F0609

D

Failure to Report Resident’s Allegation of Verbal Abuse

Stockton, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of verbal abuse in accordance with its abuse policy and mandated reporting requirements. A resident, admitted in 2025, stated that in the early morning hours of 1/10/26 he went to the snack room to get hot water for coffee and a licensed nurse told him he could not go into the snack room. The resident reported that this nurse accused him of being a thief and told him that if anything went missing he would be the number one suspect. The resident stated that the way the nurse spoke to him felt like verbal abuse and slander. He reported the incident to the licensed nurse supervisor, who told him he could enter the snack room to get hot water and that she would take care of it.

In subsequent interviews, the involved nurse (LN 1) acknowledged asking the resident not to go into the snack room at night and to use the call light so staff could get snacks or hot water for him, explaining that night shift staff kept their belongings in the snack room. LN 1 denied calling the resident a thief or saying he would be the number one suspect if anything was missing. LN 1 stated she wrote a progress note in the electronic medical record and reported the incident to administration, but could not identify to whom she reported it and ultimately confirmed she did not actually report it, stating she did not see the relevance. Review of the resident’s electronic medical record showed no progress note documenting the incident. The facility’s grievance binder showed that the nurse supervisor completed a grievance form on 1/12/26 after the resident reported that a nurse was rude and told him it was not okay to take food from the snack room at night; the grievance did not characterize the concern as abuse.

Additional interviews showed that the resident described the incident as verbal abuse to individuals outside the immediate facility chain. A transition-of-care nurse from the resident’s insurance reported that on 1/27/26 the resident called and stated he was verbally abused by a nurse, leading to a three-way call attempt to the Ombudsman’s office during which the resident left a voicemail stating he was verbally abused. Another nurse on duty the night of the incident (LN 2) stated the resident told him that a nurse had called him a thief and that he felt abused; LN 2 reported the incident to the nurse supervisor. The Ombudsman reported receiving a message that the resident had called on 1/26/26 and, upon returning the call, the resident stated that a nurse verbally assaulted him but did not provide the nurse’s name. The facility’s Elder/Dependent Adult Abuse policy required that any mandated reporter who has knowledge of an incident that reasonably appears to be abuse, or is told by an elder that they have experienced behavior constituting abuse, must immediately report the known or suspected abuse to the administrator and appropriate external authorities within specified time frames. Despite the resident’s statements to staff and others that he felt verbally abused, the allegation was not reported as required by policy and state law.