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F0550
D

Staff Member Made Inappropriate Comment to Resident with Cognitive Impairment

Mission Hills, California Survey Completed on 04-09-2025

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 staff member, specifically a Restorative Nurse Assistant (RNA), made an inappropriate and insensitive comment to a resident with severe cognitive impairment and anxiety. The comment, "Do you want to end up in the grave like your wife?", was overheard by a visitor while the resident was sitting in front of the Physical Therapy room. The incident was not reported immediately by the witness due to fear of retaliation, and the exact date of the occurrence was not specified. The resident involved had diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and dementia, and required maximal assistance with activities of daily living. Psychological notes indicated the resident had an anxious mood and severely impaired cognition, with no recollection of the incident during a subsequent therapy session. The facility's policies on resident rights and quality of life require that all residents be treated with dignity and respect. The staff member's comment was found to be in direct violation of these policies, as confirmed by interviews with facility staff and the visitor who reported the incident. The event was documented in the resident's psychological progress notes and discussed in interviews with the Assistant Director of Nursing and a Licensed Vocational Nurse, both of whom confirmed the report and the inappropriate nature of the staff member's behavior.

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