Health inspection·May 7, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local law enforcement within the two (2) hour time frame and thoroughly investigate an allegation of physical abuse (intentional act causing injury or trauma to another person or animal by way of bodily contact) of one (1) of two (2) sampled residents (Resident 1) that happened on 2/17/2025 [NAME] accordance with the facility policy. Residents Affected - Few This failure may result in psychosocial harm (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) to Resident 1 such as experiencing fear retaliation (an unpleasant emotion or thought that you have when you are frightened or worried by something dangerous, painful, or bad that is happening) and/ or anxiety retaliation (a feeling of fear, dread, and uneasiness to get revenge). Findings: During a review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), borderline personality disorder (BPD- a mental health condition characterized by significant emotional instability, unstable relationships, and impulsivity. People with BPD often struggle with regulating their emotions, maintaining stable relationships, and maintaining a stable self-image), and anxiety disorder (mental disorder that involves persistent and excessive worry that can interfere with daily activities). During a review of the Minimum Data Set, (MDS a mandated resident assessment tool) dated 2/1/2025, indicated Resident 1 had no impairment for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 1 is independent, (resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, personal hygiene, toileting, upper and lower body dressing, change of position, and transfer. Resident 1 is independent, (resident completes the activity by themselves with no assistance from a helper) for shower/bathe self. During an interview on 5/6/2025 at 3:25 PM with Resident 1 in Resident 1's room, Resident 1 stated, Resident 2 kicked her leg at the nursing station 2 a few months ago (unable to recall what month). Resident 1 also stated that Resident 1 reported the incident to the Assistant Director of Nurses (ADON) immediately after it happened. Page 1 of 3 055341 055341 05/07/2025 Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/6/2025 at 3:35 PM with ADON, ADON stated she did not report the allegation of physical abuse by Resident 2 kicking Resident 1 at the nursing station back on 2/17/2025 due to the reason that she thought it was just a kick, and it was not an allegation of physical abuse. During a concurrent interview and record review on 5/7/2025 at 9:13 AM with Medical Record Nurse (MDN), MDN stated there were incident reports filed for both incidents of Resident 2 kicked Resident 1 back in 2/17/2025 and the second report was regarding Resident 2 went into Resident 1's room on 4/24/2025. But the facility did not report anything to the SA, Ombudsman and local law enforcement regarding this resident- to- resident altercation between Resident 1 and 2 on 2/17/2025. MDN stated she did not know that it needed to be reported to SA, Ombudsman and local law enforcement. During an interview on 5/7/2025 at 10:25 AM with SSW social worker, SSW stated the abuse incident between Resident 1 and 2 on 2/17/2025 was not reported SA, ombudsman and local law enforcement in accordance with the facility's policy. SSW stated she should have reported the abuse within 2 hours from when the allegation as made. During an interview on 5/7/2025 at 3:25 PM with Assistant Director of Nurses (ADON), ADON stated she did file an incident report with Resident 1 a few months ago, she did not remember the exact day and time, but she did separate both residents right away at the nursing station 2 and she did assess both parties for wound assessment. ADON stated she did not report the allegation of physical abuse by Resident 2 to Resident 1 to Administrator, SA, and law enforcement. ADON stated she should have reported the allegation of physical abuse made by Reisdent 1 on 2/17/2025 within 2 hour from the allegation was made to SA, ombudsman and law enforcement in accordance with the facility's policy to prevent any negative impact to both residents' psychosocial wellbeing. During an interview on 5/7/2025 at 3:50 PM with the Administrator (ADM), ADM stated she should have reported the allegation of physical abuse by Resident 2 to Resident 1 on 2/17/2025 and should have investigated the allegation of physical abuse prevent other incidents for these two residents. During a record review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation, and Investigating, revision date, September 2021 indicated: All reports of resident abuse (including injuries of unknown origin) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/stale ombudsman; 055341 Page 2 of 3 055341 05/07/2025 Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105

F 0607 c. The resident's representative; Level of Harm - Minimal harm or potential for actual harm d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; Residents Affected - Few f. The resident's attending physician; and g. The facility medical director. 3. immediately is defined as: a. within two hours of an allegation involving abuse or resulting in serious bodily injury; or b. within 24 hours of an allegation that do not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies arc submitted via special carrier, fax, e-mail, or by telephone. 055341 Page 3 of 3