Health inspection·December 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was treated with respect, and dignity when Certified Nursing Assistant 1 (CNA1) used profanity around Resident 1. This failure compromised Resident's 1 dignity and violated her rights to respect, which had the potential for Resident 1 to experience psychosocial harm (mental harm and suffering). Findings: A review of Resident's 1 admission Record (a document containing clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis Alzheimer's disease (most common type of dementia, it is a progressive disease that begins with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Resident 1's History and Physical, dated October 3, 2023, at 11:36 AM, documented by Resident's 1 Family Nurse Practitioner (FNP), it indicated Resident 1 does not have the capacity to understand and make decisions. During a concurrent observation and interview, on December 7, 2023, at 12:20 PM, with Resident 1, Resident 1 sitting on a wheelchair in her room, Resident 1 was not able to recount the alleged incident. During an interview with Resident 2, (Resident 1's roommate), on December 7, 2023, at 12:30 PM, Resident 2 stated she heard CNA 1 was cussing and calling names on Resident 1. Resident 2 further stated, CNA 1 had been doing it (using profanities around Resident 1) for the last 2 months or so (since Resident 2 became a roommate of Resident 1). During a telephone interview with CNA 1, on December 12, 2023, at 3:00 PM, CNA 1 admitted using profanity, something along the lines of Are you freaking kidding me, someone could have broken their neck on this (referring to the spilled water from Resident's 1 table). During a telephone interview with the Director of Nursing (DON), on December 15, 2023, at 2:54 PM, the DON stated the facility expectation was that all staff should treat all residents with respect and dignity regardless of their mental status, and CNA 1 should have not made such statement in front of Resident 1. The DON further stated CNA 1's comment to Resident 1 was not acceptable, and she should have kept it to herself and acted professional regardless of the situation. Page 1 of 2 055183 055183 12/19/2023 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview with Administrator, on December 15, 2023, at 2:58 PM, the Administrator stated all staff were informed about Residents Rights upon hiring, and CNA 1 was not supposed to be making such comment in front of residents. The Administrator further stated CNA 1 was given disciplinary action and will be terminated if she will repeat the violation. During a concurrent record review on December 15, 2023, at 1:00 PM, the facility's policy and procedure (P&P) titled, Residents Rights, dated December 2016, was reviewed. The P&P indicated, . Employee shall treat all residents with kindness respect, and dignity. 055183 Page 2 of 2