PASADENA, CA - Federal inspectors discovered a concerning pattern of medication administration failures and safety violations at Pasadena Care Center, LLC during a June 14, 2024 inspection, with one resident experiencing a medication error rate of 28 percent—nearly six times higher than acceptable standards.
Critical Medication Management Failures Put Residents at Risk
The most serious violation documented at the 1640 N. Fair Oaks Avenue facility involved systematic medication administration errors that could have resulted in life-threatening complications for residents. During inspection observations, staff failed to properly administer seven out of 25 medications to one resident, resulting in a 28 percent error rate that far exceeded the federally mandated maximum of 5 percent.
The errors included missing critical blood pressure medications, seizure control drugs, and pain management treatments. A Licensed Vocational Nurse failed to administer essential medications including Cozaar for blood pressure control, Lasix for fluid retention, and Levetiracetam for seizure prevention. Additionally, a dose of Dexamethasone, used to treat brain cancer, was given at the wrong time—administered at 9:18 AM when it should have been given at 2 PM according to the prescribed schedule.
The medical implications of these errors are significant. Blood pressure medications like Cozaar and Norvasc must be administered consistently to maintain therapeutic levels in the bloodstream. When these medications are skipped, patients face immediate risks of hypertensive crisis, which can lead to stroke, heart attack, or organ damage. For residents with seizure disorders, missing doses of anti-seizure medications like Levetiracetam can trigger breakthrough seizures that may cause serious injury or death.
"If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition," stated the Licensed Vocational Nurse during the inspection interview. A Registered Nurse further emphasized the critical nature of these oversights, noting that "a resident who was not given Levetiracetam might have a seizure" and that consistent medication timing is "important to administer medication as ordered to get the full benefit of the medication and to prevent complications."
Dangerous Medication Storage Practices Compromise Drug Safety
Inspectors also uncovered serious medication storage violations that rendered multiple drugs potentially unsafe for patient use. The facility failed to properly store insulin medications, leaving four unopened Basaglar Kwik Pens and four Trulicity injections at room temperature instead of in required refrigeration. Both medications are critical for blood sugar management in diabetic residents and lose effectiveness when stored improperly.
The storage violations extended beyond temperature control. Expired eye medications dating back to February 2024 remained in the medication storage room, creating risks of contamination and potential harm if accidentally administered. The Director of Nursing confirmed that using expired medications "might not be beneficial and could cause harm to the residents."
The facility's medication refrigerator presented additional safety concerns. Inspectors found significant ice buildup in the freezer compartment, which can affect temperature stability and compromise the efficacy of stored medications. When medications are exposed to temperature fluctuations, their chemical composition can change, potentially making them ineffective or even toxic.
Proper medication storage is fundamental to patient safety. Insulin medications like Basaglar must be stored between 36-46°F to maintain their molecular structure and blood sugar-lowering effectiveness. When these medications are stored at room temperature, they can lose potency rapidly, potentially leading to dangerous blood sugar spikes in diabetic patients that could result in diabetic ketoacidosis—a life-threatening condition requiring emergency hospitalization.
Kitchen Safety Violations Create Fire and Contamination Risks
The facility's kitchen operations revealed multiple safety violations that created immediate fire hazards and food contamination risks. Inspectors discovered unsafe electrical configurations, including a portable air conditioning unit connected through an extension cord without proper safety switches—a configuration the Maintenance Supervisor acknowledged "could catch on fire."
Food safety violations included failure to properly label and date opened food items, storing expired turkey beyond its use-by date, and maintaining inadequate separation between clean kitchen supplies and contaminated items. A resident's personal container with a used napkin was found stored alongside food seasonings, creating cross-contamination risks.
The facility also failed to maintain proper temperature monitoring for the residents' personal food refrigerator. Temperature logs showed no recorded readings for an 11-day period, while the actual refrigerator temperature measured 50°F—well above the safe maximum of 40°F. Food stored above 40°F enters the "danger zone" where harmful bacteria multiply rapidly, significantly increasing the risk of foodborne illness.
These kitchen violations are particularly concerning in nursing home settings where residents often have compromised immune systems. Foodborne pathogens can cause severe illness in elderly populations, potentially leading to dehydration, hospitalization, or death. The combination of improper food storage, inadequate temperature monitoring, and cross-contamination risks creates a perfect environment for dangerous bacterial growth.
Medical Context: Why These Violations Matter
These violations represent fundamental failures in basic healthcare protocols that are essential for resident safety. Medication administration is governed by the "five rights" principle: right patient, right medication, right dose, right route, and right time. The documented errors at Pasadena Care Center violated multiple aspects of this standard, particularly timing and completeness of medication administration.
The human body relies on consistent medication levels to maintain therapeutic effects. When medications are skipped or given at incorrect times, blood levels fluctuate unpredictably, potentially causing withdrawal effects, breakthrough symptoms, or loss of disease control. For conditions like hypertension and epilepsy, these fluctuations can trigger medical emergencies requiring immediate hospitalization.
Medication storage requirements exist because drug stability depends on specific environmental conditions. Temperature, humidity, and light exposure all affect medication potency and safety. When storage protocols are violated, medications may degrade into inactive compounds or, worse, transform into potentially harmful substances.
Additional Issues Identified
The inspection revealed several other concerning violations including improper infection control practices for C. difficile isolation rooms, inadequate hospice care coordination affecting three residents, missing information in arbitration agreements, and failures to conduct required quality assurance meetings for seven months. Staff also failed to ensure proper use of adaptive feeding equipment for a stroke patient, potentially hindering rehabilitation progress and independence.
The facility's Quality Assessment and Assurance program had not conducted required monthly meetings for seven months, preventing systematic identification and correction of care quality issues. This oversight likely contributed to the persistence of the medication and safety violations discovered during the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Care Center, LLC from 2024-06-14 including all violations, facility responses, and corrective action plans.
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