Health inspection·May 17, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to readmit one (1) of two (2) sampled residents (Resident 1) back to the facility on 5/17/2025 after Resident 1 was discharged from General Acute Care Hospital (GACH) back to the facility in accordance with the facility's policy and procedure (P&P) titled Bed Holds and Returns. This deficient practice had the potential to violate the rights of Resident 1 and lengthen unnecessary stay in GACH. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that including but not limit to spondylosis (gradual breakdown of the spine and related structures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). During a review of Resident 1's Minimum Data Set (MDS, resident assessment screening tool), dated 2/1/2025, indicated the resident had no impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. Resident 1 required supervision (helper provides verbal cues or touching assistance) for upper and lower body dressing and putting on/taking off footwear. Resident 1 required set up or clean up assistance (helper sets up or cleans up) for eating, oral hygiene and personal hygiene. During a review of Resident 1's Physician Order Sheet (POS) for 5/2025, indicated Resident 1 had an order to be transferred to GACH on 5/12/2025, due to danger to herself. During a review of Resident 1's Progress Notes dated 5/12/2025 at 9:36 AM, Progress Notes indicated Resident 1 was transferred to GACH on 5/12/2025 for further evaluation. During a review of Resident 1's Progress Notes dated 5/16/2025 at 6:04 PM, Progress Notes indicated GACH called facility to ask if facility could readmit Resident 1 but facility will not readmit Resident 1. During a review of Resident 1's GACH Discharge Orders dated 5/17/2025 at 11:49 AM, Discharge Orders (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 2 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 05/17/2025 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)