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F0550
D

Failure to Maintain Resident Dignity During Care and Mealtimes

Sacramento, California Survey Completed on 06-13-2025

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

Multiple deficiencies related to resident dignity and rights were identified during the survey. One resident with metabolic encephalopathy and a Foley catheter was observed in bed with the urinary catheter bag uncovered, despite a dignity bag being available on the resident's wheelchair. Both a registered nurse and the Director of Nursing confirmed that the catheter bag should have been covered, as per facility policy, to maintain the resident's dignity. In the dining area, two residents with neurological impairments were observed being assisted with eating by restorative nurse assistants who remained standing over them, rather than sitting at eye level. The staff could not explain the importance of sitting while assisting with feeding, and the DON acknowledged that standing over residents during feeding is a dignity issue. Training records indicated that the staff involved had previously received training on dignity and feeding practices. Additionally, two residents with intact cognition were observed wearing clothing protectors during meals without being asked for their preference. One resident expressed that staff did not ask if he wanted to wear a bib, while another stated that wearing the clothing protector made him feel like a baby and contributed to feelings of depression. There was no documentation in their care plans regarding their choice or preference for wearing clothing protectors, contrary to facility policy that emphasizes honoring resident choices and preferences.

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