Health inspection·August 26, 2024

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 the resident's right to be free from verbal abuse (use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) by staff for one (1) of three (3) sampled residents (Resident 1), in accordance with the with the facility's abuse prevention policy. This failure had the potential for Resident 1 to feel powerless and unprotected and had the potential to place Resident 1 at risk for further abuse, which could affect the resident's emotional and psychosocial wellbeing. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 1/24/24, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 8/9/24, the MDS indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting hygiene, shower, upper and lower body dressing, and putting on and taking off footwear. The MDS further indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene and setup assistance (helper sets up; resident completes activity) with eating and oral hygiene. During a review of the Situation, Background, Assessment, and Recommendation (SBAR, developed to create a reliable consistent process to facilitate concise, clear, and focused communication), dated 8/12/24, the SBAR indicated that an Interdisciplinary Team Meeting (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) was held to address a complaint made by Certified Nurse Assistant 1 (CNA 1) against Resident 1. The SBAR report also indicated that CNA 1 responded with F_ _k you after Resident 1 called him F_g_ _t. The SBAR report further indicated that CNA 1 admitted to responding F_ _k you and expressed feelings of upset and frustration towards Resident 1. Page 1 of 4 055548 055548 08/26/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/26/24 at 11 AM, Resident 1 stated he got into a fight with CNA 1 on 8/7/24 and was upset and felt disrespected. Resident 1 also stated he told CNA 1 F_ _k you that day and CNA 1 responded by saying, F_ _k you back at him. During an interview on 8/26/24 at 12:17 PM, the Restorative Nursing Assistant 1 (RNA 1) stated she witnessed CNA 1 when he shouted, F_ _k you to Resident 1 after the resident shouted, F_ _k you f_ g_ _t to CNA 1. RNA 1 also stated saying F_ _k you to a resident is a type of verbal abuse and should have been reported immediately within two (2) hours to the Administrator (ADM) to prevent escalation and for the safety of the resident. During an interview on 8/26/24 at 2:30 PM, the Director of Nursing (DON) stated CNA 1's F_ _k you response is considered a verbal abuse and must be immediately reported to the ADM as indicated on the facility policy to ensure Resident 1's safety and to prevent further abuse. During an interview on 8/26/24 at 2:42 PM, the ADM stated CNA 1's response to Resident 1 was not appropriate and was against the facility's policy. During a review of the facility's policy and procedure (P&P) titled, Abuse-Prevention, Screening, and Training Program, revised July 2018, the P&P indicated that the facility does not condone any form of resident abuse .and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse. The policy also indicated that verbal abuse is defined as any use of oral, written, or gestured communication, or sounds that willfully includes disparaging (expressing the opinion that something is of little worth), and derogatory (insulting) terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. 055548 Page 2 of 4 055548 08/26/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed report a verbal abuse (use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) to the State Survey Agency (the Department of Public Health [DPH]) in accordance with State law within two (2) hours after the verbal abuse incident for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse, and/or under reporting from the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 1/24/24, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 8/9/24, the MDS indicated Resident 1 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting hygiene, shower, upper and lower body dressing, and putting on and taking off footwear. The MDS further indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene and setup assistance (helper sets up; resident completes activity) with eating and oral hygiene. During a review of the Situation, Background, Assessment, and Recommendation (SBAR, developed to create a reliable consistent process to facilitate concise, clear, and focused communication), dated 8/12/24, the SBAR indicated that an Interdisciplinary Team Meeting (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) was held to address a complaint made by Certified Nurse Assistant 1 (CNA 1) against Resident 1. The SBAR report also indicated that CNA 1 responded with F_ _k you after Resident 1 called him F_g_ _t. The SBAR report further indicated that CNA 1 admitted to responding F_ _k you and expressed feelings of upset and frustration towards Resident 1. During an interview on 8/26/24 at 11 AM, Resident 1 stated he got into a fight with CNA 1 on 8/7/24 and was upset and felt disrespected. Resident 1 also stated he told CNA 1 F_ _k you that day and CNA 1 responded by saying, F_ _k you back at him. During an interview on 8/26/24 at 12:17 PM, the Restorative Nursing Assistant 1 (RNA 1) stated she witnessed CNA 1 when he shouted, F_ _k you to Resident 1 after the resident shouted, F_ _k you f_ g_ _t to CNA 1. RNA 1 also stated saying F_ _k you to a resident is a type of verbal abuse and should have been reported immediately within 2 hours to the Administrator (ADM) to prevent escalation and 055548 Page 3 of 4 055548 08/26/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0609 for the safety of the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/26/24 at 11:46 AM, the Director of Staff Development (DSD) stated any alleged abuse should be reported within 2 hours to the Administrator (ADM). Residents Affected - Few During an interview on 8/26/24 at 2:30 PM, the Director of Nursing (DON) stated CNA 1's F_ _k you response is considered a verbal abuse and must be immediately reported to the ADM as indicated on the facility policy to ensure Resident 1's safety and to prevent further abuse. During an interview on 8/26/24 at 2:42 PM, the ADM stated CNA 1's response to Resident 1 was not appropriate and was against the facility's policy. The ADM stated that the staff did not report the allegation of verbal abuse of CNA1 to Resident1. ADM stated the staff had the responsibility to report any allegations of abuse to him to ensure that it will be reported to DPH within 2 hours. During a review of the facility's policy and procedure (P&P) titled, Abuse - Prevention, Screening, and Training Program, revised July 2018, the P&P indicated that the facility provides, and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment. During a review of the facility's P&P titled, Abuse - Reporting and Investigations, revised 12/21/23 with an effective date of 1/3/24, the P&P indicated that allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the ADM or designated representative immediately. 055548 Page 4 of 4