 2024, which resulted in a head injury requiring hospital transfer. The care plan was not reviewed or updated to include new interventions to prevent further falls, leading to another fall on May 4, 2024, where Resident 2 was found unresponsive and required emergency medical attention. Resident 3, admitted with difficulty walking and muscle weakness, was also not adequately protected from falls. After a fall on April 9, 2024, which resulted in a laceration and hospital transfer, the facility failed to initiate a care plan or accurately update the fall risk assessment. The assessment incorrectly indicated no history of falls, which did not reflect the resident's actual condition and needs. This oversight placed Resident 3 at continued risk for falls without appropriate interventions in place. The Director of Nursing acknowledged that no investigations were conducted for the falls involving Resident 2 and Resident 3, as there were no injuries deemed serious. However, this lack of investigation and failure to update care plans and assessments contravened the facility's policies on safety and supervision, which emphasize the importance of identifying fall causes and updating care plans to prevent future incidents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,405 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Bellefontaine Healthcare Center | 0 mi | — | 2 | 0 |
| Pasadena Palace Tcu | 0.2 mi | — | 25 | 0 |
| South Pasadena Care Center | 1.2 mi | — | 6 | 0 |
| Villa Gardens Health Care Unit | 1.9 mi | — | 16 | 0 |
| York Healthcare & Wellness Centre | 2.5 mi | — | 0 | 0 |
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