F0609

D

Failure to Report Resident’s Verbal Threat as Alleged Abuse

Pomona, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse Reporting and Investigation policy when a resident verbally threatened harm toward another resident. Resident 1, admitted with essential hypertension and hyperlipidemia and documented as having decision-making capacity and independence with most ADLs, yelled at Resident 2 and Resident 2’s family member in their shared room. Social Services Assistant (SSA) 1 documented in a social services note on 1/28/2026 that Resident 1 stated that if Resident 2’s family ever addressed Resident 1 again, Resident 1 was going to do something bad to Resident 2. SSA 1 reported this statement to the Social Services Director (SSD) and believed the SSD would inform the Administrator (ADM), but SSA 1 did not directly notify the ADM as required by the facility’s abuse policy.

Resident 2, who had diagnoses including hyperlipidemia, history of falling, and depression, was documented as having severely impaired cognition and dependence on staff for multiple ADLs. Resident 2’s family member reported that Resident 1 yelled at everyone in the room and threatened Resident 2, stating Resident 1 would show Resident 2 who Resident 1 was. The ADM stated that neither SSA 1 nor the SSD reported Resident 1’s threat to harm Resident 2 to the ADM, despite both being mandated reporters. The DON stated that verbal threats are a form of verbal abuse and should be reported within two hours to appropriate authorities and to the abuse coordinator. The facility’s Abuse Reporting and Investigation policy required all staff to report all allegations of abuse to appropriate agencies within two hours and to notify the Abuse Prevention Coordinator and their supervisor immediately, which did not occur in this incident.