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F0656
D

Failure to Implement Person-Centered Care Plan for Resident Requesting Female CNAs

Downey, California Survey Completed on 04-21-2025

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 implement a comprehensive, person-centered care plan for a resident who had a documented request and physician order to receive care only from female CNAs. The resident, who had diagnoses including psychosis, epilepsy, and anxiety disorder, alleged inappropriate touching by a male CNA during a shower. Despite a care plan intervention and a physician order specifying that only female CNAs should provide care, facility records and assignment sheets showed that male CNAs were assigned to the resident on multiple shifts. Documentation from these shifts confirmed that male CNAs were assigned and documented care activities for the resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Staffing, confirmed that the assignment of male CNAs to the resident was contrary to the resident's expressed wishes and the care plan. The facility's own policies require person-centered care and respect for resident rights, including freedom of choice in care preferences. The failure to follow the care plan and physician order resulted in the resident experiencing fear and anxiety related to potential abuse.

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