Resident 103 told inspectors on July 16 that his surgical site dressing was last changed four days earlier and the catheter site had not been cleaned, despite physician orders requiring daily cleaning with saline solution and fresh dressing changes every shift.
The Treatment Administration Record showed the suprapubic site was dressed daily, with Treatment Nurse 1 signing off on July 16 and 17. But when questioned, the same nurse admitted the last actual dressing change was July 12 — not the dates she had documented.
"The suprapubic stoma site dressing should be done daily to keep Resident 103 from getting an infection on the site," Treatment Nurse 1 told inspectors during the July 19 inspection of South Pasadena Care Center.
The 91030 facility failed to provide basic wound care to multiple residents while also endangering those with seizure disorders by leaving safety padding off bed rails, according to the federal inspection report.
Three residents with epilepsy lacked proper seizure precautions. Resident 58's bed had padding on the right side rail but none on the left. Resident 103's left side rail was missing its pad entirely — a Licensed Vocational Nurse explained it was "being cleaned at the laundry." Resident 28's quarter-length side rails had no padding at all.
"Residents with seizures, the side rails should be padded," Director of Nursing told inspectors. "The padded side rails were a standard of practice to prevent injury when residents had seizures."
A nursing assistant confirmed the oversight: "Padding should be placed on both side rails for Resident 58 since resident had seizures."
The facility's seizure precaution policy specifically requires assessing "the need to pad side rails to prevent injury during seizure activity."
Resident 287, who weighed 91 pounds, lay on a low air loss mattress set to 120 pounds — nearly 30 pounds higher than appropriate for his weight. The resident described the incorrect setting: "The mattress feels like I am laying on a stack of sand or it feels like I am laying on my waste. I always have to find ways to lay comfortably on it."
Licensed Vocational Nurse 7 immediately recognized the error. "The LAL was set up incorrectly. Resident 287 was 91 lbs. LAL should be set on 90 lb. setting. If the LAL was set incorrectly and the resident has pressure ulcer, the wound will take longer to heal."
The Director of Nursing explained the consequences: "If the LAL was set up incorrectly, it depletes the purpose of the LAL mattress. The wound will not heal. If it is for prevention, the wound might develop."
Resident 46, weighing 105 pounds, also had his mattress set incorrectly at 120 pounds. A Licensed Vocational Nurse confirmed: "It should be on 105 lb. setting. We set the LAL based on the resident's weight. If the LAL setting was set on high, it depletes the purpose of the LAL Mattress."
The facility failed to provide ordered rehabilitation services to Resident 106, who was supposed to receive range-of-motion exercises five days a week starting July 4. No documentation existed showing any services were provided through July 18.
Resident 106 told inspectors: "The last time anyone had come to help him move his upper and lower extremities was on July 3 when he was discharged from physical therapy. He felt like he might lose his functioning and would have to start all over again."
Restorative Nursing Assistant 2 admitted he had performed the services but forgot to document them. He was observed signing off on two weeks of backdated entries during the inspection — a practice the Director of Nursing called unacceptable.
"It is not acceptable to be signing off on services performed for a resident two weeks later as they will not know if there were any significant changes with the resident," the Director of Nursing stated.
Basic grooming care was neglected for multiple residents. Resident 43's fingernails were described as "long and yellowish." A nursing assistant confirmed they "needed to be trimmed" but said the resident would refuse care.
Resident 75's family member expressed concern about the facility's failure to trim fingernails. "When she had visited Resident 75, she would usually have to trim Resident 75's fingernails since they were long," according to the inspection report. During the inspection, his nails "appeared long on both sides of the hand, extending beyond the tips of the fingers."
A nursing assistant warned of the consequences: "Long fingernails could cause damage to Resident 75's palms and lead to an infection since his fists were closed."
No documentation existed showing either resident had refused nail care, despite facility policies requiring such refusals to be documented after three attempts.
Resident 112, diagnosed with kidney problems, was ordered to drink at least two liters of water daily. His family member noticed he was "always thirsty" and had never seen staff offer drinks. The resident confirmed: "Nobody offered him water and/or fluids on a regular basis."
During inspection, Resident 112 had a full water pitcher but no cup available. His mouth and tongue appeared dry and cracked. "Staff just leave the pitcher of water at the bedside but does not offer nor give it to him," the resident explained. "He needed the staff to put the water in the cup with a straw for him to drink."
A nursing assistant admitted she didn't know about the two-liter requirement. The facility's documentation system only recorded whether fluids were offered, not the actual amounts consumed.
Oxygen therapy violations put two residents at risk. Resident 7's oxygen was set at 5 liters per minute when physician orders specified 2-3 liters, with titration up to 4 liters only to maintain oxygen saturation above 92%.
"The resident's oxygen setting being at 5 LPM means the physician's order was not being followed," a Licensed Vocational Nurse confirmed.
Resident 129's oxygen equipment was improperly maintained. The nasal cannula and humidifier weren't dated, making it impossible to know when they were last changed. The oxygen concentrator had "whitish stain drop and white spots splattered on the device."
An Infection Prevention Nurse explained the risks: "When the nasal cannula is not changed every 7 days, there was a possibility to result in change of condition such as a drop in oxygen for the resident since the tubing was clogged, dirty, or kinked."
Medication administration errors included a nurse failing to check a resident's heart rate before giving metoprolol, despite orders to hold the medication if the pulse dropped below 60.
"I should have checked the resident's heart rate because if it was under 60, I would have to hold the metoprolol to prevent the heart rate from lowering even more, which could potentially cause the resident to faint and pass out," Licensed Vocational Nurse 2 acknowledged.
Food safety violations included improperly sealed containers of chicken soup base and wheat flour in the kitchen, plus a dirty refrigerator designated for residents' outside food items with "brownish to blackish crusted food residue" and spilled milk.
Environmental hazards included food debris under a resident's bed, used syringes improperly disposed on sharps containers, and exercise equipment with peeling rubber coverings in the rehabilitation room.
Call light failures left residents unable to summon help. Resident 35's call light didn't function when pressed. Resident 119's call light was found on the floor behind his bed, then later hanging on the wall out of reach.
The facility failed to provide a communication board for Resident 63, who speaks a non-English language and has aphasia. His care plan specified he required "communication board and translators to communicate as needed," but none was available in his room.
South Pasadena Care Center's violations spanned basic care, safety equipment, medication administration, and environmental cleanliness. The inspection found residents scratching infected surgical sites, lying on incorrectly calibrated medical equipment, and unable to call for help when needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Pasadena Care Center from 2024-07-19 including all violations, facility responses, and corrective action plans.