The incident occurred on the morning of May 8, 2024, when Certified Nursing Assistant 2 was assisting Resident 28 to the shower. Resident 77 yelled at Resident 28 using what facility staff later acknowledged was verbal abuse.
Resident 28, who has intact cognitive skills but needs substantial help with dressing and transfers due to one-sided paralysis from a stroke, spoke to administrators the next day. She told the Social Services Director and MDS Nurse that "no one is allowed to or has the right to speak to her like that." The inappropriate language made her feel "very angry."
Yet when federal inspectors arrived nearly a month later, they found no evidence that anyone had investigated the allegation.
The Social Services Director confirmed to inspectors that what Resident 77 said to Resident 28 "offended her and was unacceptable." The Director of Nursing stated that "if a resident was offended by this type of behavior, then it was not acceptable and should be considered an allegation of abuse."
Both residents have the mental capacity to understand and make decisions, according to their medical records. Resident 28 was readmitted to the facility in 2024 with bilateral knee arthritis and right-side paralysis following a stroke. Resident 77 was admitted with heart disease and had also suffered a stroke.
The facility's own policy defines verbal abuse as "a type of mental abuse" that includes "verbal, written or gestured communication, or sounds, to residents within hearing distance." Examples include harassing, mocking, insulting, ridiculing, or "yelling or hovering over a resident, with the intent to intimidate."
CNA 3 told inspectors that "verbal abuse is when bad words are used, yelling, saying something degrading or negative." The nursing assistant confirmed that the incident between the two residents "was considered verbal abuse."
The Director of Nursing described verbal abuse as when "a person directly screams at another person by swearing and using foul language." She warned inspectors that failing to investigate abuse allegations "could psychologically harm the resident, could be detrimental to the resident's mental health and the incident could possibly happen again."
The facility's abuse investigation policy requires that "all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be thoroughly investigated by facility management." When an incident is reported, "the Administrator will assign the investigation to an appropriate individual."
The Social Services Director told inspectors that the Administrator serves as the facility's abuse coordinator. But there was "no documentation of the allegation being investigated."
The failure left Resident 28 and other residents potentially vulnerable to future verbal abuse. Federal regulations require nursing homes to protect residents from all forms of abuse, including verbal abuse between residents.
Resident 28 requires substantial assistance with daily activities but maintains her cognitive abilities. She needs help transferring from bed to chair, substantial assistance with dressing, supervision with personal hygiene, and setup assistance with eating. Despite her physical limitations, she clearly understood that the verbal abuse was unacceptable and took the initiative to report it to facility leadership.
Resident 77, who also has intact cognitive skills, requires similar levels of assistance with transfers, dressing, and personal hygiene. The resident needs setup assistance with eating but can complete the activity independently once prepared.
The incident occurred in a common area as Resident 28 was being assisted to the shower, potentially exposing other residents to the inappropriate language. The facility's policy specifically addresses verbal abuse that occurs "to residents within hearing distance, regardless of age, ability to comprehend, or disability."
Staff members consistently recognized the incident as verbal abuse when interviewed by inspectors. The Social Services Director stated that "verbal abuse is when someone says something to someone that is offensive and unacceptable." The Director of Nursing emphasized that residents being offended by such behavior makes it unacceptable and constitutes an abuse allegation.
The facility's policy manual, revised in March 2024, clearly outlines procedures for handling abuse allegations. The policy requires thorough investigation of all reports and assigns responsibility to the Administrator for ensuring investigations are conducted by appropriate individuals.
Yet despite clear policies, staff recognition of the abuse, and the victim's direct complaint to administrators, no investigation occurred. The Social Services Director confirmed to inspectors that there was no documentation showing any investigative steps were taken.
The Director of Nursing's warning about potential psychological harm proved prescient. She told inspectors that uninvestigated abuse allegations could damage residents' mental health and increase the likelihood of repeated incidents.
Federal inspectors cited the facility for failing to investigate the verbal abuse allegation, noting that this failure "had the potential to result in failing to protect Resident 28 and other residents from abuse."
The violation occurred despite both residents having the mental capacity to understand the situation and despite facility staff acknowledging that the behavior constituted abuse under their own policies.
Resident 28's anger over the incident and her decision to report it the following day demonstrated her understanding that the treatment was inappropriate. Her statement that no one has "the right to speak to her like that" reflected both her cognitive awareness and her expectation of dignified treatment.
The facility's failure to act left her complaint unresolved and potentially exposed other cognitively intact residents to similar verbal abuse from Resident 77.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Infinity Care of East Los Angeles from 2024-06-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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