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Inspection visit

Health inspection

PASADENA NURSING CENTERCMS #5558931 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

555893 02/26/2026 Pasadena Nursing Center 1570 North Fair Oaks Ave Pasadena, CA 91103
F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) and resident's responsible party (RP) were notified and given an opportunity to participate in the care planning process for the development and implementation of the resident's person-centered plan of care. This deficient practice had the potential to prevent Resident 1 and the RP from exercising their right to participate in care planning and informed decision making to support the resident's goals, choices, and preferences.Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to paranoid schizophrenia (characterized by predominately positive symptoms of schizophrenia including delusions and hallucinations), bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]), and generalized anxiety disorder (a type of anxiety disorder feeling extremely worried or nervous about everyday things for no obvious reason). The admission Record also indicated Resident 1 had a responsible party. During a record review of Resident 1's Multidisciplinary Care Conference (MCC, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident), dated 10/27/2025, the MCC did not indicate Resident 1 and Resident 1's RP attended the meeting. During a record review of Resident 1's MCC, dated 1/16/2026, the MCC did not indicate Resident 1 and Resident 1's RP attended the meeting. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 1/16/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from a helper) by rolling left and right, lying to sitting on side of bed, and chair/bed-to-chair transfer. The MDS also indicated participation in assessment and goal setting was the resident and legal guardian. During a concurrent interview and record review on 2/26/2026 at 10:46 AM with the Interim Director of Nursing (IDON) of Resident 1's MCC, the IDON stated there was a place to document the RP was notified of the MCC. The IDON stated Resident 1's RP was not notified of Resident 1's MCC on 10/27/2025 for readmission and was not notified of the quarterly MCC on 1/16/2026. During an interview on 2/26/2026 at 1:15 PM with the IDON, the IDON stated the MCC meeting was to discuss the different areas of resident needs, changes, and if there were any recommendations to the plan of care. The IDON stated the resident's RP needed to be included in the MCC, so that they would be aware of the residents' status and condition in order to contribute to the residents' plan of care for the resident's condition. During a record review of the facility's policy and procedure titled, Care Planning Interdisciplinary Team, dated 6/2/2025, the policy indicated the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the Page 1 of 2 555893 555893 02/26/2026 Pasadena Nursing Center 1570 North Fair Oaks Ave Pasadena, CA 91103
F 0553 resident's care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555893 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0553GeneralS&S Dpotential for harm

    F553 - The right to participate in the development and implementation of his or her

    Allow resident to participate in the development and implementation of his or her person-centered plan of care.

FAQ · About this visit

Common questions about this visit

What happened during the February 26, 2026 survey of PASADENA NURSING CENTER?

This was a inspection survey of PASADENA NURSING CENTER on February 26, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PASADENA NURSING CENTER on February 26, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Allow resident to participate in the development and implementation of his or her person-centered plan of care."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.