Health inspection·January 30, 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 prevent verbal abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) A yelled and cursed at Resident 1 and told Resident 1 to not use her call light. This mistreatment caused Resident 1 distress and feelings that her needs were not met and had the potential to affect all residents under the care of RN A and negatively impact their quality of life and emotional well-being. Findings: Review of the facility's policy and procedure titled, Abuse, Resident dated 3/23/2023, indicated that the facility .ensure that each patient has the right to be free from abuse (verbal, sexual, physical and mental) and The facility prohibits mistreatment . Review of admission records for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Age related cognitive decline (difficulty thinking and making decisions), insomnia (difficulty sleeping), diabetes (high sugar in the blood), depression, and hypertension (HTN-high blood pressure). Resident 1 had a BIMS score (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 14 out of 15, which indicated she had good memory and decision making skills. Review of the facility document titled, Resident Abuse Investigation Questionnaire dated 8/12/24, showed that Resident 1 indicated that RN A had yelled and sworn at her. Review of facility's document titled, Investigation Tool Form SNF indicated that Resident 1 accused RN A of verbally abusing her on 8/11/24, that Resident 1 was upset by how she was talked to, and that Resident 1 didn't want RN A to be her nurse again. During an interview on 1/28/25 at 3:08 PM, Resident 1 stated that she liked it at the facility very much. Review of a written witness statement from Certified Nursing Assistant (CNA) C dated 8/13/24, showed that CNA C indicated Resident 1 stated RN A, gave her nothing but trouble and that Resident 1 stated she wanted another nurse to bring her medication. Page 1 of 2 056416 056416 01/30/2025 Mayers Memorial Hospital 43563 Hwy 299 E Fall River Mills, CA 96028

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a written witness statement from CNA D dated 8/14/24, indicated that RN A showed frustration with Resident 1 due to Resident 1 using the call light a lot. CNA D indicated that every time Resident 1 used her call light RN A went down and turned it off. CNA D stated RN A told her, This is bull**** your not going down there just ignore her. CNA D indicated that RN A told her to come to Resident 1's room with her. When they entered Resident 1's room, RN A started yelling at Resident 1 and told CNA D, for the rest of the night, she is not allowed to touch her call light unless it was an emergency and this is why all the residents f****** hate her and no one is gonna to come back down to help her including any CNAs. CNA D indicated that RN A told Resident 1, this is bull**** you keep pushing your button for little stupid bull**** and it's gonna f****** stop. CNA D indicated that Resident 1 asked RN A if she was the boss and RN A replied, You're damn straight I'm the boss so stop your sh**. CNA D indicated that later on that night Resident 1 requested her inhaler, and RN A told CNA D, She's [Resident 1] is being f****** ridiculous, if she's wearing oxygen then she can breathe. RN A did take Resident 1 her inhaler and slammed the inhaler down on Resident 1's bed side table and stated, Here, take it and hurry up. Two attempts to contact RN A for an interview were made on 1/29/25 and 1/30/25, RN A did not return the calls. A review of an email RN A sent to the facility dated 10/30/24, indicated, That the particular patient [Resident 1] was difficult to work with .Looking back I would definitely slow down and take a little more time with her. During an interview on 1/28/25 at 3:24 PM, with the Director of Nursing (DON), the DON confirmed that the facility investigation substantiated that RN A had verbally abused Resident 1 and the facility terminated their relationship with RN A. 056416 Page 2 of 2