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F0550
D

Failure to Ensure Resident Dignity and Respect During Care

Pasadena, California Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during the provision of care. The resident, who had a diagnosis of left breast cancer and required varying levels of assistance for activities of daily living, reported that the CNA threw her legs onto the bed and roughly tossed a pillow at her face while assisting with perineal hygiene. The resident described feeling humiliated and emotionally distressed as a result of this interaction. She did not report the incident immediately due to shock but later informed social services after reflecting on the potential for similar treatment of others. The resident's care plan indicated a risk for emotional distress and skin issues related to rough handling during care. Interviews with facility staff, including the DON and Administrator, confirmed awareness of the incident and acknowledged that the CNA was an agency staff member. The facility's policy required all employees to treat residents with kindness, respect, and dignity, and to honor residents' rights, regardless of diagnosis or condition. The actions of the CNA were inconsistent with these expectations and resulted in the resident experiencing emotional harm.

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