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F0550
E

Failure to Maintain Resident Dignity During Meals and Personal Care

San Jose, California Survey Completed on 06-27-2025

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 were identified related to the failure to maintain resident dignity and respect during mealtimes and personal care. Certified nursing assistant C was observed feeding a resident while standing over her, rather than sitting at eye level as required by facility policy. This was confirmed by both the nurse supervisor and the director of staff development, who stated that staff should sit at eye level to maintain resident comfort and dignity. The facility's policy on assisting residents to eat also specifies that staff should sit at eye level in front of the resident. In the dining room, two residents were observed waiting for their meal trays while another resident at the same table had already begun eating. Both residents confirmed they were hungry and had to wait while watching another resident eat. The activity director and assistant director of nursing acknowledged that meal trays should be served to all residents at the same table at the same time or in immediate succession, in accordance with the facility's policy to promote dignity and timely service. Additionally, a resident with an indwelling Foley catheter was observed with an uncovered drainage bag, making the contents visible. The infection preventionist confirmed that the drainage bag should have been covered for privacy. The facility's policy on dignity specifies that urinary catheter bags should be kept covered to promote resident well-being and self-esteem. These failures were observed to have the potential to affect the emotional and psychosocial well-being of the residents involved.

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