Pasadena Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725Feb 12, 2021

  Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to provide care for 28 of 46 residents by failing to: 1. Ensure there was a licensed nurse on duty between 11 a.m. to 3 p.m. on January 14, 2021 to provide care for 28 of 46 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28), who were positive for COVID-19 (Coronavirus disease, a severe respiratory illness caused by [MEDICAL CONDITION] and spread from person to person). 2. […]

• Immediate jeopardy, patternF880Jan 18, 2022

  Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person) by failing to: 1. Ensure designated staff in one (the Red Zone/area with COVID-19 positive residents) of three resident cohorting areas (areas used to house residents with similar COVID-19 risk) for COVID-19. a. Certified Nursing Assistant 1 (CNA 1), who was assigned to the Red Zone, crossed between the Red to the Green (area with residents who are COVID-19 free) Zone to provide care to the residents during the shift. b. […]

• Immediate jeopardy, patternF880Feb 12, 2021

  Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus, a severe respiratory illness caused by [MEDICAL CONDITION] and spread from person to person) in accordance with the local Public Health guidelines, facility's policies, and facility's Mitigation Plan (MP, a plan created to control the spread and impact of COVID-19 in the facility) by failing to: 1. Ensure two of three staff (Housekeeping Staff 1 and Certified Nursing Assistant 2) in the red zone (area where residents who are COVID-19 positive are isolated) and one of three staff (Certified Nursing Assistant 1) in the yellow zone (area where residents who have possibly been exposed to COVID-19 are isolated and monitored) were using… […]

• Actual harm, isolatedF689Oct 3, 2024

  Based on interview, and record review, facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) of one of two sampled residents (Resident 1) by: 1. Failing to revise Resident 1's care plan for moderate risk for fall related to gait/ balance problems after the resident's Minimum Data Set (MDS, standardized care and screening tool) and Physical Therapy Treatment Encounter Notes (PT Note - documents sequential implementation (executing one task at a time, in order)of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used) were completed on 7/15/2024 and 7/16/2024 to reflect the resident's, need for partial moderate… […]

• No harm, potential for more than minimal, widespreadF921Jan 25, 2022

  Based on observation, interview and record review, the facility failed maintain to a safe and functional environment for residents, staff, and the public regarding the unapproved installation of light fixtures. This deficient practice of an unsafe and improper functional environment had the potential to have negative effects to the safety, welfare and health of the residents, staff and the public. Findings: On November 1, 2021, at 2:05 p.m., a complaint investigation was conducted regarding the facility installing light fixtures without proper approval. The Maintenance Supervisor (MS) was informed of the complaint visit. On November 1, 2021, between 2:30 p.m. and 3:13 p.m., during a general observation and interview with MS, the ceiling light fixtures in the lobby appeared new. […]