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 Page 1 of 2 055617 055617 08/05/2025 Pasadena Grove Health Center 1470 N Fair Oaks Ave Pasadena, CA 91103

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to state exact time. DON stated facility staff completed a change of condition (COC) form, but did not report the alleged incident to CDPH because the facility needed to complete an investigation first to ensure that the abuse did occur. DON also stated he thought the dialysis social worker would report to the appropriate agencies and did not need to. DON stated facility should have reported within two (2) hours of learning of the alleged abuse incident to the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), police and CDPH. DON states facility should have reported because it is regarding an allegation of abuse, and it is mandatory for facility to report if it is alleged and/or confirmed.During a concurrent interview and record review on 8/5/2025 at 3:51 PM with the Administrator, the facility's policy and procedure (P&P) titled Abuse Prevention and prohibition Program, revised 8/1/2023, the P&P indicated:a. The P&P purpose is to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.b. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults.c. The facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. Immediately, but no later than 2 hours after forming the suspicion- if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the ombudsman.The Administrator stated according to the facility's policy, state and federal regulations, the facility should have reported this alleged incident of abuse for Resident 1 to the appropriate agencies within 2 hours of incident. Administrator also stated, it is important to report alleged and confirmed allegations of abuse to ensure Residents feel safe and secure, to prevent any other instances of abuse and to have a third party that is not affiliated with the facility investigate allegations. 055617 Page 2 of 2