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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)