Health inspection·September 20, 2023

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 two residents were treated with dignity and respect, when Certified Nursing Assistant (CNA) 1 made disrespectful comments and gestures towards Resident 1 and 2. This failure resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative psychosocial outcomes, such as changes in mood and/or behavior. Findings: 1. On July 20, 2023, at 10:40 a.m., during an interview, Resident 3 stated she heard the conversation between CNA 1 and Resident 1 on July 11, 2023, while CNA 1 was providing care to Resident 1. Resident 3 stated CNA 1 said look at that fat, referring to her roommates body. Resident 3 stated CNA 1's comments made her uncomfortable. On July 20, 2023, at 12:12 p.m., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 told him CNA 1 made her feel uncomfortable, by making statements that she was too fat. Resident 1 said to CNA 2 that CNA 1 made her feel uncomfortable and insulted her of being fat. CNA 2 stated no facility staff was allowed to make inappropriate comments to any residents and every resident has the right to be treated with dignity and respect by the staff. On July 20, 2023, at 1 p.m., an interview and observation with Resident 1 was conducted. Resident 1 was observed in bed, in her room. Resident 1 was alert and oriented. Resident 1 stated in the morning of July 11, 2023, CNA 1 provided care for her prior to her going to dialysis (a treatment to remove blood toxins when the kidneys are not able to). Resident 1 stated CNA 1 touched her abdomen, pointing a finger to it, and said look at that fat. Resident 1 stated her roommate (Resident 3) was in the room and overheard the conversation between her and CNA 1. Resident 1 stated CNA 1's comment and gesture was disrespectful and made her feel uncomfortable. Resident 1's record was reviewed. Resident 1 was re-admitted to the facility on [DATE], with diagnoses which included end stage renal (kidney) disease, dependence on renal dialysis, diabetes, morbid (severe) obesity, and anxiety disorder. 2. On July 20, 2023, at 11:12 a.m., an interview and observation was conducted with Resident 2. Resident 2 was in the activities room. Resident 2 was alert and oriented. Page 1 of 2 056229 056229 09/20/2023 Palm Springs Healthcare & Rehabilitation Center 277 S Sunrise Way Palm Springs, CA 92262

F 0550 Level of Harm - Minimal harm or potential for actual harm Resident 2 stated CNA 1 provided care for him on July 11, 2023. Resident 2 stated CNA 1 said hermano (brother in Spanish) and Joey. Resident 2 stated CNA 1 kept repeating Joey to confuse him. Resident 2 stated he did not like it and said shut up to CNA 1. Then CNA 1 showed Resident 2 the middle finger (obscene gesture). Resident 2 stated he felt disrespected by the comments and the gesture of CNA 1 towards him. Residents Affected - Few Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and aphasia (difficulty expressing speech) following cerebral infarction (stroke). On July 20, 2023, at 12:28 p.m., in an interview with the Registered Nurse Supervisor (RNS), the RNS stated the facility staff is not allowed to be disrespectful to any resident and all staff must be professional and treat all residents with dignity and respect. On July 20, 2023, at 1:40 p.m., an interview with the Administrator was conducted. The Administrator stated all residents must treated with dignity and respect by the facility staff. The Administrator stated the facility's own investigation validated CNA 1 did not treat Resident 1 and Resident 2 with dignity and respect. The Administrator stated CNA 1 was suspended and will be terminated. On August 18, 2023, at 11:38 a.m., in a phone interview, the Administrator stated CNA 1 was terminated due to his conduct. A review of the policy and procedure titled, Resident Dignity and Personal Privacy, undated, indicated, .The Company provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth . 056229 Page 2 of 2