Pasadena Palace Tcu
Pasadena Palace TCU in PASADENA, CA — inspection on November 19, 2025.
Found 16 citations. 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
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-11-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-11-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
During a concurrent interview and record review on 11/19/2025 at 3:17 PM with BOC, an email thread between BOC, Business Office Manager 2 (BOM 2) and the facility's previous biller was reviewed.
The email thread indicated BOC first reached out to the facility's previous biller on 8/13/2025 informing them that Resident 79 was requesting a refund and another email was sent out indicating the same thing to the previous biller on 10/10/2025 from BOM 2. No other email or communication was sent out after 10/10/2025. BOC stated they were first notified that Resident 79 needed a refund in the first or second week of August 2025 and provided the information to the previous biller on 8/13/2025. BOC stated the previous biller had told her that she would reach out to Resident 79's family. BOC stated BOM 2 took over afterwards and sent an email to the previous biller on behalf of Resident 79's family on 10/10/2025 and has since not heard of anything else regarding the matter until 11/19/2025 when she was informed that Resident 79 had not yet received any refund.
During the same interview on 11/19/2025 at 3:17 PM with BOC, BOC stated the normal process when a resident is newly admitted to the facility is to check and verify the resident's insurance and then speak with either the resident or family representative to explain the benefits, what insurance covers and whether there are any co-payments (a payment made by the beneficiary in addition to that made by insurance) or share of cost. BOC also stated that since the last email sent out to the facility's previous biller on 10/10/2025, another follow-up should have been made to ensure Resident 79 received her reimbursement of $8,170.50. BOC further stated the importance of following up is to make sure the process is being followed and that the residents are getting their requested refunds.
During an interview on 11/19/2025 at 3:42 PM with BOM 1, BOM 1 stated on 10/9/2025 she had spoken with Resident 79's family member about the refund and BOM 2 then sent an email to the previous biller on 10/10/2025. BOM 1 stated there was no follow up with Resident 79's family after 10/10/2025 and had assumed the refund was taken cared of.
During a concurrent interview and record review on 11/19/2025 at 4:02 PM with BOM 1, Resident 79's billing records, dated 4/3/2025 to 6/14/2025 were reviewed. Resident 79's billing records indicated an over payment of $8,170.50. BOM 1 stated the amount is a total of what Resident 79 was paying for coinsurance (the percentage of costs for a covered healthcare service that is paid after one has met their deductible [the amount of money that must be paid out-of-pocket (spending your own money) for covered services before insurance starts to pay]) out-of-pocket.
Facility ID:
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-11-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-11-19.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-11-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-11-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-11-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-11-19.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level B: isolated, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0806 during a standard health inspection conducted on 2025-11-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-11-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0813 during a standard health inspection conducted on 2025-11-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-11-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Dispose of garbage and refuse properly.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-11-19.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0908 during a standard health inspection conducted on 2025-11-19.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Keep all essential equipment working safely.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.
Federal health inspectors cited Pasadena Palace TCU in PASADENA, CA for a deficiency under regulatory tag F-F0912 during a standard health inspection conducted on 2025-11-19.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/Severity Level B: isolated, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Pasadena Palace TCU.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-12.