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F0550
D

Failure to Maintain Resident Privacy and Dignity Due to Inadequate Monitoring

Pasadena, California Survey Completed on 05-15-2025

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 resident with multiple medical conditions, including type 2 diabetes, end stage renal disease, and hypertension, was admitted to the facility and assessed as having moderately impaired cognitive skills and requiring significant assistance with daily activities such as toileting and bathing. The resident reported that another male resident entered her room without permission, touched her leg and gown, and attempted to take her snacks. Staff interviews and documentation confirmed that the male resident had a pattern of entering other residents' rooms, taking their belongings, and required frequent redirection by staff. The affected resident expressed discomfort and fear during the incident, stating she was unable to get up and feared retaliation if she resisted. Staff, including CNAs and nurses, were aware of the male resident's behavior, as he was known to enter other residents' rooms and take their items. Despite this knowledge, the male resident continued to access other residents' rooms, including the incident where he touched the affected resident and attempted to take her snacks. Facility policies reviewed indicated a requirement to promote privacy, dignity, and respect for residents, but these were not upheld in this instance, resulting in a failure to maintain the resident's right to privacy and dignity.

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