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South Pasadena Care: Seizure Safety Violations - CA
This violation created unnecessary risk of head trauma during seizure activity....
Latest reports, citations, and penalties from CMS data
This violation created unnecessary risk of head trauma during seizure activity....
## Food Safety and Temperature Violations The most widespread issue involved food service failures affecting residents across the facility....
The resident's medical records documented diagnoses including depression and a history of sexual behaviors related to psychiatric illness....
The resident's initial smoking safety evaluation from 2022 incorrectly indicated he did not use tobacco, leading to the absence of necessary safety protocols....
This represents a critical breakdown in the facility's internal oversight systems designed to ensure quality care for residents....
The resident required immediate emergency transportation and received two units of blood at the hospital after being diagnosed with iron deficiency anemia....
The nursing assistant told her to wait because breakfast trays were arriving....
The 89-year-old resident with severe cognitive impairment lay sleeping nearby while the prescription medications remained easily accessible....
When questioned, LVN 6 was unsure if there was an order for the oxygen therapy....
According to the visitor's account, a staff member responded by yelling at the resident: "We hear you....
## Pattern of Narcotic Tracking Discrepancies Federal inspectors uncovered a concerning pattern of medication tracking failures spanning several months....
The specific nature of the medication violations was documented as part of complaint investigation AL00050173....
The facility obtained the X-ray on July 11, 2024, and results showed "calcaneus erosion consistent with osteomyelitis" - a serious bone infection of the heel....
The most severe case involved a resident who missed 21 doses of gabapentin over six days without any physician notification....
The violations occurred despite facility policies requiring staff to report suspected theft or misappropriation to the State Survey Agency....
The male resident involved in the incident had been diagnosed with metabolic encephalopathy, cognitive communication deficits, and blood cancer....
The breakdown extended to nursing assistants who provide direct resident care....
On January 22, residents were scheduled to receive baked chicken breast, seasoned green beans, mashed potatoes with gravy, wheat roll, and fresh fruit....
Bank statements showed the resident's account balance plummeted from $9,539.98 in July 2024 to just $496.46 by October 2024....
One resident with spinal stenosis and muscle weakness reported waiting **up to 2 hours** during nighttime shifts for staff to respond to calls for help....