Health inspection·March 21, 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. Based on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from staff verbal abuse. This resulted in staff verbally abused Resident 1 and had the potential to result in psychosocial harm for Resident 1. Findings: During an interview on 2/22/24 at 11:41 a.m. with Interim Administrator (IA), IA stated Certified Nursing Assistant (CNA 1), was witnessed by another staff member verbally abusing Resident 1 on 2/12/24. During an interview on 2/22/24 at 11:47 a.m. with Director of Staff Development (DSD), DSD stated CNA 1 was heard calling Resident 1 you old hag. DSD stated, calling resident you old hag is verbal abuse. During an interview on 2/22/24 at 12:01 p.m. with Housekeeper, Housekeeper stated he was in dining room cleaning when he heard CNA 1 telling Resident 1 in Spanish to shut up in a deep tone, like angry tone. Housekeeper stated when he stepped out to get a closer look as to what was happening, Housekeeper stated Resident 1 became aggravated when CNA 1 continued to tell Resident 1 in Spanish to shut up. Housekeeper stated Resident 1 had diagnosis of Dementia (condition that affect the brain's ability to think, remember and function normally) and had behaviors of repeating wanting to go home and looking for her sister. During a concurrent observation and interview on 2/22/24 at 12:17 p.m. with Resident 1, Resident 1 was observed walking in the hallway. Resident 1 is Spanish speaking, stated she was looking for her sister. During an interview on 2/22/24 at 2:17 p.m. with CNA 2, CNA 2 stated on 2/12/24 she had went to the Dementia unit. CNA 2 stated she heard CNA 1 in a really rude, aggressive, serious voice calling Resident 1 a stubborn old hag. CNA 2 stated CNA 1 repeatedly called Resident 1 a stubborn old hag. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 had a diagnosis of Alzheimer (type of dementia that damages the brain and affects memory, thinking, and behavior) and Dementia. Resident 1's annual Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 12/13/24, indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 3 (score range from 0 - 7 severe impairment). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056035 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)