The Californian Pasadena Healthcare
THE CALIFORNIAN PASADENA HEALTHCARE in PASADENA, CA — inspection on February 20, 2026.
Found 13 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
During a review of Resident 9's admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included dementia in other diseases classified elsewhere (cognitive decline caused by underlying conditions rather than primary Alzheimer's or vascular dementia [brain damage or disease, resulting in a severe, progressive decline in cognitive function memory, reasoning, and behavior, that interferes with daily life]), hypertensive heart disease without heart failure ( the early-to-intermediate stage of structural heart damage caused by chronic, uncontrolled high blood pressure), and other abnormalities of gait and mobility (walking patterns or movement difficulties that do not fit into specific classifications like shuffling, limping, or stumbling).
During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 12/19/2025, indicated Resident 9 is severely impaired (never/ rarely made decisions) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making.
The MDS also indicated Resident 9 needs setup or clean-up assistance (helper sets up or cleans up) with eating, and Resident 9 needs supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral hygiene, personal hygiene, roll left and right, sit to lying and sit to stand.
The MDS indicated, Resident 9 needs substantial/maximal assistance (helper does more than half the effort.
Helper lifts or holds trunk or limbs but provides more than half the effort) for toileting hygiene, shower, bathe self, lower body dressing, putting on/ taking off footwear.
During an observation on 2/18/2024 at 12:20 PM near Nursing Station 1 and the front lobby area, Resident 9 was visible from outside the resident's room while Resident 9 is walking back to her bed from the bathroom (inside the resident's room) without being covered with a towel or clothing, and the resident was wearing a diaper.
Registered Nursing Supervisor (RNS) 1 was present in the room assisting Resident 9, and Resident 9's privacy curtain was not closed.
During an interview on 2/18/2024 at 12:35 PM, RNS 1 stated he should have provided privacy to Resident 9 by properly covering the reisdent and making sure the privacy curtain was closed while RNS 1 assisted Resident 9 back to the resident's bed. RNS 1 stated it is essential to protect Resident 9's dignity and treat the reisdent with respect.
During an interview on 2/20/2026 at 1:35 PM with the Director of Nursing (DON), the DON stated it is very important to provide privacy to residents in the facility.
The DON also stated respecting patient privacy is foundational to ethical, patient-centered care and respecting individual's autonomy.
During a review of the facility's Policy and Procedure titled Quality of Life - Dignity , dated February 2020, indicated the following:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.Residents are always treated with dignity and respect.
Demeaning practices and standards of care that compromise dignity is prohibited.
Staff are expected to treat cognitively impaired residents with dignity and sensitivity.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a review of the facility's P&P titled, Television/TV revised April 2025, the P&P indicated: Ensure televisions are accessible and positioned for optimal viewing comfort.
Maintenance Department will be responsible for any issues related to the use of television.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
indicated each resident's medication regimen shall include only those medications necessary to treat
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a concurrent interview and record review on 2/20/2026 at 10:36 AM with Assistant Director of Nursing (ADON), Resident 49's SBAR documentation dated 2/12/2026 and Care Plan dated 2/16/2026 were reviewed. ADON stated according to the care plan RNS 2 had created a care plan with custom interventions to address Resident 49's penile swelling but did not create an order for monitoring to implement the care plan intervention. ADON stated only two nursing notes for monitoring Resident 49's penile swelling were documented in Resident 49's medical records on 2/15/2026 but nothing else.
During the same interview on 2/20/2026 at 10:36 AM with ADON, ADON stated an order for monitoring Resident 49's penile swelling daily should have been implemented with an additional order to report to the MD if the condition worsens. ADON further stated Resident 49's penile swelling should have been monitored daily from 2/12/2026 so they would be able to assess if the swelling was getting better or worse and to notify the MD of the progress and because it was not monitored, it could have led to bigger consequences.
During an interview on 2/20/2026 at 2:56 PM with ADON, ADON stated Resident 49's interventions for his penile swelling should have been implemented as indicated on his care plan.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2024, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
The P&P also indicated each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a record review of the facility's policy and
monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.
The policy also indicated, if the residents continue to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a concurrent record review and interview on [DATE] at 9:18 AM with Assistant Director of Nursing (ADON), Resident 6's medical records were reviewed. ADON stated Resident 6 was admitted to the facility with diagnoses of PTSD, and the initial psychiatric consult conducted on [DATE] by Psychiatric-Mental Health Nurse Practitioner 1 (PMHNP 1, an advanced practice registered nurse licensed to assess, diagnose, and treat individuals with mental health disorders) did not and should have indicated Resident 6's diagnosis of PTSD and identified triggers to trauma. ADON stated Resident 6 has a CP for PTSD that was developed on [DATE], but the CP was not Resident 6 specific since Resident 6's trauma triggers were not identified.
