Health inspection·May 8, 2025

F 0881 Implement a program that monitors antibiotic use. 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 implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the antibiotic drug use criteria (McGeer criteria, a set of standardized definitions used to identify healthcare-associated infections in long-term care facilities for surveillance, tracking outbreaks, and making informed decisions about antibiotic use) was not met for two (2) of 2 sampled residents (Residents 1 and 2). Residents Affected - Some This deficient practice had the potential for Residents 1 and 2 to develop antibiotic resistance (when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicine and become ineffective making infections difficult or impossible to treat increasing the risk of disease spread, severe illness, disability, and death) and suffer adverse side effects from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including but not limited to cerebral infarction (a stroke, damage to tissue in the brain due to loss of oxygen to the area), epilepsy (a brain disorder that causes unprovoked, recurrent seizures), and paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 2/26/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathing self, upper and lower body dressing, personal hygiene, rolling left and right, and sitting to lying. During a record review of Resident 1's April 2025 Physician Order Sheet, dated 4/25/2025, the record indicated Keflex (an antibiotic for bacterial infections) 500 milligram (mg, unit of measurement) capsule take Keflex 500 mg via gastrostomy tube (G-Tube, a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) twice a day for seven days for urinary tract infection (UTI, an infection of the bladder and urinary system). During a review of Resident 1's Urine Culture, dated 4/25/2025, the record indicated greater than 100,000 colony-forming unit per milliliter (cfu/ml, estimates the number of bacteria, fungi, virus, etc. in the sample) of Escherichia coli (type of bacteria that lives in the intestines of humans). (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 4 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 05/08/2025 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)