Health inspection·May 7, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local law enforcement within the two (2) hour time frame and thoroughly investigate an allegation of physical abuse (intentional act causing injury or trauma to another person or animal by way of bodily contact) of one (1) of two (2) sampled residents (Resident 1) that happened on 2/17/2025 [NAME] accordance with the facility policy. Residents Affected - Few This failure may result in psychosocial harm (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) to Resident 1 such as experiencing fear retaliation (an unpleasant emotion or thought that you have when you are frightened or worried by something dangerous, painful, or bad that is happening) and/ or anxiety retaliation (a feeling of fear, dread, and uneasiness to get revenge). Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), borderline personality disorder (BPD- a mental health condition characterized by significant emotional instability, unstable relationships, and impulsivity. People with BPD often struggle with regulating their emotions, maintaining stable relationships, and maintaining a stable self-image), and anxiety disorder (mental disorder that involves persistent and excessive worry that can interfere with daily activities). During a review of the Minimum Data Set, (MDS a mandated resident assessment tool) dated 2/1/2025, indicated Resident 1 had no impairment for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 1 is independent, (resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, personal hygiene, toileting, upper and lower body dressing, change of position, and transfer. Resident 1 is independent, (resident completes the activity by themselves with no assistance from a helper) for shower/bathe self. During an interview on 5/6/2025 at 3:25 PM with Resident 1 in Resident 1's room, Resident 1 stated, Resident 2 kicked her leg at the nursing station 2 a few months ago (unable to recall what month). Resident 1 also stated that Resident 1 reported the incident to the Assistant Director of Nurses (ADON) immediately after it happened. (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 3 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 05/07/2025 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)