During a concurrent record review and interview on [DATE] at 9:18 AM with ADON, Resident 6's risk for emotional distress related to PTSD care plan and medical records were reviewed. ADON stated Resident 6's care plan was not implemented because there was no documented evidence that the staff monitored the resident for sleep pattern disturbances and psychosocial distress such as verbalization of fear, withdrawal, crying, verbalization of fearfulness and anger. ADON stated she did not know exactly what Resident 6's past trauma was. ADON stated, It's probably due to the resident's (Resident 6) amputation. ADON stated, it was important to identify trauma triggers for residents with diagnosis of PTSD to provide holistic care. ADON added that by preventing residents from encountering triggers that may cause re-traumatization, the facility staff can help ensure that the resident's PTSD is properly managed. ADON also stated if PTSD is not managed, residents may decline and become at risk for hospitalization.
During an interview on [DATE] at 3:06 PM with the Director of Nursing (DON), the DON stated, it was necessary to identify the triggers of each resident with PTSD, including Resident 6, in order to know how to care for them and promote their mental well-being.
The DON stated PMHNP 1 did not and should have identified Resident 6's trauma triggers for the facility staff to better develop specific interventions to address Resident 6's diagnosis of PTSD.
The DON stated, Triggers can be anything, it can be sensory or situational, and most manifestations are avoidance behaviors, anger and flashbacks.
The DON stated the facility policy on Trauma Informed Care did not and should have included identification of triggers for residents with PTSD to be able to provide the care they need.
During a review of facility's Policy and Procedure (P&P) titled, Trauma Informed Care, revised in [DATE], the P&P indicated the facility supports a culture of emotional well-being and physical safety for staff, residents and visitors.
The P&P indicated as part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible.
Identifying past trauma or adverse experiences may involve record review or the use of screening tools.
Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.).
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a concurrent record review and interview on 2/19/2026 at 10:44 AM with DSD, CNA 4's employee records were reviewed. DSD stated CNA 4 was hired on 9/8/2025. DSD stated CNA 4 did not have documented evidence of completed skills competency evaluation upon hire.
During a concurrent record review and interview on 2/19/2026 at 10:45 AM with DSD, CNA 5's employee records were reviewed. DSD stated CNA 5 was hired on 8/21/2023. DSD stated CNA 5 did not have documented evidence of completed skills competency evaluation upon hire and annually. DSD stated it is important to evaluate CNA's skills competency before releasing them from orientation to know if the employee needs more training and to ensure resident's safety.
During a concurrent record review and interview on 2/19/2026 at 10:51 AM with DSD, Licensed Vocational Nurse 3's (LVN 3) employee records were reviewed. DSD stated LVN 3 was hired on 12/23/2024.
DSD stated LVN 3 did not have documented evidence of completed skills competency evaluation upon hire and annually. DSD stated the facility has a form titled, Licensed Nurse Core Clinical Competencies, which is used in evaluating the competency of the Licensed Nurses' skills upon hire, and yearly thereafter. DSD stated the skills competency log includes but is not limited to evaluating licensed nurses for blood sugar monitoring (the process of measuring the amount of sugar in the blood), medication administration, documentation of change of condition and care planning. DSD stated all employees should have completed and should be deemed competent for the skills required of them, upon hire and annually to ensure that the licensed nurses are capable of providing the necessary care for the residents.
During a concurrent record review and interview on 2/19/2026 at 10:52 AM with DSD, Registered Nurse Supervisor 1's (RNS 1) employee records were reviewed. DSD stated RNS 1 was hired on 12/10/2025. DSD stated RNS 1 did not have documented evidence of completed skills competency evaluation upon hire. DSD stated the Director of Nursing (DON) was in charge of conducting the skills competency evaluation for registered nurses upon hire and annually.
The DSD stated she files the completed competency skills evaluation in the RN's employee file once received from the DON.During a review of the Facility Assessment, updated 1/19/2026, the Facility Assessment indicated DSD and/or designee are following strictly the guidelines and facility's protocol in providing training and education to the newly hired facility staff, and current facility staff, monitoring the training progress and ongoing validation of the training. It also indicated skills competencies are done yearly and as needed.During a review of facility's P&P titled, Competency of Nursing Staff, revised May 2019, the P&P indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During an observation at the facility's basement entrance lobby door, on 2/18/2026 at 8 AM, a visitor's log was observed on top of a table right beside the door.
There was no staffing information posted.
During a concurrent observation and interview on 2/19/2026 at 9:40 AM with Director of Staff Development (DSD), the posted staffing information dated 2/19/2026 was observed in Nursing Station 1, near the front lobby, and facility's main entrance.
