The Californian Pasadena Healthcare
THE CALIFORNIAN PASADENA HEALTHCARE in PASADENA, CA — inspection on September 4, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
facility's policy and procedure (P&P) titled, Care Plans- Baseline, undated, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within forty-eight (48) hours or admission.
The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Californian Pasadena Healthcare
120 Bellefontaine Street Pasadena, CA 91105
SUMMARY STATEMENT OF DEFICIENCIES
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with thinking, memory, judgement) for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating and oral/personal hygiene.
The MDS indicated Resident 1 had a central line (PICC) on admission.
During a review of Resident 1's Skin Supplemental Assessment, dated 8/13/2025, the Skin Supplemental Assessment indicated Resident 1 had a right antecubital (the area of the forearm located in front of the elbow) PICC line, 5 French (Fr- unit of measurement for outer diameter of tubing), triple lumen, intact, no signs and symptoms (s/s) of infection noted, total length 41 centimeters (cm- unit of measurement for length).
During a concurrent interview and record review, on 9/4/2025, at 12:14 PM, with the Director of Nursing (DON), Resident 1's medical records were reviewed.
The DON stated it was the responsibility of the Treatment Nurse (TN) or the Registered Nurse (RN) Supervisor to change Resident 1's PICC line dressing at least every seven days.
The DON stated Resident 1's PICC line should have been changed on 8/19/2025 and there was no documentation to indicate Resident 1's PICC line was changed on or before 8/19/2025.
During an interview, on 9/4/2025, at 12:15 PM, with the DON and the Assistant DON (ADON), the ADON stated she changed Resident 1's PICC line but could not state the date it was changed.
The ADON stated she did not document the PICC line dressing change in Resident 1's medical record.
The DON stated if the PICC line change was not documented then it was considered not done.
The DON stated the facility's policy for Central Venous Catheter Care was not followed.
The DON stated it was important to change Resident 1's PICC line dressing to prevent complications like infections.
During a review of the facility's policy and procedure (P&P) titled, Central Venous Catheter Care and Dressing Changes, undated, the P&P indicated to change the dressing if became, damp, loosened or visibly soiled and at least every 7 days.
The P&P indicated that the purpose of this procedure was to prevent complications associated with intravenous (within or through a vein) therapy, including catheter-related infections that were associated with contaminated, loosened, soiled, or wet dressings.
Facility ID: