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F0550
E

Failure to Maintain Resident Dignity and Privacy

Pasadena, California Survey Completed on 06-05-2025

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 honor residents' rights to dignity, respect, and privacy for three residents. In one instance, a certified nursing assistant (CNA) was observed feeding a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, dementia, and Parkinson's disease, while standing above the resident's eye level. The CNA acknowledged that she should have been seated at the resident's eye level during feeding, as per facility policy and the resident's care plan, which required extensive assistance with eating. Additionally, a licensed vocational nurse (LVN) was observed entering the rooms of two different residents, both with severe cognitive impairment and dependent on staff for all activities of daily living, without knocking on their doors. The LVN admitted that staff are required to knock before entering to provide privacy and maintain residents' dignity. Another registered nurse confirmed the importance of this practice, emphasizing that privacy and dignity must be maintained even if the resident is not alert. A review of the facility's policy on resident rights confirmed that each resident must be treated with respect and dignity, and their individuality must be recognized. The observed actions by staff were inconsistent with this policy, resulting in a failure to maintain privacy and dignity for the affected residents.

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