Health inspection·August 5, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged incident of staff to resident abuse for one (1) of four (4) sampled residents (Resident 1) within 2 hours to the state survey agency, adult protective services, law enforcement and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) according to federal and state regulations and facility policy.This deficiency resulted in the delay of onsite inspections and investigations which led to potential for Resident 1 to experience ongoing abuse from facility staff and/or other residents.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRDirreversible kidney failure), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed), diabetes mellitus (DM- body doesn't produce enough insulin or can't effectively use the insulin it produced leading to high blood sugar levels), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all effort needed to complete activity) for toileting, showering/bathing, partial/moderate assistance (helper does less than half the effort needed to complete the activity) with eating and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral hygiene.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 8/4/2025, timed 12:50 PM, the SBAR Communication Form indicated facility SSD was made aware of an allegation of physical abuse from Resident 1, stating he was punched and hit in the head with a broom. During a review of Resident 1's Social Services Progress Note, dated 8/4/2025, timed 13:10 PM, the Progress Note indicated Social Services Director (SSD) received a call from social worker at dialysis center Resident 1 stated to dialysis staff he was being physically abused by facility staff.During a review of Resident 1's Alleged Physical Abuse care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), dated 8/4/2025, the care plan indicated that one of the interventions is for staff to report abuse to appropriate agencies.During an interview on 8/5/2025 at 12:47 PM with Resident 1, Resident 1 stated he was hit by facility staff on the head with a broom on Sunday (8/3/2025).During an interview on 8/5/2025 at 2:08 PM with the Director of Nursing (DON), DON stated he was made aware of Resident 1's alleged incident on 8/4/2025 after Resident 1 returned to the facility from dialysis but (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055617 Printed: 05/15/2026 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 055617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pasadena Grove Health Center 1470 N 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)