Pasadena Nursing Center

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Pasadena Nursing Center

1570 North Fair Oaks Ave Pasadena, CA 91103

SUMMARY STATEMENT OF DEFICIENCIES