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F0609
E

Failure to Timely Report Alleged Abuse to Authorities

Pasadena, California Survey Completed on 11-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged incident of abuse involving two residents to the California Department of Public Health (CDPH), the local ombudsman, and local law enforcement within the required two-hour timeframe after the allegation was made. One resident reported that another resident intentionally rammed a wheelchair into her arm and kicked her leg. The incident was reported by the resident to multiple staff members, including two LVNs and the Assistant Director of Nursing (ADON), who then notified the Director of Nursing (DON) and the Administrator (ADM). The staff initiated an investigation, which included reviewing closed-circuit television (CCTV) footage of the hallway where the incident allegedly occurred. Despite the initiation of an investigation and acknowledgment by staff that suspected abuse should be reported immediately or within two hours, the ADM and ADON decided not to report the incident to CDPH, the ombudsman, or law enforcement. Their decision was based on their review of the CCTV footage, which they stated did not show any contact between the two residents. As a result, no SOC 341 abuse reporting form was completed, and the required notifications were not made to the appropriate authorities as outlined in both facility policy and state regulations. The facility's policies clearly state that all alleged violations involving abuse must be reported promptly to local, state, and federal agencies, including the state licensing agency, ombudsman, and law enforcement, within two hours if the allegation involves abuse or results in serious bodily injury. Staff interviews confirmed awareness of these requirements, but the reporting did not occur because the ADM and ADON did not believe abuse had occurred based on their review of the CCTV footage, despite the resident's allegation and the initiation of an investigation.

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