The posted staffing information reflected the facility census (the total number of residents living in the facility) of 61 for 2/19/2026, 7 AM to 3 PM shift, two (2) Registered Nurses (RN), five (5) Licensed Vocational Nurses (LVNs) and 12 Certified Nursing Assistants (CNAs).
During a concurrent observation at the facility's basement entrance door and interview on 2/19/2026 at 9:43 AM with DSD, a visitor's log was observed on top of a table right beside the door.
There was no staffing information posted. DSD stated some visitors enter through the basement entrance lobby door and would access the elevator to go up to Nursing Station 2. DSD stated visitors who usually use the basement entrance have residents to visit in Nursing Station 2. DSD stated posted staffing information should be placed in the basement entrance.
The DSD stated that it was important to post the staffing information that consists of the census, the total number of RNs, LVNs and CNAs working each shift. DSD added that this posting should be easily seen and read by residents, visitors, and staff.
During an interview, on 2/20/2026 at 3:24 PM, with Director of Nursing (DON), the DON stated he did not know why the facility never practice posting the facility's staffing information in the basement entrance lobby door.
The DON stated that they only posted the shift staffing information that consists of the census, the total number of RN, LVN and CNA's working each shift in Nursing Station 1, in the front entrance.
The DON added that this posting should be easily seen and read by residents, visitors, and staff.
The DON stated that it should be posted on both floors (basement and front lobby) of the building.
During a review of Facility's P&P titled, Posting Direct Care Daily and Staffing , revised on 3/20/2025, the P&P indicated within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.
During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool), dated 2/1/2026, the MDS indicated Resident 22 had moderately intact cognitive (ability to think, reason, and function) skills for daily decision making.
The MDS indicated Resident 22 required supervision with oral hygiene and personal hygiene and substantial/maximal assistance with toileting and showering.
During a review of Resident 22's Physician's Order dated 2/18/2026, the Physician's Order indicated Resident 22 was ordered the following medications: -Acetaminophen (a medication used to treat mild pain) 325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give two (2) tablets every four (4) hours as needed.-Folic acid (a vitamin used to help the body make new healthy blood and cells) 1 mg, give 1 tablet one time a day.-Norvasc (a medication used to treat hypertension [HTN- high blood pressure]), 10 mg, give 1 tablet one time a day.-Spironolactone (a medication used to treat HTN), 25 mg, give 1 tablet by mouth one time a day.-Simethicone (a medication used to relieve gas and bloating), 80 mg, give 1 tablet by mouth every 6 hours as needed.
During a concurrent observation and interview on 2/18/2026 at 8:09 AM with Resident 22 inside Resident 22's room, Resident 22 was lying in bed resting and on top of the resident's bedside table, in a medication cup, had 4 white tablets and 1 yellow tablet. Resident 22 stated the medications were blood pressure medications. Resident 22 stated the medications were placed on the bedside table 5 minutes ago.
During a concurrent interview and record review on 2/18/2026 at 1:27 PM with LVN 3, Resident 22's physician's orders, dated 1/30/2026 to 2/18/2026 were reviewed.
The orders did not indicate Resident 22 may self-administer (to take one's own medication by yourself without someone else giving it to you) medications. LVN 3 stated there is no order for Resident 22 to self-administer his medications, and the medications should not have been left at Resident 22's bedside. LVN 3 stated that residents must take their medications in the presence of a licensed nurse to ensure the medications were administered and will be effective.
During a concurrent interview and record review on 2/18/2026 at 4:01 PM with LVN 3 and the Director of Nursing (DON), Resident 22's Medication Administration Record (MAR), dated 2/18/2026 was reviewed.
The MAR indicated on 2/18/2026, LVN 3 administered Resident 22's medications. LVN 3 stated she gave all the morning medications to Resident 22.
The DON stated LVN 3 should not have left the medications at the bedside because other residents/staff can get the medication potentially harming the residents and/or staff.
During a review of the facility's Policy and Procedure titled, Storage of medications, biologicals and medical supplies, dated 10/2024, the P&P indicated, Medications shall not be kept by the bedside unless the resident may self-administer.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During an interview on 2/19/2026 at 1:59 PM with the Facility Chef (FC), the FC stated 3 individually prepared ice creams dated 2/16/2026 were missing a useˆby date label.
The FC stated 2/16/26 date on the 3 individually prepared ice creams was the preparation date.
The FC stated serving food without a useˆby date is not safe for residents, may cause confusion among kitchen staff, and could result in untimely disposal if foods are not properly labeled with a useˆby date. 2.
