F0609

D

Failure to Timely Report Repeated Verbal Abuse Allegations to CDPH

Lakeport, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report allegations of verbal abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 1, who had anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive ability, was the target of repeated verbal aggression and threats from Resident 2, who had no cognitive impairment (BIMS 15). On 12/25/25, progress notes and an SBAR form documented that Resident 2, alert and oriented x4, wheeled into Resident 1’s room, yelled at her to “shut up” for calling out for help, and stated “suffocate the bitch.” The SBAR and 24-hour report log were completed by LN 2, and the DON was expected to review these daily.

On 12/31/25, progress notes documented that Resident 1 was at the nurse’s station yelling when Resident 2 approached, became agitated, and verbally threatened her, saying “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, I’m going to slap that bitch.” LN 1 intervened and notified the DON and Administrator (ADM). LN 3 later confirmed she texted the DON and ADM that Resident 2 had gotten in Resident 1’s face, screamed profanities, and made threats to choke and slap her, and that she asked what else needed to be done. According to LN 3, the DON responded that an SBAR was not needed because there was no change of condition and that the incident was “yelling and no one was touched,” despite LN 3’s statement that it was a verbal threat to harm.

On 1/7/26, progress notes showed that Resident 2 again approached Resident 1 at the nurse’s station, told her to “shut up,” complained about paying money to hear her “bullshit,” and stated “I’ll tell that bitch to shut up,” after which Resident 1 became quiet. The ADM acknowledged he reported the incident that happened on 1/7/26 to CDPH but not until the following day via fax, and that no call was made to CDPH within the two-hour window. A SOC 341 form shows the verbal abuse incidents were faxed to CDPH on 1/8/26 at 4:14 p.m. The DON and ADM later confirmed they were aware of the 12/31/25 incident via text and that the initial text described Resident 2’s threats to choke and slap Resident 1. LN 2 stated the DON had called her after the 12/25/25 incident and instructed her not to use the word “abuse” in her progress notes. The facility’s policy required all alleged violations involving any type of abuse to be reported immediately, but not later than two hours, which did not occur in these events.