F0600

E

Failure to Protect Resident From Ongoing Verbal Abuse by Roommate

San Rafael, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse by a roommate. One resident (Resident 7) had Alzheimer’s disease, unspecified dementia, generalized anxiety, and severe cognitive impairment per a recent MDS. Another resident (Resident 6) had anxiety disorder, depression, and severe cognitive impairment. On 12/10/25, social services moved Resident 6 into a new room to have a Spanish‑speaking roommate, pairing her with Resident 7. Nursing notes beginning 12/11/25 documented that Resident 6 was not adjusting well to the room change, was yelling at staff and her roommate, and was shouting statements such as “WHO LET THIS WOMAN IN MY HOUSE,” with repeated documentation that she was not adjusting to the roommate.

Subsequent nursing documentation on 12/12/25 and a change of condition note on 1/9/26 showed ongoing monitoring for emotional distress and continued yelling and verbal aggression by Resident 6 toward staff and her roommate. Staff notes indicated Resident 6 continuously shouted at her roommate and staff and remained agitated. During surveyor observations on 2/10/26, Resident 6 was heard yelling loudly from her bed, saying “This is my house” and “Call the police.” Staff interviews revealed that Resident 6 did not want a roommate, believed the room was her house, and that the two residents “fought all the time,” leading staff to close the room door and to move Resident 7 out of the room during the day because the interactions upset and disturbed others.

Family members of Resident 7 reported that Resident 6 did not want anyone in the room and directed offensive words at Resident 7, causing Resident 7 to be angry and upset when sworn at. Nursing staff described Resident 6 as angry, confused, and agitated, and stated that when Resident 7 returned to the room, Resident 6 became agitated and used very ugly and hateful curse words in Spanish, including calling Resident 7 a “son of a b---” and saying “Get this b--- out of my house.” Staff, including an LN and the DON, acknowledged that such name‑calling, cursing, and use of terms like “b---” and “stupid” directed toward another resident could constitute verbal abuse if it upset the recipient. The Administrator stated he would have investigated if he had known residents were using such terms toward each other, recognizing it as potential verbal abuse. The facility’s abuse policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, and required supervisors to immediately correct and intervene in situations in which abuse is at risk for occurring.