The Suites Pasadena

In the surveyor’s words

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

• Immediate jeopardy, patternF686Aug 25, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent the development of pressure ulcers for 1 of 7 (Resident #7) residents reviewed for pressure ulcers. - The facility failed to prevent Resident #7 from acquiring DTIs to both of her heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels. Resident #7 required hospitalization for the treatment of the injuries to her heels.An Immediate Jeopardy (IJ) was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:55pm. […]

• Immediate jeopardy, patternF686Sep 19, 2023

  Based on interviews, observations, and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (CR #105) reviewed for treatment and services to prevent and heal pressure ulcers. 1. CR #105 was not provided wound care from [DATE] through [DATE] although the wound was identified as present prior to his admission on [DATE] . 2. CR #105 was not identified with wounds upon admission; skin assessments were not completed upon admission/re-admission. […]

• Immediate jeopardy, isolatedF689Feb 19, 2024

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent elopement.for 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended and was missing for 2 hours on 2/08/24 around 8:00 PM, until hospital staff contacted the facility. This failure could affect residents with diagnose of dementia at risk of elopement thus placing themselves at risk of physical harm, pain and mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 2/16/24 at 1:00 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 2/16/24 at 1:00 PM. […]

• Immediate jeopardy, isolatedF684Jan 29, 2024

  Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to ensure LVN B properly assess CR#1 when he gave medication on [DATE] at 9:00am when CR#1 vomited, aspirated and later died . The facility failed to ensure that CR#1 was checked on every two hours and was not laying in her vomit from 7:15 am until 11:15am on [DATE]. The facility failed to ensure that CNAs report to the charge nurse when they found CR#1 in her own vomit. An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Actual harm, patternF692Sep 19, 2023

  Based on observation, interview, and record review the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 3 of 18 (Residents #31, #32, and #89) reviewed for nutrition and hydration status and maintenance. 1. The facility failed ensure Resident #31, Resident #32, and Resident #89 did not sustain an unplanned and/or unexpected significant weight loss. 2. […]