Inspection citations
18’23
26’24
39’25
5’26
88 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 18, 2026 | E · potential | Honor each resident's preferences, choices, values and beliefs. | Complaint |
| Jul 15, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| May 6, 2026 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| May 5, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| May 5, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 17, 2025 | D · potential | Ensure 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. | Complaint |
| Nov 19, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Nov 19, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Nov 19, 2025 | D · potential | Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Complaint |
| Nov 19, 2025 | D · potential | Honor 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. | Routine |
| Nov 19, 2025 | E · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Nov 19, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Nov 19, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Nov 19, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Nov 19, 2025 | B · minimal | Post nurse staffing information every day. | Routine |
| Nov 19, 2025 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Nov 19, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 19, 2025 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Nov 19, 2025 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Nov 19, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 19, 2025 | D · potential | Keep all essential equipment working safely. | Routine |
| Nov 19, 2025 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Aug 5, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| May 17, 2025 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| May 16, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 16, 2025 | J · harm | Provide 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. | Complaint |
| May 8, 2025 | E · potential | Implement a program that monitors antibiotic use. | Complaint |
| May 8, 2025 | E · potential | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Complaint |
| May 7, 2025 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| May 3, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| May 3, 2025 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Complaint |
| Apr 28, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 28, 2025 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Complaint |
| Apr 1, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 1, 2025 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Complaint |
| Apr 1, 2025 | E · potential | Implement 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. | Complaint |
| Mar 20, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Feb 25, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 25, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jan 29, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 13, 2025 | E · potential | Ensure 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. | Complaint |
| Jan 13, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Jan 13, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Jan 7, 2025 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 1, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Nov 1, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Nov 1, 2024 | D · potential | Honor 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. | Routine |
| Nov 1, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 1, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Nov 1, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Nov 1, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Nov 1, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Nov 1, 2024 | B · minimal | Post nurse staffing information every day. | Routine |
| Nov 1, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 1, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 1, 2024 | D · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Sep 25, 2024 | D · potential | Provide 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. | Complaint |
| Sep 25, 2024 | E · potential | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Complaint |
| Sep 25, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Sep 23, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Sep 23, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Sep 18, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 28, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Aug 28, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Aug 21, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jul 24, 2024 | D · potential | Ensure 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. | Complaint |
| Jul 24, 2024 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| May 7, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Jan 5, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jan 5, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Oct 26, 2023 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Oct 26, 2023 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Oct 26, 2023 | D · potential | Honor 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. | Routine |
| Oct 26, 2023 | E · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Oct 26, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Oct 26, 2023 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Oct 26, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Oct 26, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Oct 26, 2023 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Oct 26, 2023 | D · potential | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Routine |
| Oct 26, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 26, 2023 | D · potential | Implement 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. | Routine |
| Oct 26, 2023 | E · potential | Ensure 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. | Routine |
| Oct 26, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 26, 2023 | E · potential | Dispose of garbage and refuse properly. | Routine |
| Oct 26, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 26, 2023 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Oct 5, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Gem Tcu
716 South Fair Oaks Ave, Pasadena, CA 91105 · (626) 737-0560
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055341
- Certified beds
- 75
- Legal owner
- Pasadena Palace Tcu LLC
- Part of
- Abraham Bak & Menachem Gastwirth
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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