Your report for Pasadena Palace Tcu
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
- Los Angeles CountyLowest tier among peers368 rated homes · average 2.5★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star4★+0.9 vs CA avg
- Quality measuresCan add or remove a star1★−3.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff5.20hrsAbove 87% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.58hrsAbove 63% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better52%Above only 12% of peersCA avg38%RN turnover43%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$27,808Above only 25% of peersCA avg$26,970Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMar 2023 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 17, 2025Cycle 1worst D · no actual harm
- F693Ensure 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.Quality of Life and CareD · isolatedCorrected Jan 15, 2026
Nov 19, 2025Cycle 1worst E · no actual harm
- F571Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.Resident RightsD · isolatedCorrected Dec 12, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 12, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Dec 12, 2025
- F584Honor 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.Resident RightsD · isolatedCorrected Dec 12, 2025
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Dec 12, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 12, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 12, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 12, 2025
- F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Dec 12, 2025
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Dec 12, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 12, 2025
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Dec 12, 2025
- F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Dec 12, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 12, 2025
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Dec 12, 2025
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalB · patternCorrected Dec 12, 2025
Aug 5, 2025Cycle 1worst E · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 8, 2025
May 17, 2025Cycle 1worst D · no actual harm$27,808
- F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident RightsD · isolatedCorrected Jun 12, 2025
May 16, 2025Cycle 1worst J · immediate jeopardy$27,808
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 11, 2025
- F742Provide 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.Quality of Life and CareJ · isolatedCorrected Jun 11, 2025
May 8, 2025Cycle 1worst E · no actual harm$27,808
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlE · patternCorrected May 11, 2025
- F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected May 11, 2025
May 7, 2025Cycle 1worst D · no actual harm$27,808
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 11, 2025
May 3, 2025Cycle 1worst D · no actual harm$27,808
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected May 11, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 11, 2025
Apr 28, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 9, 2025
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected May 9, 2025
Apr 1, 2025Cycle 1worst E · no actual harm
- F758Implement 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.Pharmacy ServiceE · patternCorrected Apr 25, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 25, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Apr 25, 2025
Mar 20, 2025Cycle 1worst D · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 8, 2025
Feb 25, 2025Cycle 1worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 21, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2025
Jan 29, 2025Cycle 2worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 20, 2025
Jan 13, 2025Cycle 2worst E · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jan 31, 2025
- F803Ensure 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.Nutrition and DietaryE · patternCorrected Jan 31, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jan 31, 2025
Jan 7, 2025Cycle 2worst E · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Feb 1, 2025
Nov 1, 2024Cycle 2worst E · no actual harm
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Dec 1, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 1, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Dec 1, 2024
- F578Honor 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.Resident RightsD · isolatedCorrected Dec 1, 2024
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Dec 1, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 1, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 1, 2024
- F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Dec 1, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 1, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 1, 2024
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Dec 1, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 1, 2024
Sep 25, 2024Cycle 2worst E · no actual harm
- F688Provide 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.Quality of Life and CareD · isolatedCorrected Oct 18, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 18, 2024
- F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Oct 18, 2024
Sep 23, 2024Cycle 2worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 4, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 4, 2024
Sep 18, 2024Cycle 2worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 2, 2024
Aug 28, 2024Cycle 2worst E · no actual harm
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Sep 19, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 19, 2024
Aug 21, 2024Cycle 2worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 30, 2024
Jul 24, 2024Cycle 2worst D · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Aug 6, 2024
- F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Aug 6, 2024
May 7, 2024Cycle 2worst D · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected May 29, 2024
Jan 5, 2024Cycle 3worst D · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 15, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jan 15, 2024
Oct 26, 2023Cycle 3worst E · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Nov 10, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Nov 10, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Nov 10, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 10, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Nov 10, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Nov 10, 2023
- F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesD · isolatedCorrected Nov 10, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 10, 2023
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Nov 10, 2023
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Nov 10, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 10, 2023
- F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected Nov 10, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 10, 2023
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Nov 10, 2023
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Nov 10, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 10, 2023
- F584Honor 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.Resident RightsD · isolatedCorrected Nov 10, 2023
Oct 5, 2023Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 31, 2023
Aug 8, 2023Cycle 3worst D · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 1, 2023
Jun 22, 2023Cycle 3worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 1, 2023
Jun 6, 2023Cycle 3worst D · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 5, 2023
May 12, 2023Cycle 3worst D · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jun 10, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 10, 2023
Apr 5, 2023Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 5, 2023
Mar 3, 2023Cycle 3worst D · no actual harm
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 1, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined5.20hrs
- Registered nursesRN hours only0.58hrs
- Licensed practical nursesLPN hours1.35hrs
- Nurse aidesCNA hours3.28hrs
- Weekend nursingAll staff on Saturdays and Sundays5.00hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better52%Above only 12% of peersCA avg 38%
- RN turnoverRegistered nurses only43%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy75 certified beds · ~66 residents a day88%Above only 32% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $27,808In fines
- 1Fine
- 0Payment denials
- $26,970CA avg in fines
Actions on record
- May 16, 2025Civil money penalty$27,808
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Grace Mercado
- Ruperto Ouano
- Saint Cabrini Healthcare Services LLC
- Grace Mercado
- Ruperto Ouano
- Grace Mercado
- Ruperto Ouano
- Yolanda Sambile
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 055341 · 716 SOUTH FAIR OAKS AVE, PASADENA, CA, 91105.
- Percentiles compare this facility with every rated nursing home in California and Los Angeles County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









