Starfile / California

Pasadena Palace TCU

716 SOUTH FAIR OAKS AVE, PASADENA, CA 91105 · CCN 055341

Inspection history vs California & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$27,808

Number of fines

1

Number of penalties

1

Payment denials

0

Inspection citations (90)1 immediate jeopardy1 actual harm

1. DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2025-12-17 · Health · corrected 2026-01-15

   Potential for more than minimal harm

2. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

3. DF0558Reasonably accommodate the needs and preferences of each resident.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

4. DF0571Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

5. DF0584Honor 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.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

6. EF0645PASARR screening for Mental disorders or Intellectual Disabilities2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

7. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

8. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

9. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2025-11-19 · Health · corrected 2025-12-12

   Potential for more than minimal harm

10. BF0732Post nurse staffing information every day.2025-11-19 · Health · corrected 2025-12-12

    Potential for minimal harm

11. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

12. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

13. EF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

14. DF0814Dispose of garbage and refuse properly.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

15. EF0880Provide and implement an infection prevention and control program.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

16. DF0908Keep all essential equipment working safely.2025-11-19 · Health · corrected 2025-12-12

    Potential for more than minimal harm

17. BF0912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.2025-11-19 · Health · corrected 2025-12-12

    Potential for minimal harm

18. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-08-05 · Health · corrected 2025-08-08

    Potential for more than minimal harm

19. DF0627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.2025-05-17 · Health · corrected 2025-06-12

    Potential for more than minimal harm

20. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-16 · Health · corrected 2025-06-11

    Actual harm

21. JF0742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.2025-05-16 · Health · corrected 2025-06-11

    Immediate jeopardy

22. EF0881Implement a program that monitors antibiotic use.2025-05-08 · Health · corrected 2025-05-11

    Potential for more than minimal harm

23. EF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2025-05-08 · Health · corrected 2025-05-11

    Potential for more than minimal harm

24. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2025-05-07 · Health · corrected 2025-05-11

    Potential for more than minimal harm

25. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-05-03 · Health · corrected 2025-05-11

    Potential for more than minimal harm

26. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2025-05-03 · Health · corrected 2025-05-11

    Potential for more than minimal harm

27. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-28 · Health · corrected 2025-05-09

    Potential for more than minimal harm

28. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2025-04-28 · Health · corrected 2025-05-09

    Potential for more than minimal harm

29. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-01 · Health · corrected 2025-04-25

    Potential for more than minimal harm

30. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-04-01 · Health · corrected 2025-04-25

    Potential for more than minimal harm

31. EF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2025-04-01 · Health · corrected 2025-04-25

    Potential for more than minimal harm

32. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-03-20 · Health · corrected 2025-04-08

    Potential for more than minimal harm

33. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-02-25 · Health · corrected 2025-03-21

    Potential for more than minimal harm

34. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-02-25 · Health · corrected 2025-03-21

    Potential for more than minimal harm

35. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-01-29 · Health · corrected 2025-02-20

    Potential for more than minimal harm

36. EF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2025-01-13 · Health · corrected 2025-01-31

    Potential for more than minimal harm

37. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-01-13 · Health · corrected 2025-01-31

    Potential for more than minimal harm

38. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-01-13 · Health · corrected 2025-01-31

    Potential for more than minimal harm

39. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-01-07 · Health · corrected 2025-02-01

    Potential for more than minimal harm

40. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

41. EF0558Reasonably accommodate the needs and preferences of each resident.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

42. DF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

43. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

44. DF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

45. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

46. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

47. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

48. BF0732Post nurse staffing information every day.2024-11-01 · Health · corrected 2024-12-01

    Potential for minimal harm

49. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

50. EF0880Provide and implement an infection prevention and control program.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

51. DF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-11-01 · Health · corrected 2024-12-01

    Potential for more than minimal harm

52. DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2024-09-25 · Health · corrected 2024-10-18

    Potential for more than minimal harm

53. EF0712Ensure that the resident and his/her doctor meet face-to-face at all required visits.2024-09-25 · Health · corrected 2024-10-18

    Potential for more than minimal harm

54. DF0880Provide and implement an infection prevention and control program.2024-09-25 · Health · corrected 2024-10-18

    Potential for more than minimal harm

55. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-09-23 · Health · corrected 2024-10-04

    Potential for more than minimal harm

56. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-09-23 · Health · corrected 2024-10-04

    Potential for more than minimal harm

57. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-09-18 · Health · corrected 2024-10-02

    Potential for more than minimal harm

58. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-08-28 · Health · corrected 2024-09-19

    Potential for more than minimal harm

59. EF0558Reasonably accommodate the needs and preferences of each resident.2024-08-28 · Health · corrected 2024-09-19

    Potential for more than minimal harm

60. DF0880Provide and implement an infection prevention and control program.2024-08-21 · Health · corrected 2024-08-30

    Potential for more than minimal harm

61. DF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2024-07-24 · Health · corrected 2024-08-06

    Potential for more than minimal harm

62. DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-07-24 · Health · corrected 2024-08-06

    Potential for more than minimal harm

63. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-05-07 · Health · corrected 2024-05-29

    Potential for more than minimal harm

64. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-01-05 · Health · corrected 2024-01-15

    Potential for more than minimal harm

65. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-01-05 · Health · corrected 2024-01-15

    Potential for more than minimal harm

66. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

67. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

68. DF0584Honor 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.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

69. EF0645PASARR screening for Mental disorders or Intellectual Disabilities2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

70. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

71. EF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

72. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

73. DF0692Provide enough food/fluids to maintain a resident's health.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

74. EF0695Provide safe and appropriate respiratory care for a resident when needed.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

75. DF0711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

76. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

77. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

78. EF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

79. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

80. EF0814Dispose of garbage and refuse properly.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

81. EF0880Provide and implement an infection prevention and control program.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

82. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2023-10-26 · Health · corrected 2023-11-10

    Potential for more than minimal harm

83. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-05 · Health · corrected 2023-10-31

    Potential for more than minimal harm

84. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-08-08 · Health · corrected 2023-09-01

    Potential for more than minimal harm

85. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-06-22 · Health · corrected 2023-07-01

    Potential for more than minimal harm

86. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-06-06 · Health · corrected 2023-07-05

    Potential for more than minimal harm

87. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-05-12 · Health · corrected 2023-06-10

    Potential for more than minimal harm

88. DF0697Provide safe, appropriate pain management for a resident who requires such services.2023-05-12 · Health · corrected 2023-06-10

    Potential for more than minimal harm

89. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-04-05 · Health · corrected 2023-05-05

    Potential for more than minimal harm

90. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2023-03-03 · Health · corrected 2023-04-01

    Potential for more than minimal harm

Ownership

Other facilities in PASADENA

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.