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F0600
D

Failure to Protect Residents from Verbal Abuse by Staff and Peers

Tarzana, California Survey Completed on 06-05-2025

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 protect residents from verbal abuse in two separate incidents involving both staff and resident-to-resident interactions. In the first incident, a resident with a history of confirmed adult physical abuse and moderate cognitive impairment reported a verbal altercation with a Certified Nursing Assistant (CNA) after the CNA removed the resident's dinner tray without consent. Both the resident and the CNA admitted to exchanging profanities, and the CNA acknowledged responding to the resident's remarks with offensive language. The Director of Nursing (DON) confirmed that staff should not use profane language toward residents and should maintain professionalism, while the Administrator (ADM) stated that the CNA's actions met the facility's definition of verbal abuse as outlined in their policy. In the second incident, a resident with mild cognitive impairment and total dependence for activities of daily living was subjected to repeated offensive and discriminatory language by a roommate who had severe cognitive impairment. Multiple CNAs reported hearing the roommate use profanities and discriminatory remarks directed at the resident, particularly regarding the resident's race and choice of television programming. The Social Services Director and the DON both acknowledged that such language constitutes verbal abuse and can cause psychosocial distress. The ADM confirmed that the roommate's words met the facility's definition of verbal abuse and should have been reported to supervisors and external entities. Both incidents were substantiated through interviews with residents, staff, and review of facility records and policies. The facility's policy defines verbal abuse as willful use of disparaging or derogatory terms, regardless of the recipient's ability to comprehend, and requires the prevention and prohibition of such abuse. The failure to prevent and address these incidents resulted in residents being subjected to verbal abuse by both staff and another resident.

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