Health inspection·November 14, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor the intake and output for two (2) of 2 sampled residents (Resident 1 and 3) who had an indwelling catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) according to facility's policy. This deficient practice had the potential to delay in the necessary care and services for Resident 1 and 3 which can lead to serious illness or injury. Findings: 1. During a review of Resident 1's admission Record, indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of urinary tract infection (UTI - an infection in the bladder/ urinary tract), chronic kidney disease (CKD; longstanding disease of the kidneys [filter waste and excess fluid in the body] leading to failure), and anemia (a condition where the body does not have enough healthy red blood cells) in CKD. During a review of Resident 1's History and Physical (H&P), dated 7/11/2024, indicated resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2024, indicated resident is moderately impaired in cognitive (ability to understand and make decisions) skills in daily decision making. The MDS also indicated resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene. The MDS indicated resident has an indwelling catheter. During a review of Resident 1's Care Plan with focus of the resident has indwelling catheter, revised 9/24/2024, indicated to monitor and document intake and output as per facility policy. During a review of Resident 1's Physician Orders, dated 9/25/2024, indicated indwelling catheter: 16 French (fr, unit of measurement) due to quadriplegia (paralysis of all four limbs) diagnosis one time a day. 2. During a review of Resident 3's admission Record, indicated resident was admitted on [DATE] with the following diagnoses of UTI and retention of urine. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055617 Printed: 05/15/2026 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 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103 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)