Health inspection·April 29, 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. Based on observation, interview, and record review, the facility failed to ensure the right to be free from verbal abuse for one of three sampled residents (Resident 1) when a staff member used profanity while providing toileting care to Resident 1. This failure resulted in Resident 1 feeling disrespected by the facility staff. Findings: During a review of the Face Sheet (a document used to communicate basic information about a resident) for Resident 1, undated, the record indicated Resident 1 was admitted to the facility in May 2022 with generalized weakness and hemiplegia (the loss of muscle function on one side of the body) affecting the dominant side of the body. During a review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) for Resident 1, dated 2/27/24, the record indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). The record indicated that Resident 1 was always incontinent of both bowel and bladder and required substantial/maximal assistance (a term used to describe when the person assisting the resident does more than half the effort) for toileting hygiene. During a concurrent observation and interview on 4/29/24 at 9:55 a.m., Resident 1 was lying in bed with the head of bed elevated. Resident 1 stated on 4/14/24, Resident 1 was waiting in bed for toileting hygiene care to be provided. Resident 1 had an incident of diarrhea after receiving a laxative and wore adult briefs, which required Resident 1 to have the brief changed when toileting hygiene was provided. Resident 1 stated Certified Nursing Assistant 1 (CNA 1) came to provide the requested care. Resident 1 stated she heard CNA 1, cursing every other word, saying the F-word and S-word under his breath while CNA 1 changed Resident 1 ' s brief. Resident 1 spoke with the Licensed Vocational Nurse (LVN) the next morning during their daily check-in about the incident. Resident 1 stated when CNA 1 used profanity while providing care, it made me feel like they did not respect me. During a phone interview with CNA 1 on 4/29/24 at 11:38 a.m., CNA 1 stated on 4/14/24, he worked during evening shift (3:00 pm until 11:30 pm). CNA 1 stated Resident 1 received toileting hygiene care at the start of the shift. CAN 1 stated right as dinner trays came out for the evening, Resident 1 requested toileting hygiene care again. CNA 1 stated since there was no other staff available, he then stopped passing trays and entered Resident 1 ' s room to provide care. During the provision of Page 1 of 2 555358 555358 04/29/2024 Fruitvale Healthcare Center 3020 East 15th Street Oakland, CA 94601

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care, CNA 1 stated I was cursing under my breath a little . I was frustrated because I had been getting her in and out of bed all day already. CNA 1 stated Resident 1 asked the CNA to stop cursing at her, and CNA 1 informed Resident 1 that it was not directed at Resident 1. CNA 1 then left the room after providing care to Resident 1. During an interview with LVN 1 on 4/29/24 at 11:01 a.m., LVN 1 stated Resident 1 reported the incident with CNA 1 the next morning on 4/15/24. Resident 1 informed LVN 1 that the CNA was cursing every other word, using the F-word. Resident 1 stated it was inappropriate for a CNA to talk to a resident like this and that Resident 1 no longer wanted to work with CNA 1 anymore. During a concurrent interview and record review with the Director of Nursing (DON) on 4/29/2024 at 12:21 p.m., Resident 1 ' s Progress Notes, dated 4/15/24 were reviewed. The record indicated Resident 1 spoke to the LVN caring for her, stating, the CNA kept using the F word while taking care of her. DON stated that it was not acceptable for a CNA to curse or use profanity while providing care because, it would be derogatory and very inappropriate and would of course be potential verbal abuse. A review of the facility policy titled, Abuse Prevention Program, dated 5/28/2019, indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from . verbal abuse. 555358 Page 2 of 2