PASADENA, CA - State health inspectors uncovered serious reporting failures at Pasadena Nursing Center after staff failed to notify administrators or authorities about a violent altercation between two residents that left one with facial injuries, according to a March 28, 2025 inspection report. The facility at 1570 North Fair Oaks Avenue also failed to properly supervise a resident with documented aggressive behavior who had been placed on one-to-one monitoring.
Violent Altercation Goes Unreported Despite Multiple Witnesses
On March 26, 2025, a physical altercation occurred between two residents sharing a room at Pasadena Nursing Center, resulting in visible facial injuries to one resident. Despite multiple staff members witnessing the aftermath and the injured resident's condition, no one reported the incident to the facility administrator, law enforcement, or state agencies as required by federal regulations.
The incident involved two residents with significant mental health diagnoses. The first resident, admitted with schizophrenia and movement disorders, had moderate cognitive impairment but was largely independent in daily activities. The second resident, who had schizoaffective disorder and a documented history of aggressive behavior, required substantial assistance with daily tasks and had previously struck another resident in the face according to care plan documentation from November 2024.
According to staff interviews, the altercation occurred during evening care around 5 or 6 PM. A certified nursing assistant reported that while providing perineal hygiene to the resident with aggressive behaviors, he "began to yell and punch her on the left side of her chest." The CNA left the room to find the charge nurse, and during her absence, the two roommates engaged in a physical altercation.
When staff returned, they found the first resident with scratches on the right side of his face, dried blood stains, and a bruise on his right eye. The resident told staff that "someone else had done it" when asked about his injuries. Despite these clear signs of resident-to-resident abuse, nursing staff made the decision not to report the incident.
Failure to Investigate Despite Clear Evidence of Harm
The facility's response to the visible injuries and resident's statement reveals fundamental breakdowns in their abuse prevention and reporting protocols. A licensed vocational nurse who responded to the scene stated she "did not report this to the administrator because she believed Resident 1 had done this to himself, despite not having witnessed it."
This assumption directly violated the facility's own policies and federal regulations. When injuries of unknown origin occur or when resident-to-resident altercations are suspected, immediate reporting and investigation are mandatory. The nurse acknowledged during her interview that since she didn't witness what happened, "it was considered an unknown injury or allegation of physical abuse" - yet she still failed to report it.
The facility's policies clearly state that all reports of resident abuse or injuries of unknown source must be "promptly reported to local, state, and federal agencies and thoroughly investigated by facility management immediately, but no later than 2 hours." The policy further requires interviewing witnesses, reviewing events leading to the incident, and documenting findings. None of these steps were taken.
Breakdown in One-to-One Supervision for High-Risk Resident
The resident with documented aggressive behavior had been placed on one-to-one monitoring for 72 hours starting March 26, 2025, due to being "verbally and physically aggressive towards staff and roommate." This intensive supervision level means a staff member should maintain constant visual observation of the resident to prevent harm to themselves or others.
Despite this critical safety order, the resident was left unsupervised long enough to engage in a physical altercation with his roommate. The one-to-one monitoring order was implemented the same day as the incident, indicating the facility recognized the immediate risk but failed to maintain the required supervision level.
Medical records showed this resident had required varying levels of assistance with daily activities, including maximal assistance for showering and moderate assistance for most mobility tasks. His medication administration record documented two behavioral episodes of yelling on the evening of the incident. The care plan had specifically identified interventions including "monitor closely for aggressive behavior, separate resident from others, and remove resident from situation" when aggressive behavior was present.
The failure to maintain one-to-one supervision is particularly concerning given the resident's documented history. Care plans dating back to March 2024 identified aggressive behavior directed toward others, with a specific incident in November 2024 where he had struck another resident in the face. The facility had clear knowledge of the risk this resident posed when exhibiting aggressive behaviors.
Medical Significance of Reporting Failures
When nursing homes fail to report and investigate resident injuries, critical opportunities for preventing future harm are lost. Proper investigation helps identify environmental triggers, medication issues, staffing problems, or care plan inadequacies that may contribute to aggressive behaviors. Without investigation, patterns cannot be identified and preventive measures cannot be implemented.
For residents with cognitive impairment and mental health conditions, unexpected injuries require thorough assessment. Changes in behavior, unexplained injuries, or resident reports of harm may indicate various forms of abuse, medication problems, or progression of underlying conditions. Medical evaluation following any injury is essential to document the extent of harm, provide appropriate treatment, and establish a baseline for monitoring healing.
In this case, the resident with facial injuries received only basic wound care - normal saline and antibiotic ointment - without the comprehensive assessment and documentation that should follow suspected abuse. The facility's failure to conduct any investigation meant no review of factors that might have prevented the incident, such as room assignments, activity scheduling, or behavioral intervention timing.
Industry Standards Demand Immediate Action
Federal regulations and industry best practices are unambiguous about handling suspected abuse. The Centers for Medicare & Medicaid Services requires immediate reporting of all allegations of abuse, regardless of the source or perceived credibility. Facilities must report to the administrator immediately and to state agencies within 24 hours, with written reports following within 48 hours.
Standard protocols for managing residents with aggressive behaviors include environmental modifications, structured routines, trigger identification, and consistent implementation of behavioral interventions. When one-to-one supervision is ordered, facilities must ensure adequate staffing and clear communication about supervision requirements across all shifts.
Room placement decisions for residents with behavioral challenges require careful consideration of compatibility, especially when cognitive impairment affects residents' ability to protect themselves or seek help. The facility's decision to maintain these two residents as roommates, despite one having documented aggressive behavior and the other having moderate cognitive impairment with schizophrenia, warranted heightened vigilance.
Additional Issues Identified
The inspection also revealed inadequate staff training on abuse reporting requirements. Multiple staff members who knew about the incident failed to fulfill their mandatory reporting obligations. One CNA stated that "her and another male CNA" helped move the injured resident to a different room after the altercation, but "no one had reported the alleged physical abuse."
Documentation practices were also deficient. While the facility documented the room changes and the one-to-one supervision order, there was no incident report, investigation documentation, or notification to required agencies. The administrator confirmed during the inspection that she had not been notified about the injuries or altercation and had not initiated any internal investigation.
The facility's 2017 Abuse Investigation and Reporting policy and 2007 Unusual Occurrence Reporting policy were not followed, suggesting systemic issues with policy implementation and staff accountability.
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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