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F0550
E

Failure to Maintain Resident Dignity and Respect

Pomona, California Survey Completed on 04-24-2025

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

The facility failed to maintain or enhance the dignity and respect of four residents, as evidenced by several incidents. One resident with end-stage renal disease and anxiety disorder was awakened in the early morning by a loud noise made by an LVN, without the light being turned on, which startled and scared her. The resident, unable to communicate due to her tracheostomy, felt unsafe and experienced increased anxiety as a result. The incident was corroborated by the resident's roommate, who witnessed the event and observed the resident's distress. Another resident, who required maximal assistance for daily activities and had intact cognition, reported that staff did not clean his urinal receptacles, leaving them with urine residue and without proper labeling. The resident expressed feelings of disgust due to the persistent smell and the staff's disregard for his requests to properly dispose of the urine. Staff interviews confirmed that the urinals were not labeled or adequately cleaned, contrary to facility policy. A third resident, admitted for post-fracture care and self-responsible, reported that staff were routinely rude and disrespectful when responding to call lights, often speaking in an unfriendly manner and making loud jokes outside the resident's room while the resident was trying to nap. This behavior made the resident feel unimportant and horrible. Additionally, another resident with metabolic encephalopathy and parkinsonism, who was dependent on staff for all activities of daily living, was observed sitting in a hallway in a short-sleeved shirt and incontinence brief, without pants, compromising her privacy. Staff acknowledged that residents should be fully dressed and covered when out of bed, in accordance with facility policy.

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