Health inspection·November 6, 2023

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 observation, interview, and record review, the facility failed to ensure two of five sampled residents, (Residents 1 and 3) who were roommates, were free from verbal abuse when Certified Nursing Assistant (CNA) B yelled profanities at Resident 1 and 3 while in their room and continued yelling profanities in the hallway within hearing range after CNA B left the resident's room. This failure resulted in anger, frustration, and humiliation for Residents 1 and 3, and had the potential to negatively impact the emotional and psychosocial well-being of all the residents that CNA B cared for. Findings: During a review of the facility's policy, revised 7/2017 titled, Abuse and Neglect -Clinical Protocol, the policy indicated, Abuse is defined as the willful infliction of injury. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish, includes verbal abuse. This facility's policy also indicated willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. During a review of the facility's policy, revised 10/2010, titled, Resident Rights Guidelines for all Nursing Procedures, indicated the purpose of this policy is to provide guidelines for resident rights while caring for the resident. During a review of the facility's training fact sheet dated 2016, published by the CDC (Centers for Disease Control), for National Center for Injury Prevention and Control, titled Understanding Elder Abuse, indicated elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult, age [AGE] or older. Six frequently recognized types of abuse included Emotional or Psychological. This type of abuse refers to verbal or non-verbal behaviors that inflict anguish, mental, pain, fear, or distress on an older adult. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility for diagnoses that included Oglivie syndrome (a type of colon obstruction), hypokalemia (low potassium), acute respiratory disease (shortness of breath caused by fluid in the lungs), and heart disease. A review of Resident 3's clinical record indicated Resident 3 was admitted to the facility for diagnoses that included Sepsis (an infection that is a medical emergency), surgical site infection, (infection of lower back area following a surgical repair), and depression (persistent sadness, lack of Page 1 of 4 055807 055807 11/06/2023 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0600 interest or pleasure with enjoyable activities, and could include tiredness and poor concentration). Level of Harm - Minimal harm or potential for actual harm During an interview on 9/27/23 at 11:30 am, Resident 1 stated, Yes, I remember the incident. [CNA B] kept yelling at me. [CNA B] used dirty words, cuss words I don't want to say, like the F word and the B word. I do remember what happened, but not her name. I was mad, it was awful. Residents Affected - Few During an interview on 9/27/23 at 11:40 am, Resident 3 stated, Yes, I absolutely remember the incident. It took me back to my childhood, way back, places I have not been in years. I was balled up in my bed, afraid to ask for anything. I cannot believe anyone would treat my roommate this way. [CNA B] came into our room yelling profanities, it was terrible and traumatic for me. If she does this to us, imagine what she does to people who cannot tell. I cannot remember her name, but I will never forget the incident. The curtain was pulled, but I would know her voice. During an interview on 9/27/23 at 12:02 pm, the Social Services Supervisor (SSS) stated, I went down to talk with Resident 3, she was not getting out of bed due to this incident of [CNA B] yelling in the room and out in the hallway. I asked Resident 3 why she was depressed. Resident 3 stated to me [CNA B] entered the room yelling profanities, and it took her back to her childhood. Resident 3 stated she curled up into a ball. I knew she had abuse from her childhood. During an interview on 9/27/23 at 12:20 pm, CNA C stated, I was here the day the incident happened. I was at the nursing station from 10 to 10:30 pm, on 9/20/23. I saw [CNA B] walk down the hallway to the residents room, heard [CNA B] at the nurse's station, yelling profanities, ck I am coming, use your call light, you two know how to use it. I also heard [CNA B] in the hall using profanities after she left the resident's room. During an interview on 9/27/23 at 12:54 pm, the Administrator (Admin) stated, I have zero tolerance for any type of abuse. This was humiliating for the residents, and I have been going every day to check on [Resident 1] and [Resident 3] since I heard about the incident. During an interview on 9/27/23 at 1:10 pm, the Director of Nursing (DON) confirmed that CNA B admitted to her that she had verbally abused Residents 1 and 3. The DON stated, I will not tolerate any type of abuse. Documentation by Licensed Nurse (LN) A dated 9/21/23, was reviewed. LN A documented that CNA C told her that morning that she heard CNA B yelling profanities at Resident 1 and 3, the night before [9/20/23]. LN A stated that she interviewed