Health inspection·March 5, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a cognitively impaired resident was treated with dignity and respect by not preventing a staff member from communicating to the resident (R1) in an inappropriate and unprofessional manner while providing personal care services. This failure affected 1 of 4 (R1) residents reviewed for dignity in a sample size of 4. Findings include: R1's medical record indicated that resident last admitted to the facility on [DATE] with a past medical history not limited to: hypertension, dementia, anxiety, and urinary tract infection. R1's Minimum Data Set (MDS) Section C for cognitive patterns dated 02/19/2025 documented that R1's cognition is severely impaired. Review of facility's final incident report with incident date of 02/26/2025 at 1300 (1:00 PM) revealed that a comment was overheard outside the beauty salon. It was reported that the beautician [V3] stated to a resident, you b***h about a lot. Beautician was removed and investigation initiated. Beautician states that the comment was in relation to the resident having a difficult day complaining about several things in the time she was in the salon .The beautician relays the comment was a statement to engage the resident in what was going on not to inflict any type of harassment or threat. She admits she should have used complain not b***h. Interviews with resident involved revealed no issues and no recall of incident. R1's progress noted dated 02/26/2025 at 13:22 (1:22 PM) documented, there was an incident with the hairdresser which is being addressed by Administrator. [Medical Doctor] notified. Administrator notifying family. On 03/05/2025 at 12:55 PM, V3 (Beautician) said on the day of the incident, she was trying to have a conversation with R1 while she (V3) was doing her hair but R1 wasn't happy and complained that V3 was hurting her and that she didn't want to have her hair done. V3 said that R1 was extra cranky because of her recent surgery. V3 (Beautician) said while she attempted to wash R1's hair, that R1 continued to complain so V3 asked R1 if she likes to b***h. V3 then said that she called V8 (Family Member) and asked her to talk with her mother (R1) so that she could finish doing R1's hair. V3 (Beautician) added that she talks like a sailor and thought she knew R1 well enough to talk openly to her. V3 also said that she apologized to R1 and to V8 (Family Member) for her poor word choice and should not have used the word b***h. Page 1 of 2 145476 145476 03/05/2025 Oregon Living and Rehabilitation Center 811 South 10th Street Oregon, IL 61061

F 0557 Level of Harm - Minimal harm or potential for actual harm On 03/05/2025 at 01:16 PM, V8 (Family Member) who is R1's daughter said that R1 has dementia and can't remember having her hair done from week to week. V8 then said the facility contacted her and indicated that V3 (Beautician) was asked to leave the facility because she was overheard making an inappropriate comment to R1. V8 added that she was not upset with V3's (Beautician) poor word choice because she knows R1 complains often due to her cognition. Residents Affected - Few On 03/05/2025 at 01:40 PM, R1 was observed lying in bed resting. R1 did not recall alleged incident and was not interviewable due to impaired cognition, alert to self only. On 03/05/2025 at 02:02 PM, V1 (Administrator) said she was told that V3 (Beautician) said something along the lines of, do you like to b***h a lot? V1 added that she went to the beauty parlor, spoke with R1 in private but she couldn't recall what was said to her. V1 (Administrator) then informed V3 about their abuse policy and escorted her out of the building and initiated her investigation. When asked if it is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to a resident and/or resident behavior, V1 (Administrator) said staff attend abuse in-services upon hire and annually. V1 added that it is her expectation for staff to be in control of their behavior, behave professionally, and understand how to work with the nursing home population. On 03/05/2025 at 02:25 PM, V1 (Administrator) said V3 (Beautician) last attended an abuse in-service in October of 2024, then said upon V3's hire, the previous administrator should have gone over the abuse policy, conducting herself in a professional manner when working with nursing home residents, and the expected customer service etiquette. Resident Rights policy with last review date of 03/29/2024 reads in part: To ensure that resident rights are respected and protected. To inform residents of their rights and provide an environment in which they can be exercised . Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee upon hire. Each employee has a duty to read and learn the residents' rights .Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights .The resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. (Never use nicknames, such as Honey, Sweetie, Gramps, or Cutie. Nicknames show disrespect for the person). 145476 Page 2 of 2