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F0557
E

Failure to Provide Portable Oxygen Tanks Limits Resident Dignity and Mobility

Fall River Mills, California Survey Completed on 08-07-2025

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 ensure that two residents were treated with dignity and respect by not providing access to portable oxygen tanks. Instead, residents were required to use large, noisy, non-portable oxygen concentrators that needed to be plugged into electrical outlets. This limitation prevented the residents from moving freely within the facility, going outdoors, attending appointments, or leaving with family, as the concentrators were cumbersome and required constant access to electricity. The issue was ongoing due to repeated malfunctions of the equipment used to fill portable tanks, and the facility's oxygen service provider was frequently called for repairs, but the problem persisted. Resident records indicated that one resident had severe cognitive impairment and was not their own representative, while the other had intact cognition and made their own medical decisions. Both residents expressed feelings of embarrassment, confinement, anger, and anxiety due to their restricted mobility and reliance on the concentrators. Staff interviews confirmed the recurring equipment failures, the need for staff assistance to move the concentrators, and the resulting impact on residents' ability to participate in activities and outings. The facility's own resident rights documentation emphasized the right to dignity and individuality, which was not upheld in this situation.

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