Health inspection·May 1, 2025

REGULATION VIOLATION(S) F600: 483.12 Freedom from Abuse, Neglect, and Exploitation: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 483.12(a) The facility must- 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to prevent verbal abuse towards one sampled resident (Resident 1) when Unlicensed Staff C yelled profanities while Resident 1 was speaking to Licensed Staff A about his concerns regarding Unlicensed Staff C caring for his roommate. This led to emotional harm. Resident 1 became angry and anxious; he did not want Unlicensed Staff C to care for him ever again. A review of the facility's investigation, dated 5/24/21 at 1:45 p.m., indicated Resident 1 had called Licensed Staff A into his room because he was concerned in how Unlicensed Staff C was caring for his roommate. When Resident 1 addressed Unlicensed Staff C with his concern regarding how she was tending to his roommate, with Licensed Staff A in the room, Unlicensed Staff C stated to Resident 1, "Mind your F ...ing business." A verbal altercation occurred between Resident 1 and Unlicensed Staff C, both using inappropriate language. Licensed Staff A separated Resident 1 and Unlicensed Staff C by having Unlicensed Staff C leave Resident 1's room. A review of the facility's investigation and documentation of what Licensed Staff A witnessed, dated 5/24/21 at 1:44 p.m., Licensed Staff A indicated, when Unlicensed Staff C stepped out of Resident 1's room to grab a few items, Resident 1 had called Licensed Staff A into his room because he was upset in how Unlicensed Staff C was tending to his roommate. When Unlicensed Staff C returned to Resident 1's room, Resident 1 confronted Unlicensed Staff C stating, "Why did you leave him like that?" Unlicensed Staff C replied, "Mind your own "F ...ing" business." Resident 1 then started yelling curse words at Unlicensed Staff C, and Unlicensed Staff C started yelling curse words back to Resident 1. Resident 1 then became agitated and threatened to punch Unlicensed Staff C. Resident 1 and Unlicensed Staff C were in each other's face when Licensed Staff A told Resident 1 to sit down and Unlicensed Staff C to leave the room; Licensed Staff A finished tending to Resident 1's roommate, who still needed to be cleaned. Resident 1 was still calling Unlicensed Staff C a, "Bitch" when she left the room, and Licensed Staff A was explaining to Resident 1 such behavior was inappropriate and she would report the incident to the Director of Nursing (DON.) A review of the facility's investigation and documentation of what Licensed Staff B witnessed, dated 5/24/21 at 1:45 p.m., Licensed Staff B indicated while at Nurse's Station 2 she overheard Resident 1 and Unlicensed Staff C arguing. Resident 1 called Unlicensed Staff C a, "Bitch," and Unlicensed Staff C answered back to Resident 1 using the "F" word, "F ... mind your own business. I don't work for you," and called him a, "Bitch." During an interview on 6/7/21 at 12 p.m., Licensed Staff B stated while she was at the Nurse's Station, which was near Resident 1's room, she could overhear Resident 1 yelling at Unlicensed Staff C, calling her a, "Bitch" and Unlicensed Staff C was yelling back to Resident 1, calling him a, "Bitch." Unlicensed Staff C went on to tell Resident 1, "I don't work for you." Licensed Staff B stated Licensed Staff A was in Resident 1's room trying to stop the argument and directed Unlicensed Staff C, who was being aggressive toward Resident 1, to leave Resident 1's room. During an interview on 6/7/21 at 2 p.m., Resident 1 stated he had called Licensed Staff A into his room because he could hear his roommate yelling, "Help, Help," when Unlicensed Staff C was caring for him. Unlicensed Staff C overheard the conversation and started using profanity towards Resident 1 and stated, "If you have something to say, talk to my union." Resident 1 stated he did call Unlicensed Staff C a, "Bitch," but long after she called him names. Resident 1 stated Licensed Staff A told Unlicensed Staff C to leave the residents' room; she would finish tending to Resident 1's roommate. Resident 1 stated, "I don't want to see her face again." During an interview on 6/24/21 at 2:30 p.m., Unlicensed Staff D stated she was working in the same hall as Unlicensed Staff C when the incident occurred. She had the rooms at the end of the hall, and Unlicensed Staff C had the rooms in the middle of the hall. Unlicensed Staff D stated, while she was helping the resident across from Resident 1's room, Unlicensed Staff C was so loud; she could hear her using the word, "Bitch," and the "F" word. Unlicensed Staff D stated the nurse was trying to intervene. Unlicensed Staff D stated, she was, "shocked" by what Unlicensed Staff C was saying to Resident 1. "A Certified Nursing Assistant (CNA) should never talk back to a resident. We work for the residents. This is their home." Unlicensed Staff D stated Resident 1 could be moody, but if a resident became verbally aggressive, you would leave the room to prevent a confrontation, and tell the nurse. During an interview on 6/24/21 at 3 p.m., Licensed Staff A stated, when Unlicensed Staff C stepped out of the room to get supplies needed for Resident 1's roommate, Resident 1 called her into his room to discuss the care of his roommate. Resident 1 thought Unlicensed Staff C was being too rough. As Resident 1 was discussing his concerns, Unlicensed Staff C returned and overheard Resident 1 and started in on him stating, "Mind your own business," and calling him a, "Bitch." Licensed Staff A stated she was in between Resident 1 and Unlicensed Staff C when they both starting to get in each other's face. Licensed Staff A stated she told Unlicensed Staff C to step back and leave the room. Unlicensed Staff C used the "F" word to Resident 1, and then they both started calling each other all sorts of names. Resident 1 stated he was going to punch Unlicensed Staff C, and Unlicensed Staff C stated to him, "Like to see you try." Licensed Staff A stated she repeated to Unlicensed Staff C to leave the room, and she would tend to Resident 1's roommate. Licensed Staff A stated Resident 1 was not talking nice about Unlicensed Staff C, but no staff member should talk back to a resident. Licensed Staff A stated, "We work for the residents." Licensed Staff A stated she could not believe what she was hearing/seeing. Licensed Staff A stated, before Unlicensed Staff C left Resident 1's room, she took the towel in her hand and threw it at Licensed Staff A. The facility job description titled, "CNA," updated 8/2011, indicated, "Position Summary ... Ensures resident's needs are maintained with the highest degree of dignity." The CNA's, "Duties and Responsibilities," indicated: 5. "Complies with all company and department policies and procedures." The CNA's, "Knowledge, Skills, Abilities & Qualifications," indicated: 8. "Must be able to relate to and work with physically and /or mentally ill, disabled, elderly, emotionally upset, and at times hostile people within facility and treat them with respect and consideration regardless of their cognitive or functional level. 9. Ability to understand and follow applicable regulations, policies, and procedures fully and consistently... 11. Must demonstrate flexibility and ability to adapt to change." The facility policy and procedure titled, "Abuse Prohibition & Prevention Policy and Procedure & Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure," revised 3/2018, indicated, "This facility prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident's property. Each resident has the right to be free from abandonment, mental/emotion, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect... Residents must not be subject to abuse by anyone, including but not limited to, facility staff, other residents..." XXXII. "Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within hearing distance, regardless of their age, ability to comprehend, or disability." Therefore, the facility failed to prevent verbal abuse towards Resident 1 when Unlicensed Staff C yelled profanities while Resident 1 was speaking to Licensed Staff A about his concerns regarding Unlicensed Staff C caring for his roommate. This led to emotional harm. Resident 1 became angry and anxious; he did not want Unlicensed Staff C to care for him ever again. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.