F0609

D

Failure to Report Resident-to-Resident Verbal Abuse and Threats to Required Authorities

San Pablo, California Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of verbal abuse and threat of harm made by one resident against another to the State Agency, local law enforcement, and the Long-Term Care Ombudsman. Resident 1, who was cognitively intact with a BIMS score of 15/15, reported that his former roommate, Resident 2, threatened to kill him, called him a derogatory name, and threw items across the room, breaking dishes. Resident 1 stated that staff initially moved Resident 2 to another room, then returned Resident 2 to the original room and moved Resident 1 instead. When Resident 1 expressed concern for his safety, he reported that staff responded by asking him what else he wanted them to do.

Progress notes dated 11/3/25 documented that the Social Services Assistant (SSA) spoke with Resident 1 about the altercation, including Resident 2 calling him a derogatory name and threatening to kill him, and noted that the roommate had already been moved and staff were aware of the altercation. Resident 2, who also had a BIMS score of 15/15, was documented by an LVN as having become upset about Resident 1 being on the phone in the mornings and throwing his breakfast tray on the floor, stating he wanted to change rooms. The SSA stated that threats between residents are considered abuse and must be reported to the State agency, local law enforcement, and the Ombudsman, and did not recall notifying the Administrator, who was the Abuse Coordinator, and had no documentation of doing so. The DON confirmed that the incident was not reported to any external authorities because an internal investigation found the allegation unsubstantiated, despite facility policy requiring all allegations of resident abuse to be promptly reported to appropriate agencies and thoroughly investigated.