Pasadena Care Center: Medication Errors, CA
PASADENA, CA - State health inspectors documented significant medication management violations at Pasadena Care Center during a June 2024 inspection, finding that staff failed to administer critical medications on time and did not properly follow up on pharmacy safety recommendations.
Critical Medication Administration Failures
During the inspection, surveyors identified serious medication administration errors affecting a resident with multiple serious health conditions. On the morning of June 14, 2024, a Licensed Vocational Nurse failed to provide six essential medications to a resident diagnosed with seizures, high blood pressure, and brain cancer.
The missed medications included Levetiracetam, a critical anti-seizure medication prescribed at 750 mg twice daily. Inspectors also documented the failure to administer three blood pressure medications: Cozaar 50 mg, Norvasc 5 mg, and Lasix 20 mg. Additionally, the resident did not receive Docusate Sodium for bowel management and a Lidocaine patch for pain relief.
During observation at 8:56 AM, the nurse prepared only five medications for the resident instead of the required eleven. When questioned at 10:55 AM, the nurse acknowledged the medication errors. A Registered Nurse confirmed these failures during a subsequent interview, stating that "missed blood pressure medications might lead to uncontrolled high blood pressure" and that a "resident who was not given Levetiracetam might have seizure."
The facility's own Licensed Vocational Nurse acknowledged that "failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization."
Medical Consequences of Medication Errors
These medication failures created immediate health risks for the affected resident. Anti-seizure medications like Levetiracetam require consistent blood levels to prevent breakthrough seizures. Missing doses can lead to seizure activity, which poses serious risks including injury from falls, respiratory distress, and potential brain damage.
The failure to administer multiple blood pressure medications simultaneously compounds cardiovascular risks. Cozaar, Norvasc, and Lasix work through different mechanisms to control blood pressure and manage fluid retention. Missing these medications can result in dangerous blood pressure spikes, increased strain on the heart, and worsening of existing heart conditions.
Pain management medications require consistent administration to maintain therapeutic levels. The missed Lidocaine patch meant the resident experienced unnecessary discomfort, which can impact sleep, mobility, and overall quality of life.
Improper Medication Timing
Beyond missed medications, inspectors found timing violations with Dexamethasone, a critical anti-inflammatory medication prescribed for the resident's brain cancer. The medication was ordered to be given every eight hours at 6 AM, 2 PM, and 10 PM. However, staff administered the 2 PM dose at 9:18 AM instead, disrupting the therapeutic schedule.
Dexamethasone timing is particularly important for cancer patients because it helps reduce brain swelling and inflammation around tumors. Irregular dosing can lead to inadequate symptom control and potential complications from increased intracranial pressure.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Cedar Pine Post Acute in PASADENA, CA was cited for violations during a health inspection on June 14, 2024.
The missed medications included **Levetiracetam**, a critical anti-seizure medication prescribed at 750 mg twice daily.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.