Health inspection·March 19, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect one of three sampled residents (Resident 2) who is legally blind verbally abuse repeatedly by Resident 1. This deficient practice resulted in Resident 2 feel unsafe and uncomfortable. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disruptive blood flow to the brain), and paranoid personality disorder (a mental condition in which a person has a long-term pattern of distrust and suspicion of others). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/11/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance with toileting, dressing, and personal hygiene. During a review of Resident 1's care plan initiated 9/26/2024, the care plan focus was physical abuse, with goals including resident will verbalize understanding of need to control physically abusive behavior and resident will not harm self or others. Interventions for Resident 1 included analyze key times, places, circumstances, triggers, and what deescalates behaviors, explore source of resident's dissatisfaction/agitation, and always approach the resident in calm, unhurried manner; do not argue with the resident. During a review of Resident 1's care plan initiated 3/14/2024, the care plan focus was risk for violence, with goals including resident will make all efforts to express self calmly. Interventions for Resident 1 included attempt behavioral intervention if resident becomes verbally/physically abusive, speak in a calm voice, and always approach the resident calmly and unhurriedly. During a review of Resident 1's Change in Condition (COC) dated 12/23/2024 timed 5:04 a.m., the COC indicated Resident 1 was exhibiting aggressive behavior, yelling at the staff, and [NAME] other residents to fight. During a review of Resident 1's COC dated 3/1/2025 timed 1:00 a.m., the COC indicated Resident 1 was displaying disruptive behaviors by arguing, yelling, and screaming at the staff by wanting to fight the staff. Page 1 of 2 055070 055070 03/19/2025 Seacrest Post-Acute Care Center 1416 West 6th Street San Pedro, CA 90732

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's COC dated 3/13/2025 timed 10:40 a.m., the COC indicated Resident 1 was angry, agitated, and yelling using profanity towards Resident 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including legal blindness, anxiety, and leukemia (cancer of the body's blood-forming tissues, including the bone marrow and the lymphatic system). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and he was dependent (helper does all the work) for all activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was intact and required supervision with ADL's. During an interview on 3/19/2025 at 11:43 a.m., with Resident 2,. Resident 2 stated Resident 1 yelled at him when he was in the bathroom to wash his hands. During an interview on 3/19/2025 at 11:59 a.m., with Resident 3, Resident 3 stated Resident 1 bullies Resident 2 because he is blind. Resident 3 stated Resident 1 is always in their shared bathroom and will get upset with him and the other roommates when they use their shared bathroom. During a subsequent interview on 3/19/2025 at 1:15 p.m., with Resident 3, Resident 3 stated he has had verbal altercations with Resident 1 in the past when he uses their shared bathroom in their room. Resident 3 stated Resident 1 yells and curses at him, it makes him feel uncomfortable. Resident 3 stated Resident 1 has random outbursts of yelling and screaming, and he does not like it because Resident 1 will curse at the other roommates when they use their shared bathroom. During an interview on 3/19/2025 at 1:25 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she has heard Resident 1 curse at other residents in the past. CNA 1 stated Resident 1 should be in a room by himself because Resident 1 scares some of the residents CNA 1 stated some of the female resident near Resident 1's room will verbalize they are worried that he will hurt someone and feels if Resident 1 had his own room and didn't have to share a bathroom with someone, this could have been prevented. CNA 1 stated Resident 1 prefers to share rooms with residents that are bed-bound. During an interview on 3/19/2025 at 1:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 has had verbal aggressiveness towards others and feels he should be in a room alone for the safety of the other residents. LVN 1 stated this was not the first time Resident 1 has had altercations with a roommate. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse . 055070 Page 2 of 2