Inspection Reports for Pasadena Highlands

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not provide resident records to the resident's authorized representative.

The investigation found that although there was a delay in providing the requested resident records, the facility did not deny the request and ultimately provided the records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not provide resident#1's authorized representative with resident records requested on 08/18/2025. Interviews with three staff members indicated the request was received but required verification of legitimacy before release. Records were sent by 09/18/2025. The allegation was unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation that staff did not safeguard a resident's personal belongings, specifically a missing wedding ring.

The investigation included interviews with staff and residents, review of documentation, and a police report. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The allegation was that staff did not safeguard resident R-1's personal belongings, specifically a missing wedding ring. Interviews and documentation did not corroborate the allegation. The allegation was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-07-17 regarding staff not timely responding to resident calls for assistance, resulting in hospitalization, and other related complaints.

The investigation substantiated that staff failed to respond timely to a resident's call for help, resulting in the resident having to call 911. Other allegations related to missed medications, failure to follow physician orders, failure to provide meals, and failure to check on the resident were found to be unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated for the allegation that staff did not answer resident's calls for assistance timely, resulting in hospitalization. Other allegations including staff neglect related to missed medications, failure to follow physician orders, failure to provide meals, and failure to check on the resident were unsubstantiated.

Unannounced complaint investigation visit conducted due to multiple allegations including inadequate supervision resulting in resident falls and injuries, unsafe transfers, pressure injuries due to neglect, worsening resident condition, and isolation of a resident in her room.

The investigation found no preponderance of evidence to substantiate any of the allegations. Interviews with residents and staff, as well as review of medical and hospital documentation, indicated that incidents were either assist to ground rather than falls, injuries were minor and promptly addressed, and residents did not have pressure injuries or worsening conditions due to neglect. The allegation of isolation was also unsubstantiated.

The complaint investigation was unsubstantiated for all allegations including inadequate supervision, unsafe transfers, pressure injuries, worsening condition, and isolation. Documentation and interviews did not support the claims, and the facility responded appropriately to incidents.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-19 regarding allegations that staff did not adequately address a change in a resident's condition and did not inform the resident's representative of incidents as required.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and documentation showed appropriate tracking and communication of residents' health conditions. The findings remain unsubstantiated.

The complaint involved allegations that staff failed to adequately address changes in resident R1's condition and failed to inform R1's power of attorney (POA) of incidents. Interviews with staff and residents, as well as review of records, did not substantiate these allegations. The report notes that although the allegations may have happened or be valid, there was insufficient evidence to prove violations occurred.

Licensing Program Analyst Mary Flores conducted an unannounced collateral visit to conduct interviews regarding a recent incident at a different licensed facility.

Interviews were conducted with 7 residents regarding the incident that occurred at their previous facility. An exit interview was conducted with the administrator and a copy of the report was provided.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not adequately address a change in a resident's condition and did not inform the resident's representative of incidents as required.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the allegations, and documentation showed appropriate tracking and communication of residents' health conditions. The resident's POA was involved during behavioral episodes, and staff assisted the resident accordingly.

The complaint involved two allegations: 1) staff did not adequately address a change in resident R1's condition related to dementia, and 2) staff did not inform R1's POA of incidents. Both allegations were unsubstantiated after interviews with staff, residents, and the resident's POA, and review of records.

The inspection was a required unannounced annual inspection to evaluate compliance with regulatory standards for the Pasadena Highlands facility.

The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. The inspection covered infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and residents with special health needs.

The inspection was an unannounced complaint investigation visit triggered by allegations related to improper wound care, neglect, failure to note changes in medical condition, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident requiring a higher level of care.

The investigation found that although there were allegations of neglect and improper wound care resulting in worsening wounds, the resident was receiving hospice services and skilled care. Facility staff documented changes in condition and timely hospital transfers were made upon family request. There was insufficient evidence to substantiate any violations, and all allegations were determined to be unsubstantiated.

The complaint involved multiple allegations including improper wound care handling, neglect leading to wound worsening, failure to note medical condition changes, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident needing higher level care. The investigation included interviews with staff, residents, family, hospice care, and review of medical and facility records. The complaint was found to be unsubstantiated.

An unannounced Case Management visit was conducted to evaluate the third floor Memory Care unit for health and safety compliance.

The facility was found to be in full compliance with health and safety standards, including fire clearance and emergency systems. The memory care unit was ready and appropriately equipped to house residents with dementia needs.

An unannounced complaint investigation visit was conducted in response to an allegation that staff do not keep the facility free from pests.

The investigation found no evidence of pests in the facility. Interviews with staff and residents, inspection of the facility, and review of pest control documentation revealed no observations of roaches, rodents, or flies. The allegation was determined to be unsubstantiated.

The complaint alleged that staff do not keep the facility free from pests. The allegation was unsubstantiated based on interviews, inspections, and documentation review.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-25 regarding pest control, sanitation of kitchen items, mildew presence, and food handling techniques at the facility.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not keeping the facility free from pests, improper sanitization of kitchen items, presence of mildew, and improper food handling techniques. Interviews with staff and residents, observations, and document reviews did not confirm these allegations.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-25 regarding pest control, sanitation, mildew, and food handling practices at the facility.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore unsubstantiated.

The complaint included allegations that staff did not keep the facility free from rodents, did not properly sanitize kitchen items, did not keep the facility free from mildew, and did not follow proper food handling techniques. All allegations were investigated and found to be unsubstantiated based on staff and resident interviews, observations, and documentation review.

An unannounced complaint investigation visit was conducted in response to an allegation of wrongful eviction of residents R1 and R2.

