Health inspection·April 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate assistance to prevent accidents for one (1) of two (2) residents (Resident 1). On 4/24/2024, Certified Nursing Assistant 2 (CNA 2) assisted Resident 1 back to bed from the resident's wheelchair without assistance of another facility staff. This failure resulted in Resident 1 having an assisted fall with CNA 2 and placed resident at risk of injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of atherosclerotic (a buildup of fats, cholesterol [waxy, fat-like substance found in the blood and cells] and other substances in and on the artery [a blood vessel that carries blood away from the heart and to the body's tissue and organs] walls) heart disease (a group of conditions that affect the heart and blood vessels) and intracranial injury (also known as traumatic brain injury [TBI] is a brain injury caused by external force). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/15/2025, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers (the ability to transfer to and form a bed to a chair or wheelchair), going from lying to sitting on the side of the bed, lower body dressing (the ability to dress and undress below the waist), and putting on/taking off footwear. Resident 1 needed substantial/minimal assistance (helper does more than half the effort) with upper body dressing (the ability to dress and undress above the waist and personal hygiene and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. During a review of Resident 1's Physical Therapy (PT; treatment that helps you improve how your body performs physical movements) Evaluation and Plan of Treatment dated 4/10/2025, the PT Evaluation and Plan of Treatment indicated Resident 1 was referred to PT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, and reduced functional activity tolerance which placed Resident 1 at risk for falls, further decline in function, immobility, limited out-of-bed activity, muscle atrophy (wasting), decrease in level of mobility and decreased ability to return to prior level of assistance. The PT Evaluation and Plan of Treatment also (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 055341 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)