Failure to Timely Report Alleged Verbal Abuse Incident to State Agency
Penalty
Summary
The facility failed to report to the California Department of Public Health (CDPH) an alleged verbal abuse incident involving the Social Services Director (SSD) and Resident 1, as required by federal and facility policy. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, was partially dependent on staff for various ADLs. On 2/3/2026, Resident 1’s family member entered the facility without a facemask and went into Resident 1’s room. The SSD saw the family member and requested that a mask be worn. When Resident 1 asked the SSD what the outbreak was, the SSD responded that Resident 1 should not worry because she was leaving the facility. Resident 1 did not like this response and called the SSD a “bitch” as the SSD was stepping out of the room. The SSD then raised her voice and asked Resident 1 why she had to be called that name, and RN 1 intervened by getting between them to calm the situation. Following the incident, Resident 1 reported that the SSD’s behavior was threatening and unprofessional and that the SSD should not be in her room. RN 2 stated she reported the 2/3/2026 verbal altercation to the Administrator (ADM) but did not know if the ADM reported it to CDPH. The ADM later stated that no one, including Resident 1, reported feelings of fear or threat or said they were scared for their life, and that if there had been such a report, she would have reported the incident to CDPH. Facility policies on abuse prevention and prohibition required reporting all abuse allegations to the State agency within required timeframes, and CMS Appendix PP required that all alleged violations involving abuse or mistreatment be reported to the State Survey Agency immediately, but not later than 2 hours after the allegation, with investigation results reported within 5 working days. Despite these requirements, the allegation that the SSD’s behavior was threatening and unprofessional toward Resident 1 was not reported to CDPH, resulting in a failure to timely report suspected abuse and the results of the investigation to the proper authorities.
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