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Complaint Investigation

Pasadena Grove Health Center

September 3, 2025 · Pasadena, CA · 1470 N Fair Oaks Ave
Citations 1
CMS Rating 2/5
Beds 71
Provider ID 055617
Healthcare Facility
Pasadena Grove Health Center
Pasadena, CA  ·  View full profile →
Inspection Summary

PASADENA GROVE HEALTH CENTER in PASADENA, CA — inspection on September 3, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

During a review of the facility's Policy and Procedure (P&P) titled, Refusal of Treatment, revised 5/1/2023, the policy indicated the Charge Nurse or DON would document information relating to the refusal in the resident's medication record.

Documentation would include at least the following: a.

The date and time a medication or treatment was attempted. b.

The medication or treatment refused.c.

The resident's reason(s) for refusal.d.

The name of the person attempting to administer the treatment.e.

That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication. f.

The residents' condition and any adverse effects due to such refusal.g.

The date and time the Attending Physician was notified and his or her response.

The P&P indicated the IDT would assess the resident's needs and offer the resident alternative treatments while continuing to provide other services in the care plan.

During a review of the facility's P&P titled, Medication - Administration, revised 11/1/2017, the policy indicated when administration of the drug was dependent upon vital signs or testing, the vital signs/testing would be completed prior to administration of the medication and recorded in the medical record (i.e., blood pressure, pulse, finger stick blood glucose monitoring etc.).

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASADENA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PASADENA GROVE HEALTH CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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