The May incident at Infinity Care of East Los Angeles violated federal requirements that facilities report abuse allegations within two hours to the California Department of Public Health, the state ombudsman, and local police.
Resident 77 yelled at Resident 28 and used what staff later described as offensive and unacceptable language while Certified Nursing Assistant 2 was helping Resident 28 to the shower on the morning of May 8. The victim didn't speak to administrators about the incident until the next day.
Both residents have cognitive capacity to make their own decisions, according to their medical records. Resident 28 was admitted with bilateral knee osteoarthritis and right-side paralysis following a stroke. She needs substantial help with dressing and depends completely on staff for transfers between bed and chair. Resident 77 was admitted with heart disease and had also suffered a stroke.
The Social Services Director acknowledged during a June interview with federal inspectors that what Resident 77 said constituted verbal abuse. "Verbal abuse is when someone says something to someone that is offensive and unacceptable," she told inspectors. "What Resident 77 said to Resident 28 offended her and was unacceptable."
Resident 28 described her reaction to the incident: "No one is allowed to or has the right to speak to me like that." She told inspectors the inappropriate language made her feel "very angry."
The facility's own policy defines verbal abuse as communication intended to harass, mock, insult, ridicule, or intimidate residents through yelling or hovering. Examples include "mocking, insulting, ridiculing" and "yelling or hovering over a resident, with the intent to intimidate."
CNA 2 witnessed the entire incident but failed to report it immediately to supervisors or authorities. The Social Services Director confirmed that CNA 2 should have reported the abuse allegation within two hours since she was the only staff member who saw it happen.
"It was important that allegations of abuse be reported to SA so it will not happen again for the safety and wellbeing of the residents and staff involved," the Social Services Director told inspectors.
The Director of Nursing defined verbal abuse as when "a person directly screams at another person by swearing and using foul language." She confirmed that if a resident was offended by such behavior, "it was not acceptable and should be considered an allegation of abuse."
The nursing director warned that failure 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."
A third nursing assistant, CNA 3, also recognized the incident as verbal abuse during interviews with inspectors. "Verbal abuse is when bad words are used, yelling, saying something degrading or negative," she said. She confirmed the incident "should have been reported within two hours to CDPH, the ombudsman, and the police."
The facility's written policies require immediate reporting of all abuse allegations. Staff must telephone the California Department of Public Health, the Long Term Care Ombudsman, and police within two hours of any suspected abuse incident.
The policy states that "all alleged violations involving abuse, neglect, exploitation, or mistreatment" must be reported to state licensing agencies, the ombudsman, law enforcement officials, and the resident's physician. The timeline is explicit: "An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse of any kind."
Federal inspectors discovered the unreported incident during a June 7 inspection of the 101 S Fickett Street facility. They reviewed interdisciplinary team meeting notes from May 6 that documented the verbal abuse incident between the two residents.
The inspection report indicates that Infinity Care's failure to follow its own reporting procedures "has the potential to result in unreported abuse in the facility and failure to protect Resident 28 and other residents from abuse."
The facility serves residents with complex medical needs, including those recovering from strokes, heart disease, and joint conditions requiring substantial daily assistance. Many residents depend on staff for basic activities like transfers, dressing, and personal hygiene.
Resident 28 told inspectors she spoke with both the Social Services Director and MDS Nurse the day after the incident occurred. By then, the facility had already missed the two-hour reporting deadline required under federal regulations and its own written policies.
The violation affects how quickly state authorities can investigate abuse allegations and implement protections for vulnerable residents. Delayed reporting can allow patterns of abuse to continue unchecked and prevents immediate intervention to protect victims.
Both the Social Services Director and Director of Nursing confirmed during inspector interviews that they understood the two-hour reporting requirement. The Social Services Director specifically stated "the timeline for reporting is within two hours" and that proper reporting helps ensure incidents "will not happen again."
The nursing assistant who witnessed the incident remained on duty but had not received additional training on abuse reporting procedures as of the inspection date. The facility's policies clearly designate staff members as mandatory reporters who must immediately notify supervisors and external authorities of suspected abuse.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the failure to report verbal abuse allegations undermines the federal system designed to protect nursing home residents from all forms of mistreatment.
Resident 28 continues living at the facility alongside Resident 77. The inspection report does not indicate whether any steps were taken to prevent future incidents between the two residents or whether additional staff supervision was implemented in common areas like the shower room where the original incident occurred.
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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