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F0609
D

Failure to Timely Report Alleged Resident-to-Resident Abuse

Pasadena, California Survey Completed on 12-19-2025

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 abuse incident involving two residents to the required authorities within the mandated two-hour timeframe after the allegation was reported to a Registered Nurse Supervisor (RNS). According to interviews and record reviews, one resident, who had moderately impaired cognitive skills and required assistance with daily activities, reported being physically assaulted and verbally abused by another resident. The assaulted resident informed the RNS about the incident, but the RNS did not report the allegation to the California Department of Public Health (CDPH), Ombudsman, or local law enforcement as required by facility policy and state regulations. Staff interviews confirmed that all facility staff are mandated reporters and are aware that suspected abuse or allegations of abuse must be reported to the appropriate state agencies immediately or within two hours of becoming aware of the incident. Despite this, the RNS did not follow the facility's abuse policy, and the Director of Nursing (DON) was not informed of the abuse allegation or the reason for the police visit to the facility. The Social Services Director (SSD) also was not notified about the incident or the involvement of law enforcement until after the fact. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The failure to report the abuse allegation in a timely manner was confirmed through staff interviews and documentation review, demonstrating noncompliance with both facility policy and regulatory requirements.

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