Pasadena Nursing Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

up his wheelchair when Resident 4 saw Resident 1 and Resident 4 rammed his wheelchair against Resident 1. Resident 1 stated Resident 4's wheelchair hit her left arm and Resident 4 also kicked her left leg. Resident 1 stated she informed Licensed Vocational Nurse 2 (LVN 2), LVN 3, and the Assistant Director of Nursing (ADON) about the incident with Resident 4. Resident 1 stated she saw the Social Services Director (SSD), ADON, and the Administrator (ADM) go to the office to talk about the incident after it happened. Resident 1 stated the police did not come and talk to her after the incident. During an interview

on 11/25/2025, at 12:07 PM, with LVN 2, LVN 2 stated on 11/25/2025, at around 4:45 PM, Resident 1 informed LVN 2 that Resident 4 crashed into her wheelchair and hit her left arm on her way to the Nurse's Station. LVN 2 stated the ADON, Director of Nursing (DON), and Administrator (ADM) were notified about

the incident between Resident 1 and Resident 4. LVN 2 stated what Resident 1 reported about the incident with Resident 4 prompted an investigation of an allegation of abuse. LVN 2 stated if an investigation is prompted then abuse was suspected. LVN 2 stated suspected abuse should be reported to CDPH immediately or within two hours of the incident or when the allegation was made. LVN 2 stated he was not sure if the incident between Resident 1 and Resident 4 was reported to CDPH. During an interview on 11/26/2025, at 12:59 PM, with SSD, SSD stated on 11/25/2025, at approximately 5:20 PM, SSD was notified that Resident 4 allegedly ran over and hit by Resident 1's wheelchair. SSD stated he did not know if

the incident between Resident 1 and Resident 4 was reported to CDPH. During an interview on 11/26/2025 at 1:13 PM, with the ADM, the ADM stated she was informed about the incident between Resident 1 and Resident 4 on 11/25/2025, at approximately 5 PM . The ADM stated she did not report the incident to CDPH, local PD and to OMB because she did not see any contact between Resident 1 and Resident 4 in

the hallway when she checked the closed-circuit television (CCTV- video surveillance). ADM stated she did not think abuse occurred because she did not see any contact between Resident 1 and Resident 4 in the CCTV recording. ADM stated suspected abuse should be reported to CDPH immediately or within 2 hours from the incident or when the allegation was made on 11/25/2025 around 4:45 PM. ADM stated abuse was suspected if the incident prompted her to check the CCTV. ADM stated she should have reported the incident between Resident 1 and Resident 4 to CDPH. During an interview on 11/26/2025, at 3:32 PM, with ADON, ADON stated she and the ADM watched the CCTV recording after Resident 4 reported the alleged abuse by Resident 1 last 11/25/2025 around 4:45 PM and did not see Resident 4 hit Resident 1. The ADON stated they thought the facility did not need to fill out an SOC 341 (abuse reporting form) form and report to CDPH since there was no proof or witness regarding what happened between Resident 1 and Resident 4.

During a review of the facility's P&P, titled, Abuse Investigation and Reporting, revised on 1/21/2025, the P&P indicated the following: All reports of resident abuse, shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing

the facility; the local/State Ombudsman; Law enforcement officials. An alleged violation of abuse will be reported immediately, but not later than: two hours if the alleged violation involves abuse OR has resulted in serious bodily injury. During a review of the facility's policy and procedure (P&P), titled, Abuse Prevention Program, revised on 2/21/2025, the P&P indicated as part of the resident abuse prevention, the administration will investigate and report any allegations of abuse within timeframes as required by federal requirements.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Nursing Center

1570 North Fair Oaks Ave Pasadena, CA 91103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. During a review of the facility's P&P, titled, Controlled Substances, revised 6/2/2025, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. During a review of the facility's P&P, titled, Administering Medications, revised 6/2/2025, it indicated the medications are administered in a safe and timely manner and as prescribed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Nursing Center

1570 North Fair Oaks Ave Pasadena, CA 91103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:o The date and time the medication was administered; o Any results achieved and when those results were observed; and o The signature and title of the person administering the drug. During a review of the facility's P&P, titled, Carting and Documentation, revised 6/2/2025, the P&P indicated the following: All services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: objective observations; medications administered. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

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Facility ID:

If continuation sheet