The Suites Pasadena

Ensure that residents are free from significant medication errors.

F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Apr 6, 2026) · From a complaint

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

F0636 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 20, 2026) · From a complaint

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Feb 27, 2026)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 27, 2026)

Assure that each resident’s assessment is updated at least once every 3 months.

F0638 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 21, 2026)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0657 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 20, 2026)

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

F0644 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 21, 2026)

Ensure services provided by the nursing facility meet professional standards of quality.

F0658 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 20, 2026)

Keep residents' personal and medical records private and confidential.

F0583 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 22, 2025) · From a complaint

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Sep 22, 2025) · From a complaint

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Sep 22, 2025) · From a complaint

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

F0806 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Mar 12, 2025) · From a complaint

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 25, 2025) · From a complaint

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024)

Ensure that residents are fully informed and understand their health status, care and treatments.

F0552 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024) · From a complaint

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

F0644 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024) · From a complaint

Ensure that residents are free from significant medication errors.

F0760 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024)

Provide and implement an infection prevention and control program.

F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Apr 25, 2024) · From a complaint

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Apr 25, 2024) · From a complaint

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Apr 25, 2024) · From a complaint

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Apr 5, 2024) · From a complaint

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Apr 1, 2024) · From a complaint

Ensure services provided by the nursing facility meet professional standards of quality.

F0658 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 5, 2024) · From a complaint

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 5, 2024) · From a complaint

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 5, 2024) · From a complaint

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

F0568 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jan 24, 2024) · From a complaint

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F0690 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jan 24, 2024) · From a complaint

Ensure medication error rates are not 5 percent or greater.

F0759 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Develop and implement policies and procedures for flu and pneumonia vaccinations.

F0883 · Infection Control Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Ensure each resident receives an accurate assessment.

F0641 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

F0693 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

F0835 · Administration Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

F0801 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Provide and implement an infection prevention and control program.

F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Ensure that residents are fully informed and understand their health status, care and treatments.

F0552 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Dispose of garbage and refuse properly.

F0814 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

F0655 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

PASARR screening for Mental disorders or Intellectual Disabilities

F0645 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Assure the security of all personal funds of residents deposited with the facility.

F0570 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

F0569 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Provide enough food/fluids to maintain a resident's health.

F0692 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Honor the resident's right to manage his or her financial affairs.

F0567 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Implement a program that monitors antibiotic use.

F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Sep 20, 2023)

Install corridor and hallway doors that block smoke.

K0363 · Smoke Deficiencies · Deficient, Provider has date of correction (Apr 16, 2026)

Have properly located and lighted "Exit" signs.

K0293 · Egress Deficiencies · Deficient, Provider has date of correction (Apr 16, 2026)

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

K0342 · Smoke Deficiencies · Deficient, Provider has date of correction (Feb 19, 2026)

List the names and contact information of those in the facility.

E0030 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Feb 19, 2026)

Install an approved automatic sprinkler system.

K0351 · Smoke Deficiencies · Deficient, Provider has date of correction (Feb 23, 2026)

Use approved construction type or materials.

K0161 · Construction Deficiencies · Deficient, Provider has date of correction (Feb 19, 2026)

Provide a written emergency evacuation plan.

K0711 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Feb 19, 2026)

Develop and maintain an Emergency Preparedness Program (EP).

E0004 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Feb 17, 2026)

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

K0372 · Smoke Deficiencies · Deficient, Provider has date of correction (Feb 24, 2026)

Have proper medical gas storage and administration areas.

K0923 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Feb 21, 2026)

Establish policies and procedures including evacuation.

E0020 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Feb 23, 2026)

Have properly installed electrical wiring and gas equipment.

K0511 · Services Deficiencies · Deficient, Provider has date of correction (Apr 16, 2026)

Have simulated fire drills held at unexpected times.

K0712 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Jan 31, 2026)

Provide properly protected cooking facilities.

K0324 · Smoke Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024)

Have generator or other power source capable of supplying service within 10 seconds.

K0918 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Nov 22, 2024)

List the names and contact information of those in the facility.

E0030 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

K0222 · Egress Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

K0908 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Establish emergency prep training and testing.

E0036 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Develop and maintain an Emergency Preparedness Program (EP).

E0004 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Provide a written emergency evacuation plan.

K0711 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Install proper backup exit lighting.

K0281 · Egress Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Inspect, test, and maintain automatic sprinkler systems.

K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Conduct risk assessment and an All-Hazards approach.

E0006 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Have simulated fire drills held at unexpected times.

K0712 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)

Ensure medical gas and vacuum systems have documented maintenance programs.

K0907 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Aug 25, 2023)