Health inspection·March 6, 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 ensure one of three sampled residents (Resident 2) was free from verbal abuse when Licensed Vocational Nurse (LVN) 2 cursed at her. This deficient practice resulted in Resident 2 feeling unsafe when LVN 2 was working in the facility. This deficient practice had the potential to cause psychosocial (mental, emotional, and social) harm. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set ([MDS] resident assessment tool) dated 2/5/2025, the MDS indicated Resident 2 was mildly cognitively (ability to think and reason) impaired. During a review of the facility's Investigation Report dated 2/26/2025, the Investigation Report indicated on 2/25/2025 Resident 2 requested to speak to Licensed Vocational Nurse (LVN) 2 regarding her (Resident 2's) medication. The Investigation Report indicated LVN 2 told Resident 2 that she had already given her, her medication. The Investigation Report indicated Resident 2 asked LVN 2 if her doctor had spoken to the psychiatrist regarding her medication. The Investigation Report indicated Resident 2 cursed at LVN 2 who cursed back at Resident 2. During an interview on 3/5/2025 at 12:26 p.m., Resident 2 stated on 2/25/2025, sometime around 8 p.m., LVN 2 came in her room angry because she (Resident 2) requested to speak with her. Resident 2 stated LVN 2 was yelling and stated she was on her break and had already given her, her medication. Resident 2 stated she expressed to LVN 2 that she did not feel right and wanted to the dosage of her medication adjusted. Resident 2 stated LVN 2 reminded her again that she was on her break, so she (Resident 2) told her Family Member (FM) who was on the phone with her, that LVN 2 was a f****ing b**** and LVN 2 responded no you're a f****** b****. Resident 2 stated she was angry and that LVN 2 responded to her that way, when all she wanted was for LVN 2 to contact her physician about her medication. Resident 2 stated LVN 2's response triggered her which was why she cursed at LVN 2. Resident 2 stated she did not feel safe the rest of the shift with LVN 2 as her nurse. During an interview on 3/5/2025 at 1:09 p.m., Resident 4 stated she witnessed LVN 2 curse at Page 1 of 2 056007 056007 03/06/2025 Pacific Care Nursing Center 3355 Pacific Place Long Beach, CA 90806

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 on 2/25/2025. Resident 4 stated it was upsetting to see that LVN 2 had no patience or and empathy when Resident 2 cursed at her, and she was disappointed how aggressive and brutal (yelling and curing) LVN 2's response was to Resident 2. During an interview on 3/5/2025 at 2:13 p.m., LVN 2 stated on 2/25/2025, while she was on break, CNA 1 informed her that Resident 2 wanted to speak to her about her medication. LVN 2 stated she was on break but went to see Resident 2 to make sure it was nothing urgent. LVN 2 stated she informed Resident 2 that she had given her all of her medications, but Resident 2 told her she did not feel right and believed there had been changes made to her medication and wanted to discuss it with her physician. LVN 2 stated she asked Resident 2 if she had discussed this with any of the other nurses and began looking into her chart to see if there were any changes but was not able to find any. LVN 2 stated, Resident 2 told her next time do not come here on your break. LVN 2 stated Resident 2 called her a b**** to which she (LVN 2) replied, If I'm a b**** you are one too. LVN 2 stated she was shocked that she cursed back at Resident 2 and had not been able to sleep since it happened. LVN 2 stated she resigned from the facility after that. During an interview on 3/5/2025 at 3:19 p.m., the Director of Nursing (DON) stated LVN 2 was suspended for verbally abusing Resident 2. The DON stated verbal abuse by LVN 2 towards Resident 2 was inappropriate and could cause mental or emotional harm. The DON stated LVN 2 resignedbefore her suspension ended. During a review of facility's Policy and Procedure (P&P) titled Residents Rights dated 9/2017, the P&P indicated residents had the right to be free from mental and physical abuse. 056007 Page 2 of 2