Health inspection·August 27, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the resident ' s right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of three residents (Resident 1) when staff witnessed a Respiratory Therapist 1 (RT 1, a professional person who is responsible in taking care of patients who has respiratory problems) clapping loudly in Resident 1 ' s face while using foul language. This failure resulted in resident 1 ' s rights being violated and had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident 1 ' s admission Record (contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (number of complications of high blood pressure affecting the heart), chronic kidney disease(disease that cause kidney failure), and chronic respiratory failure (a long term condition that makes difficult to breathe). During a review of a facility provided document titled, Investigation Statements, dated August 3, 2024, by Licensed Vocational Nurse 1 (LVN 1), the Investigation Statements indicated, Resident 1 Vent alarm was going off. RT 2 went in to assess. RT 2 asked for more 02 (oxygen). Needed hyper oxygenated (administration of a higher than usual concentration of oxygen). Resident1 was de-sating (when blood oxygen level drop below a normal range below 90 percent). Grabbed ambu bag (device used to provide respiratory support). CNA (certified nursing assistant) was instructed to get RT. Many responded. All the RT's responded. Resident 1 was being bagged, RT 1 was standing by the head of the bed on the right at the head of the bed. Resident 1 was mouthing things, RT 1 I'll beat your ass, I'll fuck you up RT 1 started clapping loudly in patient face. I told him to STOP! RT1 walked out of the room. We stayed with thee resident to make sure if he would stay stable. Resident 1 was stable. LVN 1 went to find the RN (Registered Nurse). Asked RN if she heard the ruckus. LVN 1 was stopped by RT1 in ' the hallway. RT 1 tried to explain away his behavior. LVN explained that it doesn't matter and that his behavior is abuse. LVN 1 told him this has to be reported. RT1 acted like a small child, put his head down and said he was sorry. RT 1 walked off was very angry . During a subsequent review of a facility provided document titled, Investigation Statements, dated August 3, 2024, by RT 2, the Investigation Statements indicated, .RT 1 went so calmy out of the Resident 1 room and then I saw him in RT charting room and getting ready for last rounds. RT 1 said I'm Page 1 of 2 555350 555350 08/27/2024 Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few done with this shit Fuck this shit (he said it calmly), walked towards the computer. Kicked the chair into the desktop, lifted his fist and punched the desktop computer. Picked up the computer and broke it over his knee and threw it at the wall. He said, I'm going to lose my job, threw his Tupperware bowl to the window. Walked out, kicked the wall and made a hole. He was punching walls as he walked out. Tore the kiosk off the wall and threw it on the floor. Headed out threw the station 3 door. They heard a car burning out and drove off . During an interview on August 6, 2024 at 12:20 PM, with the Assistant Director of Nursing (ADON), the ADON stated, On August 3, 2024, around 3:30 AM in room [ROOM NUMBER] B, the RT 1 was verbally abusive toward [name of Resident 1] when [Resident 1] was in distress. The ADON further stated, LVN 1 told RT 1 to step out of room [ROOM NUMBER] B. When RT 1 left the room, was very upset, broke the laptop and made a hole on the wall, by kicking it. During a concurrent interview and record review on August 6, 2024, at 2:20 PM, with the ADON, the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, was reviewed. The P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This include but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. The resident abuse, neglect, exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; . The ADON acknowledged and stated the policy was not followed. During a telephone interview on August 8, 2024, at 11:57 AM, with LVN 1, LVN 1 stated, I witnessed the incident when RT1 was verbally abusive towards Resident 1. Resident 1 was bagged; RT 1 was standing by the head of the bed on the right, at the head of the bed. Resident 1 was mouthing things, RT 1 said I'll beat your ass, I'll fuck you up RT 1 started clapping loudly in Resident 1 ' s face. I told him to STOP! RT 1 walked out of the room. We stayed with the resident to make sure if he would stay stable. Patient was stable. During a phone interview on August 8, 2024, at 12:34 PM, with RT2, RT 2 stated, I was shocked by seeing RT 1 verbally abusive and was loud towards Resident 1 when resident 1 was in distress. Even after LVN 1 told RT 1 to stop the aggressive behavior, RT 1 continued. RT 1 went so calmy out of the Resident 1 room and then I saw him in RT charting room and getting ready for last rounds. RT 1 said I'm done with this shit. Fuck this shit. RT 1 walked towards the computer, kicked the chair into the desktop, lifted his fist and punched the desktop computer. Picked up the computer and broke it over his knee and threw it at the wall. He said, I'm gonna lose my job, threw his Tupperware bowl to the window. Walked out, kicked the wall, and made a hole. He was punching walls as he walked out. Tore the kiosk off the wall and threw it on the floor. Headed out threw the station 3 door. We heard a car burning out and drove off. 555350 Page 2 of 2