Resident 1 and 3 that morning and immediately reported the allegation to the DON, Admin, and California Department of Public Health (CDPH). During a record review of CNA B's employee file on 10/13/23, a record titled, Performance Improvement Plan, dated 7/11/22, indicated CNA B expressed increased difficulty with being able to emotionally handle her current workload and that she was experiencing burnout, which had negatively impacted CNA B's ability to properly handle stressful situations at work. As a solution, CNA B was assigned half of her duties in the facility's kitchen and the other half providing resident care. During an interview on 9/27/23 at 2:15 pm, the Admin and DON confirmed CNA B's employment had been terminated. Both Admin and DON confirmed that CNA B had been on a performance improvement plan since July 2022, for previous discussions regarding CNA B's rude and disrespectful behavior. 055807 Page 2 of 4 055807 11/06/2023 Shasta Healthcare 445 Park Street Weed, CA 96094

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. Based on observation, interview, record and Abuse Policy review, the facility failed to report an abuse allegation within the mandated timeframe for two of five sampled residents (Resident 1 and 3), when Certified Nursing Assistant (CNA) C witnessed CNA B cursing and yelling at Residents 1 and 3 around 10 pm on 9/20/23, and had not reported this until around 6:30 am on 9/21/23, about 8 hours later. This had the potential for abuse to continue to all residents and negatively impact their safety and emotional well-being, by not initiating investigations and protecting the residents immediately. Findings: A review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, indicated all types of resident abuse shall be promptly reported to local, state, and federal agencies. This facility's policy indicated an alleged violation of abuse will be reported immediately, but no later than 2 hours. During a review of the facility's policy, revised 7/2017, titled, Abuse and Neglect -Clinical Protocol, indicated Abuse is defined as the willful infliction of injury. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish, includes verbal abuse. This facility's policy also indicated willful as used in the definition of abuse, , means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility for diagnoses that included Oglivie syndrome (a type of colon obstruction), hypokalemia (low potassium), acute respiratory disease (shortness of breath caused by fluid in the lungs) and heart disease. A review of Resident 3's clinical record indicated Resident 3 was admitted to the facility for diagnoses that included Sepsis (an infection that is a medical emergency), surgical site infection, (infection of lower back area following a surgical repair), and depression (persistent sadness, lack of interest or pleasure with enjoyable activities, and could include tiredness and poor concentration). During an interview on 9/27/23 at 11:30 am, Resident 1 stated, Yes, I remember the incident. [CNA B] kept yelling at me. [CNA B] used dirty words, cuss words I don't want to say, like the F word and the B word. I do remember what happened, but not her name. I was mad, it was awful. During an interview on 9/27/23 at 11:40 am, Resident 3 stated, Yes, I absolutely remember the incident. It took me back to my childhood, way back, places I have not been in years. I was balled up in my bed, afraid to ask for anything. I cannot believe anyone would treat my roommate this way. [CNA B] came into our room yelling profanities, it was terrible and traumatic for me. If she does this to us, imagine what she does to people who cannot tell. I cannot remember her name, but I will never forget the incident. The curtain was pulled, but I would know her voice. During an interview on 9/27/23 at 12:20 pm, CNA C stated, I was here the day the incident happened. I was at the nursing station between 10 and 10:30 pm on 9/20/23. I saw [CNA B] walk down the hallway to the resident's [Residents 1 and 3], room and heard [CNA B] from the nurse's station, yelling 055807 Page 3 of 4 055807 11/06/2023 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few profanities, ck I am coming, use your call light, you two know how to use it. I also heard [CNA B] in the hall using profanities after she left the resident's room. Documentation by Licensed Nurse (LN) A dated 9/21/23, was reviewed. LN A documented that CNA C told her that morning that she heard CNA B yelling profanities at Resident 1 and 3, the night before [9/20/23]. LN A stated that she interviewed Resident 1 and 3 that morning and immediately reported the allegation to the DON, Admin, and California Department of Public Health (CDPH). During an interview on 9/27/23 at 12:54 pm, the Administrator (Admin) confirmed that the verbal abuse occurred to Resident 1 and 3 around 10 pm on 9/20/23. The Admin confirmed that the abuse allegation was not reported until around 6:30 am on 9/21/23, when LN A reported it. Admin confirmed that all abuse allegtions must be reported immediately. 055807 Page 4 of 4