Other·May 15, 2026

REGULATION VIOLATION(S) Code of Federal Regulations, Title 42, Section 483.12 Freedom from Abuse, Neglect, and Exploitation (c)(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. California Code, Welfare and Institutions Code §15630 Mandatory and Nonmandatory Reports of Abuse (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, suspected, or alleged 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. (A) If the known, suspected, or alleged abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (ii) In all other instances, immediately or as soon as practically possible, but no longer than two hours, the reporter shall submit a verbal report of the known, suspected, or alleged instance of abuse to the local law enforcement agency, and shall submit a written report to all the following agencies within 24 hours: (III) The corresponding state licensing agency. California Code of Regulations, Title 22, Section §72527 Administration (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 2/9/26 at 9:30 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of verbal abuse which occurred on 1/7/26. The department determined the facility failed to report an allegation of verbal abuse to the California Department of Public Health (CDPH) for Patient 1 when Patient 2 yelled and threated Patient 1 on 12/31/25. This failure led to the facility's negligence to protect Patient 1 from further abuse from Patient 2 which recurred on 1/7/26. A review of Patient 1's admission record indicated she has anxiety disorder (excessive, persistent fear or worry that interferes with daily life) and depression (a mood disorder characterized by persistent sadness). Patient 1 was her own responsible party (a person who can manage their own health and financial decisions). A review of Patient 1's Brief Interview for Mental Status (BIMS) score conducted on 11/5/25, indicated she had a BIMS score of 12 which meant she had moderate ability to think, reason, and learn. A review Patient 2's BIMS score conducted on 12/3/25, indicated Patient 2 had a BIMS score of 15 (no cognitive impairment). A review of Patient 1's progress note dated 12/31/25 at 8:39 p.m. indicated, "[Patient 1] was at the nurse station watching a movie and yelling when...Another resident [Patient 2] came where [Patient 1] was residing and became agitated with her yelling. [Patient 2] became aggressive and started yelling 'Shut the fuck up bitch, there is no reason to be yelling on New Year's Eve, I'm going to choke you out. Somebody should choke you, [sic] I'm going to slap that bitch.' Writer [Licensed Nurse 1 (LN 1)] intervened and corrected aggressor [Patient 1] where he said, 'too late I already said it.'...DON/Administrator [ADM] notified..." A review of Patient 1's progress note dated 1/7/26 at 6:18 p.m. indicated, "[Patient 2] as previously documented again came to the nurses [sic] station while [Patient 1] was sitting with [LN 1]. [Patient 1] was yelling as baseline and...[ Patient 2] said 'shut up' [LN 1] tried to deescalate, and [Patient 2] continued 'shut up, I don't pay money to hear your bullshit. Tell her to shut up.'...[LN 1] said tried to redirect [Patient 2] into room, then [Patient 2] says 'I'll tell that bitch to shut up.' [Patient 1] got quiet..." During a concurrent record review and interview on 2/9/26 at 11:40 a.m. LN 1 reviewed the progress note she documented on 12/31/25. LN 1 confirmed she reported the incident to the DON and ADM. During an interview on 2/9/26 at 2:45 p.m., Patient 2 stated he heard Patient 1 yelling "Help me" every day. Patient 2 started yelling for help, which meant somebody was having an emergency. Patient 2 stated he went to Patient 1 with the intention of making her "shut up." During a concurrent record review and interview on 2/9/26 at 3:25 p.m., LN 3 stated she texted the DON on 12/31/25 at 6:57 p.m. LN 3 notified them that Patient 2 went to the nurse's station and got in Patient 1's face, screamed at her to "shut the fuck up" and that someone should "choke her out" and he was going to "slap that bitch [Patient 2]" which was witnessed by LN 1. LN 3 indicated she was going to complete a SBAR form and asked the DON and ADM what else she needed to do regarding the incident. The DON replied that an SBAR was not needed, there was no change of condition, and to keep both patients separated. LN 3 indicated she knew nurses were supposed to fill out the forms for allegations of abuse. The response she received from the DON was not to fill out the forms because it was yelling and no one was touched. LN 3 responded, "It was [a] verbal threat to harm..." During a concurrent record review and interview with the DON and ADM on 2/20/26 at 3:31 p.m., the DON and ADM both acknowledged they were made aware of the incident which occurred on 12/31/25 between Patient 1 and Patient 2 via text message from LN 3. The ADM stated he called the nurses and investigated. The ADM also acknowledged he had not reported this incident to CDPH because in the process of the investigation, he was made aware that the patients were together in one table and were okay. Both the DON and ADM confirmed that the initial text message by LN 3 sent to them on 12/31/25 indicated Patient 2 said to Patient 1, "Someone should choke you" and "I'm going to slap that bitch." A review of a facility policy and procedure titled, "Elder/Dependent Abuse," dated 5/29/25, indicated, "The facility will protect... patients from any type of abuse... Any mandated reporter who...has observed or has knowledge of an incident that reasonably appears to be any type of abuse...will report the known or suspected instance of abuse... as follows...All alleged violations-Immediately but not later than 2 hours...involve any type of abuse." Therefore, the department determined the facility failed to report an allegation of verbal abuse within two hours to the CDPH for Patient 1 when Patient 2 yelled and threated Patient 1 on 12/31/25. This failure led to the facility's negligence to protect Patient 1 from further abuse from Patient 2 which recurred on 1/7/26. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.