Other·April 22, 2026

California Health & Safety Code, Section 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. California Welfare and Institutions Code, Section 15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. Federal Regulations, Title 42, Section 483.12 (c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 4/2/26, at 8 a.m. an unannounced visit to the facility was conducted to investigate Complaint CA002804161. The Department determined the facility failed to report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 1 reported an allegation of verbal abuse to staff on 4/1/26 around noon time, to a mandated reporter and the allegation was not reported to the Department. This failure resulted in a delay of investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish to Resident 1. During a review of Resident 1's Minimum Data Set (MDS: federally mandated assessment) Section C dated 3/16/26, MDS-C indicated Resident 1 had a Brief Interview for Mental status (BIMS: a standardized assessment used by healthcare professionals to evaluate cognitive function, with a score 13-15: indicating Intact cognition) score of 13. This indicated Resident 1's cognition (ability to think and rationalize) was intact. During a review of Resident 1's "Order Review History Report" dated 3/2/26-4/2/26, report indicated, Resident 1 had an order indicating "Resident is capable of making her own health decisions." Order start date 11/18/23. During an interview on 4/2/26, at 8:05 a.m., with Licensed Nurse (LN 1) , LN 1 stated, Resident 1 told her recently that she has been unable to sleep due to her roommate, and that she notified the Provider who increased some of her medication to let her sleep better. LN 1 stated, Resident 1 told her yesterday (4/1/26) that her roommate (Resident 2) called her a "f... c... [a derogatory offensive insult]". During an interview on 4/2/26, at 8:46 a.m., with Resident 1, in Resident 1's room, Resident 1 stated, she had not been getting along with her roommate (Resident 2). Resident 1 stated, for several weeks her T.V. has been too loud, and she curses at me every day. Resident 1 stated she was told by staff there is nothing they can do, and they cannot force Resident 2 to move rooms and that she can move if she doesn't get along with her roommate. Resident 1 stated, she should not have to move rooms when she's been in this room for years and has not had any issues before her current roommate. Resident 1 stated, her roommate (Resident 2) moved to this room around 2 months ago. Resident 1 stated, she feels like she is less than a person, because the staff won't move her roommate who has been cursing at her and making her feel uncomfortable. During an interview on 4/2/26, at 8:58 a.m., with Resident 2, Resident 2 stated, in an aggressive tone "I liked my old room better, the staff were better over there". Resident 2 stated, she did not like her current roommate (Resident 1). During an interview on 4/2/26, at 10:09 a.m., with Social Services Director (SSD), SSD stated, they changed the process for grievances recently. SSD stated, she was informed the new process for grievances is, if a family member or resident has a grievance they will complete a form, and the form will go to the department involved in the grievance, they will then investigate the concern and fill in the outcome on the form. SSD stated, regarding room changes, if a resident has a concern with their roommate we will usually move the roommate who has the concern, "unless it's a safety concern" then we will move the other resident. SSD stated, she had a care conference with Resident 1's family member (FM) on 3/18/26. SSD stated, she was informed by FM that Resident 1 and Resident 2 were not getting along. SSD stated, yesterday (4/1/26) we were notified by LN 1 that Resident 2 used curse words towards Resident 1. SSD stated, FM filed a grievance regarding the curse words on 4/1/26 around 3 p.m. SSD stated, she reviewed the incident of the curse words with the Administrator who is the abuse coordinator. SSD stated, she believes verbal abuse can only occur in residents who are cognizant (having knowledge or being aware of) or if they were cognitively intact and saying the words purposefully. SSD stated, if she saw or heard of residents verbally abusing one another she would separate them immediately "for their safety". SSD stated, neither of the residents have any disease which cause them to say things out loud uncontrollably ( like Tourette's Syndrome: a nervous system disorder characterized by involuntary, repetitive movements and sounds). SSD stated, both residents are capable of making their own medical decisions. SSD stated, she did not report this incident as abuse because she did not think it constituted abuse. During a review of "Resident Grievance/Complaint Form" dated 4/1/26, form indicated a grievance was made by FM regarding Resident 1, the form indicated, "[Resident 1's] roommate was upset her T.V. was not working. It was after hours & she asked her [Resident 1] for the remote to be turned on, [Resident 1] said no, the roommate called her a "f... c... [a derogatory offensive insult]" . . .what actions or recommendations do you feel need to be taken? The roommate need to be changed to a room that she cannot abuse [Resident 1] or bully her". During a review of Resident 1's "Nurses Notes", dated 4/1/26, notes indicated, "Resident informed writer that her roommate called her a "f... c... [a derogatory offensive insult]" last night". Signed by LN 1. During an interview on 4/2/26 at 12:40 p.m., with LN 1, LN 1 stated, she had noticed issues between Resident 1 and Resident 2 for a while. LN 1 stated, "I don't think it's appropriate" the words Resident 2 stated to Resident 1 yesterday. LN 1, stated, "I guess it is abuse, verbal abuse is yelling or saying bad words". During an interview on 4/2/26, at 12:53 p.m., with MDS Nurse, MDS Nurse stated, she was aware of the incident between Resident 1 and Resident 2 sometime around noon yesterday 4/1/26. MDS stated, we had a care conference with FM about the issues of a room change for Resident 2, but since then, they were still having issues. We let FM know she can file a grievance regarding the words Resident 2 stated to Resident 1. MDS stated, she had LN 1 put in the chat for their charting system to notify management about the incident, the administrator is in that chat so he can see it. MDS stated, "It would constitute abuse" the cursing of Resident 2 to Resident 1. During an interview on 4/2/26, at 1:17 p.m., with Administrator (ADM), ADM stated, he was notified of the incident between Resident 1 and Resident 2 yesterday from the SSD. ADM stated, the incident was not an allegation of verbal abuse because Resident 2 did not have intent. During a concurrent interview and record review on 4/2/26, at 1:19 p.m., with ADM, the facility's Policy and Procedure (P&P) titled, "Abuse Prevention Policy" dated, 2024 was reviewed. The P&P indicated, "[facility name] will prohibit abuse. . .for all residents. . .Verbal Abuse: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory [expressions intended to insult, belittle, or diminish a person or group, expressing a low opinion or disrespect] terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability.. . .if the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting. . "Immediately" means as soon as possible but ought not exceed 2 hours after discovery of the incident, the facility administrator or designee will report the immediate allegations to the California Department of Health using the SOC 341 form . . . Staff will identify events - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient to patient abuse. . Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect. the ED or designee will perform the following: a. Report allegation not later than two hours after the allegation is made". The ADM stated, there was no intent so we did not consider this an allegation of abuse, which is why it was not reported. ADM was unable to point out where in the abuse policy the word intent was stated. ADM stated, "I'm not sure, it depends" whether it was okay for residents to use derogatory remarks to one another. ADM stated, "Yes" it is the facility's policy to protect residents from verbal abuse. ADM further stated, "I think I've already said what I need to say in this particular case, there is a differentiation of understanding of what abuse is, our understanding may differ". ADM was not willing to explain the incident further. Therefore, The Department determined the facility failed to report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 2 used derogatory remarks to Resident 1, and Resident 1 reported it to a mandated reporter on 4/1/26 and the incident was not reported to the Department. This failure resulted in a delay of investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish for Resident 1, given the alleged abuser was still her current roommate. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.