PASADENA, CA - Federal inspectors documented serious reporting failures at Pasadena Nursing Center after staff failed to properly report a resident-to-resident assault that left one resident with facial injuries, scratches, and bruising.
Resident-to-Resident Violence Incident
On March 26, 2025, an altercation occurred between two residents sharing a room at the facility located at 1570 North Fair Oaks Avenue. The incident involved Resident 2, who had a documented history of aggressive behavior, physically attacking Resident 1, resulting in visible injuries to the victim's face.
According to the federal inspection report, Resident 1 was discovered with scratches on the right side of his face and told staff that "someone else had done it." When interviewed by inspectors, Resident 1 stated: "I was attacked yesterday or the day before by my roommate. No one helped him."
The victim was observed by inspectors with dried blood stains on the right side of his face, and a scratch and bruise on his right eye. Medical orders were issued to treat the injuries with normal saline and antibiotic ointment.
Known Aggressive Behavior Pattern
Inspection records revealed that Resident 2 had an established pattern of violent behavior documented in his care plan. The resident's care plan, dated November 22, 2024, indicated he "had struck another resident in the face" and required interventions including close monitoring for aggressive behavior and separation from other residents when aggressive episodes occurred.
On the day of the assault, Resident 2 was placed on 1:1 monitoring for 72 hours due to being "verbally and physically aggressive towards staff and roommate." The resident's medication records documented two behavioral episodes of yelling on the evening of the incident.
During the inspection, Resident 2 told investigators: "He was moved from his room because he beat somebody up."
Staff Witness Account and Response Failures
A Certified Nursing Assistant (CNA1) assigned to care for both residents provided a detailed account of the evening's events. According to her testimony, while providing care to Resident 2 around 5 or 6 PM, the resident became agitated, throwing towels on the floor and repeatedly pressing the call light.
During personal care assistance, Resident 2 began yelling and punched the CNA on the left side of her chest. The CNA reported running from the room to find the charge nurse, and during her absence, the two residents got into an altercation.
Most concerning, the CNA stated that licensed nurses "refused to report this altercation to law enforcement, the administrator, and state agency" despite being aware of the incident and the resulting injuries.
Mandatory Reporting Requirements Violated
Federal regulations require nursing homes to report suspected abuse immediately and no later than two hours after an incident occurs. The facility's own policy, titled "Abuse Investigation and Reporting," mandates that all reports of resident abuse be promptly reported to local, state, and federal agencies within 2 hours.
The Director of Staff Development confirmed during interviews that "facility staff are required to report to SA, OMB and local law enforcement any type of abuse immediately and no later than two hours."
However, multiple staff members failed to follow these protocols:
- Licensed Vocational Nurse 3 (LVN3) witnessed Resident 1 with facial scratches and heard the resident state "someone else did it," but "did not report this to the administrator" because she believed the resident had injured himself, despite not witnessing the incident.
- Social Services staff visited Resident 1 the day after the incident, noted the facial scratch, but "did not report it to the licensed nurses nor the Administrator."
- The facility Administrator confirmed that "no one from the facility notified her to report the unknown injuries, resident-resident altercation and/or any allegation of abuse" that occurred on March 26, 2025.
Supervision Protocol Breakdown
Despite Resident 2 being placed on mandatory 1:1 supervision due to his aggressive behavior, inspectors found significant gaps in monitoring. During the inspection, a CNA assigned to watch a resident in the same room as Resident 2 stated he "was not assigned to provide 1:1 sitter to Resident 2" and was observed leaving Resident 2 unattended when following another resident out of the room.
This supervision failure directly contradicted the medical order requiring constant staff presence to monitor Resident 2's behavior and prevent further aggressive incidents.
Medical and Safety Implications
Facial injuries from physical assault can result in various complications beyond visible trauma. Scratches and bruising around the eye area require careful monitoring for potential vision impacts, infection risk, and underlying tissue damage. The delay in proper medical evaluation and incident investigation could have compromised the resident's recovery and safety.
Proper wound care protocols were eventually implemented, but the failure to immediately assess the cause of injuries violated standard medical practice for trauma evaluation in vulnerable populations.
Investigation and Documentation Failures
The facility's policy requires comprehensive investigation of suspected abuse incidents, including interviews with witnesses, staff members from all shifts, and the resident's roommate. This investigation process was never initiated because staff failed to report the incident to administrators.
No internal investigation was started to identify potential causes or prevent future incidents, leaving both residents at continued risk. The lack of proper documentation also hindered the ability to implement appropriate interventions or modify care plans based on the incident.
Regulatory Violations and Consequences
Federal inspectors cited the facility under F607 (Freedom from Abuse and Neglect) and F610 (Respond appropriately to all alleged violations) for failing to protect residents from abuse and properly investigate allegations.
The inspection report noted this "deficient practice resulted in compromising the safety of Resident 1 and placed the resident at risk for further physical abuse."
Under federal regulations, nursing homes must ensure residents are free from abuse and must thoroughly investigate any allegations or suspicions of mistreatment. The facility's failure to follow its own reporting policies and federal requirements represents a significant breach of resident protection standards.
Facility Response and Corrective Measures
The inspection revealed systemic failures in staff training and protocol adherence regarding abuse reporting. Multiple licensed staff members demonstrated lack of understanding of reporting requirements, despite facility policies clearly outlining the mandatory procedures.
The facility's "Unusual Occurrence Reporting" policy, dating from December 2007, requires reporting events threatening resident welfare to appropriate agencies within 24 hours, with detailed written reports delivered to state agencies within 48 hours.
These protocols exist specifically to ensure rapid response to potential abuse situations and protect vulnerable residents from further harm. The breakdown in communication and reporting at Pasadena Nursing Center represents a serious compromise of resident safety systems designed to prevent exactly these types of incidents.
The federal inspection demonstrates how multiple system failures - from inadequate supervision of aggressive residents to staff refusing to report suspected abuse - can create dangerous conditions for nursing home residents who depend on facility staff for their safety and protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Healthcare Center from 2025-03-28 including all violations, facility responses, and corrective action plans.
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