Health inspection·July 18, 2025

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 interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse as stated in the facility's policy and procedure (P&P) when a nursing student witnessed Certified Nurse Assistant (CNA 1) used verbally abusive words to Resident 1. This failure had the potential to result in Resident 1 having emotional harm such as feeling unsafe, loss of trust, and can lead to behavioral issues.Findings: An unannounced visit was conducted to the facility on July 18, 2025, for investigation of a facility reported incident of abuse. During a review of Resident 1's Face Sheet (FS- a document containing patient demographics) the FS indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's Progress Note - Physician (PN- A document containing the progression of the residents and past medical history), dated July 16, 2025, indicated Resident 1 has a history of extreme prematurity (baby born before 28 weeks), short gut (a condition that occurs when the small intestine is damaged or shortened) and is gastrostomy tube (G tube-a tube inserted through stomach to provide nutrition, food, and medication) dependent (someone who relies on G tube). During an interview on July 18, 2025, at 12:25 PM, with Resident 2's mother, Resident 2's mother stated that she has seen CNA 1 be very rough when turning Resident 2. Resident 2's mother further stated that she has brought it up to management before and management stated they would talk to CNA 1. During an interview on July 18, 2025, at 12:45 PM, with CNA 2, CNA 2 stated that she has seen CNA 1 give an attitude to other staff members. During an interview on July 18, 2025, at 1:40 PM, with Resident 1's father, Resident 1's father stated, that the facility called him to let him know that one of the staff members was telling his son Bad things and that they sent that staff member home. Resident 1's father further stated, he is concerned for his son's safety. A review of nursing student's statement Notes, dated July 8, 2025, indicated on July 8, 2025, I went into Resident 1's room with my assigned nurse and witnessed Resident 1 run away from the CNA 1 and grab my nurse's leg. CNA 1 said you better get back in that damn bed and when the CNA 1 checked on another patient, the CNA 1 again said get back in the f****ng bed.During a concurrent interview and record review, on July 18, 2025, at 2:44 PM, with the HR Director (HRD), the employee separation report (document used for termination of an employee), dated July 16, 2025, was reviewed. The employee separation report indicated, [CNA 1] was witnessed verbally abusing a patient in the subacute department [provides level of care between hospital care and skilled nursing care] which is called for immediate termination. The HRD stated that CNA 1 did not sign the document. A review of notice of disciplinary action (document that contains unsatisfactory performance given to staff for them to sign), dated May 27, 2025, in CNA 1's file, indicated there must be immediate improvement in: polite and professional interactions with other at all times. Your negative interactions can cause disruption and jeopardize safe care for our children. During an interview on July 18, 2025, at 3:46 PM, with the Chief Nursing Officer (CNO), the CNO stated verbal abuse is anything that can be intimidating to Page 1 of 2 555587 555587 07/18/2025 Totally Kids Rehabilitation Hospital - D/P Snf 1720 Mountain View Loma Linda, CA 92354

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents, using foul language especially at a child. During a concurrent interview and record review on July 18, 2025, at 3:48 PM, with the CNO, the child abuse reporting requirement for CNA 1, dated May 3, 2024, was review. The child abuse reporting requirement indicated, resident abuse can take many forms including, but not limited to, tone of voice, name calling, swearing, threats, theft of possession.I am aware of the requirements stated above and will comply with these requirements. I understand that this signed statement will be maintained in my personal file.signed by CNA 1 on May 3, 2024. The CNO verified and stated, this was not followed and should have been. During a concurrent interview and record review on July 18, 2025, at 3:50 PM, with the CNO, the P&P titled, abuse: screening, training, prevention, identification, investigation, protection, and reporting/response, dated July 18, 2024, was reviewed. The P&P indicated .patients have the right to be free from mental, physical, sexual and verbal abuse.verbal abuse any use of oral, written, gestured language that includes disparaging [something that is little worth] and derogatory [disrespectful attitude] terms to patients. The CNO stated that the policy was not followed and should have been. The CNO further stated, everyone has the right to be free from abuse and this situation is never acceptable. 555587 Page 2 of 2