Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
10’23
28’24
23’25
23’26
84 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 16, 2026 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 16, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jun 9, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jun 9, 2026 | D · 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. | Complaint |
| May 12, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 17, 2026 | E · 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 |
| Apr 17, 2026 | E · 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 |
| Apr 17, 2026 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Apr 17, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Apr 17, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Apr 17, 2026 | D · 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 |
| Apr 17, 2026 | 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. | Routine |
| Apr 17, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 17, 2026 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Apr 17, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 17, 2026 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Apr 17, 2026 | D · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Apr 17, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Apr 3, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Mar 18, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 26, 2026 | D · potential | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Complaint |
| Feb 5, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Feb 5, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Nov 26, 2025 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Nov 26, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Nov 26, 2025 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Oct 19, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Mar 28, 2025 | E · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Mar 28, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Mar 20, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Mar 20, 2025 | 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 |
| Mar 20, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Mar 20, 2025 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Mar 20, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 20, 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. | Routine |
| Mar 20, 2025 | B · minimal | Post nurse staffing information every day. | Routine |
| Mar 20, 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. | Routine |
| Mar 20, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Mar 20, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Mar 20, 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 |
| Mar 20, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Mar 20, 2025 | E · potential | Have policies on smoking. | Routine |
| Mar 7, 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 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 25, 2025 | 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. | Complaint |
| Jan 28, 2025 | E · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| Oct 3, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Sep 3, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| May 10, 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 |
| Apr 17, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 17, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Apr 5, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Apr 5, 2024 | E · 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 |
| Apr 5, 2024 | E · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Apr 5, 2024 | D · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Apr 5, 2024 | E · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Apr 5, 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. | Routine |
| Apr 5, 2024 | 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. | Routine |
| Apr 5, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Apr 5, 2024 | E · potential | Provide activities to meet all resident's needs. | Routine |
| Apr 5, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Apr 5, 2024 | 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. | Routine |
| Apr 5, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 5, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Apr 5, 2024 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Apr 5, 2024 | B · minimal | Post nurse staffing information every day. | Routine |
| Apr 5, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 5, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 5, 2024 | D · 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 |
| Apr 5, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 5, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 5, 2024 | 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 |
| Apr 5, 2024 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Feb 1, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 26, 2023 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Dec 26, 2023 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 26, 2023 | D · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| Dec 26, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Dec 26, 2023 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Dec 26, 2023 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Dec 2, 2023 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 15, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Oct 25, 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. | Complaint |
| Oct 25, 2023 | 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 |
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
Pasadena Nursing Center
1570 North Fair Oaks Ave, Pasadena, CA 91103 · (626) 798-0558
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555893
- Certified beds
- 52
- Legal owner
- Rg Legacy II, LLC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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