Pasadena Palace Tcu
Pasadena Palace TCU in PASADENA, CA — inspection on May 16, 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.
Inspection Findings
During a review of Resident 1's progress notes dated 5/12/2025 at 9:36 AM indicated at 5:20 AM License Vocational Nurse (LVN 1) LVN 1 went to Resident 1's room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal.
The progress notes also indicated 911(the telephone number used to reach emergency medical, fire, and police services) transferred Resident 1 to General Acute Care Hospital Emergency (GACH) for further evaluation.
During a review of Local Police District (LPD1) report dated 5/12/2025 indicated, on 5/12/2025 at approximately 10:17 AM LPD1 were dispatched to the facility to respond to a possible overdose.
The LPD1 report indicated Resident 1 was unresponsive and was sent to GACH. LPD1 report also indicated according to the interview with ADM, the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed.
The report also indicated Resident 1 was taken to GACH on 5/12/2025 at approximately 6AM and according to the interview with ADM, the medications found at Resident 1's bedside were not provided by their facility (from Pharmacy 2) but belonged (was labeled under Resident 1's name) to Resident 1.
The LPD 1 repot also indicated the following medications (total of 8 bottles) were found in the resident's belongings:
1.
One bottle of ondasentron (medication to prevent nausea and vomiting- (miscellaneous [misc] amount and dosage not indicated.)
2.
Two bottles of Doxepin (used to treat anxiety or depression - misc amount and dosage not indicated)
3.
One empty bottle of Doxepin (misc amount and dosage not indicated)
4.
One bottle of Klonopin (used to control seizures [a sudden, abnormal electrical disturbance in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness. It's often characterized by involuntary muscle contractions, convulsions, and sometimes a loss of awareness] in epilepsy [a chronic neurological disorder characterized by recurrent, unprovoked seizures] and for the treatment of panic disorder- misc amount and dosage not indicated)
5.
Two empty bottles of Klonopin (misc amount and dosage not indicated)
6.
Blue and tan pills (did not indicate name of medication- misc amount)
During a review of the facility's Final Investigation Summary Report submitted to the surveyor on 5/16/2025, it indicated, LPD 1 came to the facility at approximately 11 AM (date not specified) and searched Resident 1's room and LPD 1 found pill bottles (bottle of medications) inside a shopping bag and 1.5 Liters bottle of Wine 1.
The report also indicated the facility found the following items in Resident 1 belongings on 5/12/2025:
1.
Crumpled receipt from Pharmacy 2 shopping bag and the receipt indicated Wine 1 was purchased from Pharmacy 1 on 5/9/2025 at 5:46 PM.
055341
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055341 B.
Wing 05/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Gem Transitional 716 South Fair Oaks Ave Pasadena, CA 91105