Pasadena Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF580Feb 2, 2024

  Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when the resident experienced a change in condition for 1 of 8 residents (Resident #55) reviewed for a change in condition. The facility failed to notify the physician when Resident #55 was pocketing Oxycodone pills on [DATE]. Resident #55 was found unresponsive and was sent to the local hospital on [DATE] for respiratory distress. The local hospital sent her to an inpatient behavioral hospital where she was admitted due to worsening of mood and suicidal attempt by drug overdose. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. […]

• Immediate jeopardy, patternF656Feb 2, 2024

  47722 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 residents (Resident #55) reviewed for care plans. […]

• Immediate jeopardy, patternF689Feb 2, 2024

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #55) reviewed for supervision. -The facility failed to put interventions in place to prevent overdose of medications when Resident #55 was first noticed by the staff on [DATE] pocketing medications including narcotics. Resident #55 was found unresponsive and was sent to the hospital on [DATE] for respiratory distress with a hospital discharge diagnosis of drug overdose/suicidal attempt. An immediate jeopardy (IJ) was identified on [DATE] at 5:21 p.m. […]

• No harm, potential for more than minimal, widespreadF812Aug 3, 2021

  Based on observation, interview, and record review the facility failed to serve food under sanitary conditions in 1 of 1 kitchen. Staff was not wearing a hair net or a mask. 3 large baking sheets containing carbon build-up were stacked against each other Large and medium steam table pans stacked on rack contained moisture and water on the inside and food particles on the inside Open packaged meat, in a 2-door refrigerator, was not labeled, was not in a sealed container. Corn in sealed zip lock bag, in a 2-door refrigerator, was not labeled or dated. [MEDICATION(S)] wrapped in clear plastic wrap, in a 2-door refrigerator, was not dated. […]

• No harm, potential for more than minimal, patternF584Feb 2, 2024

  Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for six (Resident #44, #27, #82, #84, #309, #99) of six residents reviewed for receiving enteral feeding via a pump. -The facility failed to clean enteral feeding pumps and poles, which were dirty on 01/09/24, 01/10/24, and 01/11/24 for Residents #44, #27, #82, #84, #309, and #99. This failure could affect the residents who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination, and possible infection. […]