The Californian Pasadena Healthcare

In the surveyor’s words

From the most serious findings on record at The Californian Pasadena Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 19, 2024

  Based on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 3) who was assessed at risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities) was free from falls and injury in accordance with the resident's care plan for At risk for fall and Occupational Therapist (OT; a healthcare provider who helps you improve your ability to perform daily tasks like getting dressed or using a computer) Evaluation & Plan of Treatment (OTEPT) to provide maximal assistance (helper does more than half the effort) to the resident when showering/bathing. […]

• No harm, potential for more than minimal, patternF755Aug 26, 2026

  Based on observation, interview, and record review, the facility failed to verify the resident's identify before medication administration for two (2) of 2 sampled residents (Resident 1 and 2). This deficient practice has the potential to result in medication errors and had the potential to cause dangerous allergic reactions, toxic overdoses (when a person takes more of a substance than their body can safely process, creating a dangerous and overwhelming level of toxicity), or untreated conditions to Resident 1 and Resident 2. 1. […]

• No harm, potential for more than minimal, patternF550Jul 31, 2026

  Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of three (3) sampled residents (Resident 3 and 4) in accordance with the facility's policy and procedure (P&P) when:On 7/30/2026 and 7/31/2026, facility staff did not ensure Resident 3's lunch meal tray was served within the facility's scheduled mealtimes. 2. On 7/30/2026, Licensed Vocational Nurse 1 (LVN 1) did not ensure Resident 4 was given medication in a private room such as the resident's room and not in the dining room while wearing gloves. These deficient practices have the potential to affect Residents 3 and 4 sense of self-worth and self-esteem, which could negatively impact the residents' emotional and mental well being.Findings:1. […]

• No harm, potential for more than minimal, patternF755Jul 17, 2026

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquisition and administration of drugs and biologicals to meet the needs of two (2) out of four (4) sampled residents (Residents 1 and 2), in accordance with the facility's policy and procedure (P&P), by failing to: Administer Pregabalin (medication commonly used to treat neuropathy (damage or dysfunction of the nerves) Pregabalin 75 milligram (mg, unit of measurement) capsule for neuropathic pain (nerve pain) in accordance with the physician's order on 7/15/2026.Document in Resident 2's Cefalexin (antibiotic for treating bacterial infections) count sheet that Cefalexin 500 mg capsule for the resident's infection, status post laminectomy… […]

• No harm, potential for more than minimal, patternF761Jul 17, 2026

  Based on observation, interviews, and record review, the facility failed to ensure that medications were securely stored and properly disposed of by failing to ensure: Two (2) of three (3) medication carts (Med Cart, mobile cart used by nursing staff to store, organized and administer medication to residents) were unlocked and unattended.Discontinued medications were disposed of in accordance with the facility's policies and procedures.Three (3) of 14 emergency kits (E-kit, sealed container that holds a limited supply of emergency medications that can be used immediately while waiting for medication from the pharmacy) were sealed.The Medication refrigerator located in the medication room was locked. […]