During an observation in the kitchen on 2/19/2026 at 6:24 AM, Kitchen Freezer 2 (KF2) was observed with one gallon of ice cream, with open date of 2/18/2026, and use by date of 10/15/2026 (approximately eight months from open date).
During an interview on 2/19/2026 at 7:25 AM with FC, FC stated the one gallon of ice cream was opened yesterday, 2/18/2026, and kitchen staff (unknown) labeled the ice cream incorrectly. use by date according to manufacturer's use by date of 10/15/2026.
During a concurrent observation, policy review and interview on 2/19/2026 at 8 AM with Dietary Service Supervisor (DSS), DSS stated the facility's P&P titled.
Freezer Storage Guidelines, dated 2023, indicated that the ice cream can be kept in the freezer for 6 months.
The DSS stated that the 1 gallon of ice cream's use by date should have been labeled 8/18/2026, and not 10/15/2026. 3.
During an observation in the kitchen on 2/19/2026 at 6:25, KF 1 was observed dirty with crumbs and ice built up that dripped down to the bottom of KF1.
During a concurrent observation and interview on 2/19/2026 at 2 PM with the FC, FC verified that the KF1 was not clean. FC stated the bottom level of KF1 was dirty with crumbs and was also observed with a pool of frozen liquid that dripped from the top part of the freezer. FC stated there was ice built up on the top portion of KF1. FC stated a dirty freezer was not acceptable because it can cause food contamination (introducing harmful or unwanted substances) which was harmful to the residents that could possibly cause sickness such as diarrhea.
During an interview on 2/20/2026 at 2:13 PM with DSS, the DSS stated she did not know why there was pool of frozen liquid on the bottom of KF1. DSS stated the water must have dripped from the top part of KF1 where there were some ice-built ups.
The DSS stated this was unsanitary because it can contaminate the food that was stored in KF1 which could cause residents to get sick.
During a review of facility's P&P titled, Refrigerators and Freezers, revised November 2022, the P&P indicated the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines.
During a review of facility's P&P titled Food Receiving and Storage, revised November 2024, the P&P indicated all foods stored in the refrigerator or freezer are covered, labeled and dated use by date).
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a review of Facility's Policy and Procedure (P&P) titled, Medication Regimen Review, revised on May 2019, the P&P indicated PC reviews the medication regimen of each resident at least monthly.
The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medications related problems, mediation errors and other irregularities.
During a review of Facility's P&P titled, Charting and Documentation, revised in July 2025, indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During an observation on 2/17/2026 at 9:55 AM in Resident 48's room, observed Resident 48's breathing treatment mask and tubing was stored inside a respiratory/patient set up bag dated 2/1/2026.
There was no date on the breathing treatment mask nor the tubing beside the date on the respiratory/patient set up bag.
During an interview on 2/17/2026 at 1:45 PM with Licensed Vocational Nurse (LVN1), LVN 1 stated Resident 48's breathing treatment mask, tubing and respiratory/ patient set up bag are supposed to be changed every seven days by night shift nurses to help prevent infection. LVN 1 stated, the label on the respiratory/ patient set up bag was dated 2/1/2026 and the breathing treatment mask and respiratory/ patient set up bag should have been changed on 2/8/2026 but it was not changed.
During an interview on 2/18/2026 at 4:25 PM with Registered Nurse 1(RN1), RN 1 stated Resident 48's breathing treatment mask, tubing and the respiratory set up bag are supposed to be changed every seven days per facility's policy, and it is to prevent the accumulation of bacteria and germs that can cause lung infection if not changed accordingly.
During an interview on 2/20/2026 at 11:14 AM with Infection Preventionist Nurse (IP), IP nurse confirmed the breathing treatment mask and tubing is supposed to be stored inside a clean respiratory set up bag with date of first use to determine when it needs to be changed with a new set. IPN also stated it is important to change the breathing treatment mask, tubing and respiratory set up bag every seven days to prevent infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).
During a record review of the facility's policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2024, the policy indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.
The policy also indicated the following steps for the use of the device: When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it.
Change equipment and tubing every seven days, or according to facility protocol.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105
During a concurrent interview and record review on 2/20/2026 at 2:54 PM with the DON and ADON, the facility's policy and procedure (P&P) titled, Call Light revised 2/20/2026 was reviewed.
The P&P indicated, The purpose of this procedure is the respond to the resident's requests and needs, and also indicated the call light is to be plugged in at all times and if a call light malfunctions it shall be reported to the maintenance supervisor promptly and the residents will be provided with a call bell and provided close staff monitoring (as indicated) until the call light is fixed.
The DON and ADON stated the facility's P&P indicated, the resident's call light should always be functioning properly.
055480 02/20/2026
The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105