Health inspection·May 6, 2025

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 three sampled residents (Resident 1) was treated with respect, kindness, and dignity, when a Certified Nursing Assistant (CNA 1) engaged in a verbal altercation with Resident 1. This failure resulted in Resident 1 ' s basic right to be violated, which had the potential for Resident 1 to feel disrespected and unsafe. Findings: During a review of Resident 1 ' s admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (one side of the body paralyzed) and hemiparesis (weakness of one side of the body). During a review of Resident 1 ' s Change in Condition Evaluation, dated April 4, 2025, it indicated on April 4, 2025 at around 3 PM, Resident [Resident 1] had a derogatory verbal altercation with a staff member [CNA 1]. Both staff member and Resident educated on the importance of proper communication, mutual respect. Resident on monitoring for psychosocial well-being. Resident reassured that he is safe and that the CNA in question will no longer be assigned to his care. Resident verbalized feeling safe and does not appear in any distress. During a review of Employee Separation Report dated April 9, 2025, it indicated CNA 1 used the word F*** multiple times in a verbal interaction with a resident. This was witnessed by another staff member and the resident who was alert and oriented. There is no circumstance where any expletive may be used in a verbal interaction with a resident. This is expressly against facility policy and practice . During an interview on April 11, 2025, at 2:38 PM, with the Administrator (Admin), the Admin stated CNA 1 validated the incident had occurred. The Admin further stated although Resident 1 initiated the use of profanity, CNA 1 ' s response was inappropriate and not permitted under facility policy. The Admin stated staff were expected to walk away and report such incidents, rather than engage in verbal altercations with residents. During an observation on April 11, 2025, at 4:00 PM, Resident 1 was lying down in bed, with his eyes open. Resident 1 stated on April 4, 2025, at approximately 11:30 AM, CNA 1 was providing care for him, when CNA 1 pulled his pillow really hard, which upset him and led him to use the F-word first Page 1 of 2 055183 055183 05/06/2025 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 toward CNA 1. Resident 1 further stated, in response, CNA 1 replied F*** you, and continued to exchange offensive language with him. Resident 1 stated This should not happen in places like this. During a concurrent phone interview and record review. on May 2, 2025, at 4:16 PM with the Director of Nurses (DON), the facility ' s policy and procedure (P&P) titled Resident Rights, dated revised December 2016, was reviewed. The P&P indicated, Employees shall treat all residents with kindness, respect and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .b. Be treated with respect, kindness and dignity . The DON stated staff were expected to follow this policy, and acknowledged CNA 1 failed to do so during the incident involving Resident 1. 055183 Page 2 of 2