The Californian Pasadena Healthcare
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
focus on Resident 1's actual fall and risk for further falls, dated 8/10/2025 was reviewed. The DON stated Resident 1 was confused, had poor safety awareness, and tried to get out of bed numerous times. The DON stated on 8/12/2025 at approximately 6:15 PM, LVN 1 was charting on the computer inside the Nurse's Station when he heard a sound in the hallway. The DON stated LVN 1 stood up and saw Resident 1
on the floor. The DON stated LVN 1 was not able to catch Resident 1 before she fell on the floor. The DON stated Resident 1's care plan for fall did not include resident-specific interventions on how to supervise and what type of monitoring Resident 1 needed to prevent further falls. The DON stated the purpose of a care plan was to provide interventions for facility staff to follow in order to tackle residents' needs and meet specific goals. The DON stated the IDT recommendation from 8/11/2025 for ongoing monitoring of Resident 1 should have been included in Resident 1's interventions to prevent falls. During a concurrent
interview and record review, on 8/28/2025, at 10:09 AM, with the DON and the ADON, Resident 1's care plan for risk for further falls and injuries related to (r/t) balance problem, gait abnormality (unusual pattern of walking), poor trunk control (difficulty maintaining upright posture, balance, and performing daily activities) , bowel/bladder incontinence (involuntary and unexpected passage of urine or stool), poor communication/comprehension, dated 8/10/2025 was reviewed. The DON stated the care plan was not resident-specific and did not and should have included supervision and monitoring as an intervention to prevent Resident 1 from falling. During a concurrent interview and record review, on 8/28/2025, at 10:50 AM, with the DON, the facility's Falling Star Program policy was reviewed. The DON stated the Falling Star Program did not indicate what type of supervision or monitoring a resident receives once added to the program. The DON stated both the facility's Falling Star Program and Resident 1's care plan for falls did not indicate what type of supervision and monitoring Resident 1 needed to prevent falls. During a review of the facility's undated Policy and Procedure titled, Falling Star Program, the P&P indicated The IDT is responsible for implementing individualized interventions for each resident's fall risks. During a review of the facility's P&P, titled, Managing Falls and Fall Risk, , revised 03/2018, the P&P indicated the following:1. The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 2. The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a review of the facility's P&P, titled, Safety and Assistance of Residents, revised 02/2021, the P&P indicated the following:1. Our facility strives to make the environment as free from accident hazards as possible. Our residents' safety and needs to prevent accidents are facility-wide priorities.2. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including assisting the residents as needed and assisting on any assistive devices. During a review of the facility's P&P, titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated the following:1. A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan describes services that are to be furnished to attain or maintain
the Resident's highest practicable physical, mental, psychosocial well-being.
Event ID:
Facility ID:
If continuation sheet
THE CALIFORNIAN PASADENA HEALTHCARE in PASADENA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASADENA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE CALIFORNIAN PASADENA HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.