South Pasadena Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jan 3, 2022

  Based on interview and record review, the facility failed to ensure a wound for one of four sampled residents (Resident 1) received appropriate wound care and treatment services. Resident 1, who had type 1 diabetes (a condition in which the body does not make insulin; thus, could not control the amount of sugar in the blood. With diabetes, the wounds tend to heal more slowly and progress more quickly) developed a fluid filled blister on his right lateral malleolus (right ankle) on 3/25/2021 that measured 2.5 centimeters (cm, unit of measurement) (length, extent from end to end or head to toe) x 2.5 cm (width, extent from side to side) x 0.5 cm. (depth, deepest point of the wound). […]

• No harm, potential for more than minimal, patternF684Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident's blood pressure was not taken on the left arm in accordance with the physician's order and care plan for one of 32 sampled residents (Resident 1). This deficient practice had the potential to increase pressure and dislodge the clot or worsen venous congestion leading to pulmonary embolism (blockage in one of the pulmonary [relating to the lungs] arteries in the lungs usually caused by blood clots that travel to the lungs from the legs or other parts of the body), stroke (medical emergency that occurs when blood supply to the brain is blocked or when a blood vessel bleeds in the brain), or heart attack (blood flow that brings oxygen to the heart muscle is reduced or cut off). […]

• No harm, potential for more than minimal, patternF755Aug 20, 2026

  Based on interview and record review, the facility failed to administer medications as ordered by the physician for two (2) of 32 sampled residents (Residents 5 and 67) by failing to:Administer as needed medication for constipation (infrequent bowel movements or difficulty passing stool) for no bowel movement for three (3) days as ordered by the physician and in accordance with Resident 5's care plan. Administer eight (8) medications as ordered by the physician for Resident 67. […]

• No harm, potential for more than minimal, patternF812Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by failing to:1. Label food in the kitchen with item name and use by date (the last date recommended for the use of the product) and/or open date.2. Discard expired food items in the kitchen.3. Ensure staff personal belong and beverages were kept off the dishwasher station area.4. Ensure chlorine level was within the recommended level. […]

• No harm, potential for more than minimal, patternF880Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper cleaning and maintenance of three (3) of five (5) medication crushing devices by not ensuring they were free from dark, iron colored stains and tarnish colored substances.This failure had the potential to create conditions that could lead to contamination of residents' medications, increasing the risk of infection and creating an unsafe environment for resident care. Findings:During a concurrent observation and interview on 8/20/2026 at 2:56 PM with Licensed Vocational Nurse 4 (LVN 4), the medication crushing device being used was observed to be unclean, rusted, aged, and had blackened substances around the pill chamber. […]