The Californian Pasadena Healthcare

F 0655 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Californian Pasadena Healthcare

120 Bellefontaine Street Pasadena, CA 91105

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the peripherally inserted central catheter (PICC linea long flexible catheter that is inserted through a vein in the upper arm) care and dressing was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1).

Resident 1's PICC line was not changed every seven days as indicated in the facility's policy. This deficient practice had the potential to result in Resident 1 developing an infection on the PICC line insertion site.

Findings

During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including obstructive hydrocephalus (when excess fluid builds up in the brain, normal pathways that drain the fluid are blocked, often by a tumor, infection), type 2 diabetes mellitus without complications (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of the brain (a dangerous growth of cancerous cells in the brain that invades and destroys health tissue). 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet