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F0550
E

Failure to Treat Residents with Dignity and Respect by CNA

Pomona, California Survey Completed on 06-27-2025

Penalty

Fine: $64,875
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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

Certified Nursing Assistant (CNA) 1 failed to treat three residents with dignity and respect, as evidenced by multiple incidents observed, reported, and documented. One resident, who was dependent on staff for most activities of daily living and had intact cognitive skills, reported that CNA 1 slapped their hand and spoke rudely when the resident requested anti-itch cream for the perineal area. The resident expressed feeling angry as a result of this interaction. Another resident, also cognitively intact and with significant physical limitations, stated that CNA 1 refused to change the television channel upon request, which left the resident feeling upset and that their needs were not being met. A third resident, who was dependent for personal care due to paraplegia and other medical conditions, reported that CNA 1 did not change their incontinence brief in a timely manner, resulting in the resident waiting over an hour for care. This was corroborated by a family member who also requested assistance from CNA 1 and was told that other tasks would be completed first. The resident expressed frustration at not receiving proper care. Facility records, including grievance forms and interviews with staff, confirmed that CNA 1's actions were inconsistent with facility policy, which requires staff to treat residents with dignity, respect, and kindness. Interviews with facility leadership, including the Director of Staff Development and the Assistant Director of Nursing, confirmed that the behaviors exhibited by CNA 1—such as slapping a resident's hand, refusing reasonable requests, and delaying personal care—were not acceptable and violated both facility policy and residents' rights. The facility's policies emphasize the importance of providing care that maintains residents' dignity and comfort, including prompt and respectful assistance with personal needs.

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