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Deficiency Records for Pasadena Grove Health Center
A list of the most recent deficiencies for Pasadena Grove Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pasadena Grove Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-08-22 | 2024-09-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-16 | 2024-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-16 | 2024-09-06 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-16 | 2024-09-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-15 | 2024-09-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-15 | 2024-09-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-28 | 2024-07-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-12 | 2024-07-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-05-31 | 2024-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-17 | 2024-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-12 | 2024-04-16 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-01 | 2024-03-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-23 | 2024-03-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-23 | 2024-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-23 | 2024-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-02-23 | 2024-03-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-23 | 2024-03-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-23 | 2024-03-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-01 | 2024-03-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-01 | 2024-03-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-01 | 2024-03-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-01 | 2024-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-18 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-12-15 | 2023-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-18 | 2023-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-04 | 2023-09-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-05 | 2023-06-27 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-18 | 2023-06-18 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-02-16 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-04 | 2023-02-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-07 | 2022-12-07 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-20 | 2022-11-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-10-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-20 | 2022-05-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-12 | 2022-04-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-11 | 2022-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-11 | 2022-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-07 | N |
| Post nurse staffing information every day. | Health | 2022-03-11 | 2022-04-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-11 | 2022-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-03-23 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-02-01 | 2022-02-08 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-02-03 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-12-29 | 2020-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-29 | 2020-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-29 | 2020-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-29 | 2020-01-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-29 | 2020-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-29 | 2020-01-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-29 | 2020-01-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-29 | 2020-01-21 | N |
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