Pasadena Grove Health Center

In the surveyor’s words

From the most serious findings on record at Pasadena Grove Health Center, in the surveyor’s own words.

• Actual harm, isolatedF580Dec 12, 2025

  Based on interviews and record reviews, the facility failed to immediately inform the physician of one of two sampled residents (Resident 1), who had a diagnosis of hypertension (high blood pressure) and cerebral infarct (the death of brain tissue from a sudden blockage of blood flow, depriving brain cells of oxygen and nutrients) of Resident 1's change of condition by failing to: 1. Ensure the physician was notified by licensed nurse when Resident 1 was reported by Certified Nurse Assistant (CNA) 1 that Resident 1 was sleepier than usual on 12/7/2025 and 12/8/2025.2. […]

• No harm, potential for more than minimal, widespreadF921Apr 20, 2022

  Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to: Provide a remote alarm annunciator or remote alarm system for the emergency power generator at two of two workstations (Nursing Stations) that is readily observable by personnel for monitoring the condition of the emergency power generator by providing warning lights such as fuel level, power source, oil level, battery charger issues, etc. […]

• No harm, potential for more than minimal, patternF689Apr 3, 2026

  Based on observation, interview and record review, the facility failed to provide a safe environment that is free from accident hazards for two (2) of three (3) sample residents (Residents 44, and 9) reviewed for accident hazards by failing to ensure:A black synthetic gait belt (a type of belt used to support, steady, or assist a resident during movement), approximately five (5) feet long, was not left on the floor near Resident 44's bed.Resident 9's feet were not dangling while sitting in the wheelchair.The base of the Hoyer lift (a mechanical device designed to safely transfer individuals with limited mobility between surfaces, such as a bed, chair, or wheelchair) stored in the hallway was not left wide open. […]

• No harm, potential for more than minimal, patternF812Apr 3, 2026

  Based on observation, interview, and record review, the facility failed to maintain the food service area in a clean and sanitary condition and failed to follow its proper food - handling policy procedure by failing to ensure: A container of lentils was properly covered with a lid.The can opener was sanitized and free of dry food residue. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings: During a concurrent kitchen observation and interview on 3/31/2026 at 12:46 PM, with the… […]

• No harm, potential for more than minimal, patternF921Apr 3, 2026

  Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home-like environment for two (2) of five (5) sampled residents (Resident 11 and 18) reviewed for environment by failing to:Ensure Resident 11's bedside rails (safety devices or barriers attached to the sides of a bed to prevent falls, assist with repositioning, and provide support for getting in and out of bed) foam padding was in good condition. The facility failed to ensure two wash basins and three hand towels were not placed in the toilet tank in Resident 18 's restroom. […]