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F0550
D

Failure to Ensure Privacy During Perineal Care and Incontinence Brief Changes

Pomona, California Survey Completed on 08-21-2025

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

Staff failed to provide adequate privacy during perineal care and incontinence brief changes for two residents. In both cases, certified nursing assistants closed the privacy curtain around the residents' beds but left a visible gap of 2 to 3 feet, making the residents visible to anyone entering the room. One resident, admitted with hypertension and diabetes, required moderate to maximal assistance with personal care and was exposed during perineal care and a diaper change. The other resident, diagnosed with Alzheimer's disease and experiencing memory problems, also required significant assistance and was similarly exposed during perineal care due to the curtain not being fully closed. Interviews and policy review confirmed that facility procedures require staff to fully close privacy curtains during personal care to maintain resident dignity and privacy. The Director of Staff Development acknowledged that privacy was not maintained as required, and the facility's policy emphasized the importance of protecting bodily privacy during care activities. These observations and interviews demonstrate that staff did not follow established protocols to ensure resident privacy during intimate care tasks.

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