The investigation found no evidence of wrongful eviction. Staff and residents denied the allegation, and no eviction notices were found in the residents' files. The residents were moving out by choice, supported by a 30-day notice from the responsible party. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged wrongful eviction of residents R1 and R2. The allegation was unsubstantiated after interviews with staff, residents, and review of documentation showed no eviction notices or wrongful eviction actions.

The inspection was a required unannounced annual inspection to evaluate compliance with regulatory standards for the Pasadena Highlands facility.

The facility was found to be in compliance with all applicable regulations, including infection control, operational requirements, physical plant safety, staffing, personnel training, resident records, residents' rights, planned activities, food service, incidental medical and dental care, and disaster preparedness. No deficiencies were observed during the visit.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff was not providing adequate care and supervision to a resident.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as file reviews, indicated that the resident received proper care and medication management was appropriately handled by certified staff.

The allegation was that staff was not providing adequate care and supervision to a resident, specifically that the resident was denied care and the private caregiver was not allowed to administer medication. The allegation was unsubstantiated based on interviews and documentation reviewed.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide adequate supervision to a resident while in care.

The investigation found insufficient evidence to substantiate the allegation. Staff and residents interviewed denied the claim, and records showed adequate supervision and staffing. The resident in question was reported missing briefly but was not found after a search and police notification. The allegation was determined to be unsubstantiated.

The complaint alleged inadequate supervision of a resident who went missing on 01/21/2023. The investigation included interviews with staff and residents, review of resident files, and facility policies. The allegation was unsubstantiated due to lack of evidence.

The visit was an unannounced Case Management site visit focused on COVID-19 to assist the facility in reducing their COVID-19 positive cases.

The facility was closed for new admissions and conducting twice-weekly COVID-19 testing. Communal areas were closed due to the outbreak, and residents isolated in their rooms. Infection control measures including hand sanitizers, PPE availability, cleaning protocols, and mask usage were observed and enforced throughout the facility.

An unannounced required 1-year visit focusing on the Infection Control Domain was conducted to evaluate compliance with health and safety regulations.

The facility was found to be in compliance with infection control and safety standards, including adequate PPE supplies, proper signage, mask usage, and safe medication storage. No deficiencies were cited during the visit.

An unannounced complaint investigation was conducted in response to an allegation that facility staff did not provide a resident's records to the authorized representative upon written request.

The investigation found that the initial document request lacked proper authorization or power of attorney, making it a HIPAA violation to provide the documents. An updated request with proper authorization was provided on 08/31/2022, and the facility agreed to provide the requested documents accordingly. Therefore, the allegation was unsubstantiated.

The complaint alleged that facility staff did not provide resident's records to the authorized representative upon written request. The allegation was unsubstantiated due to lack of evidence and proper authorization in the initial request.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-11 regarding multiple allegations including resident injury from a fall, staffing shortages, care plan non-adherence, inadequate food services, and medication administration errors.

The investigation substantiated all allegations, finding that a resident fell resulting in brain injury, staffing shortages led to missed care such as repositioning and feeding, the resident's care plan was not consistently followed or updated, food services were delayed due to staff shortages, and medications were not administered according to physician orders including medication errors.

The complaint investigation was substantiated based on evidence including interviews, record reviews, and video surveillance. Allegations included a resident fall causing injury, insufficient staffing, failure to follow care plans, inadequate food services, and medication administration errors.

An unannounced required 1-year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with health and safety regulations.

The inspection found deficiencies related to failure to screen visitors for COVID-19 symptoms and temperature checks, and improper medication storage in a resident's room. Infection control signage and PPE were observed, and staff were wearing masks. The facility removed medications from the resident's room during the visit and planned staff training on medication handling.

An unannounced complaint investigation was conducted in response to allegations that staff did not follow a resident's Care Plan, did not aid a resident with incontinence needs, and did not ensure a resident's room was not malodorous.

The investigation found that the alleged resident (R1) was not and has never been a resident of the facility. Interviews with multiple facility directors and observations of resident rooms showed no evidence supporting the allegations. The complaint was determined to be unfounded and dismissed.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without reasonable basis.

The visit was a Case Management - Other type, conducted to address the facility's failure to report a Covid-19 outbreak in a timely manner.

The facility had an outbreak of Covid-19 involving 12 individuals starting on 2021-12-25 but failed to report the outbreak to the licensing agency and local health officer within the required 24 hours. A citation was issued for this failure to report.

Licensing Program Analyst conducted a Case Management-Deficiencies visit due to observations made during a complaint investigation (control #: 28-AS-20210607141758).

The inspection found that the right delayed egress door in the memory care unit did not open after the 15-second delay and the alarm did not sound, posing an immediate health and safety risk. Additionally, the required complaint poster was not displayed in the main entryway of the facility.

The visit was triggered by a complaint investigation under control number 28-AS-20210607141758.

The visit was an unannounced complaint investigation triggered by an allegation of lack of supervision resulting in a resident eloping from the facility.

The investigation substantiated the allegation that a memory care resident eloped from the facility due to staff failing to supervise and ensure the delayed egress door closed properly. The resident was found safe after being missing for approximately 20 minutes. No injuries were observed upon return.

The complaint was substantiated. The resident eloped on June 4, 2021, from the memory care unit. Staff failed to supervise and ensure the door closed after exiting. The resident was found safe approximately 1.5 miles away after a search and police involvement. The resident has a history of elopement and dementia diagnosis.

The inspection was an unannounced complaint investigation triggered by an allegation that residents were not being changed timely due to lack of staff.

The investigation found that the facility was short-staffed, with residents waiting 25 minutes to an hour for assistance. Staff reported being overwhelmed and that management had not improved staffing levels. The allegation was substantiated based on interviews and evidence.

The complaint was substantiated. Residents and staff reported short staffing causing delays in care. The assisted living floor had reduced caregivers from 4-5 to 1-2, posing a potential health and safety risk.