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F0550
E

Failure to Promote Resident Dignity and Respect in Personal Care

Pasadena, California Survey Completed on 05-23-2025

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 promote dignity and respect for two residents by not adhering to its own policies regarding resident choice and personal care. One resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, was observed wearing a hospital gown despite having personal clothing available in their closet. The resident reported that staff did not ask for their preference and dressed them in a hospital gown for staff convenience. A Certified Nursing Assistant confirmed the resident's dissatisfaction with wearing the gown, and the facility's administrator acknowledged that staff should offer residents a choice in what to wear. Another resident, who was severely cognitively impaired and dependent on staff for all personal care, was observed with food debris around their mouth and a brown stain on the shoulder of their gown. These observations were made during two separate visits, and both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed the presence of the food debris and the stained gown. The CNA stated that it is important to keep residents clean for their well-being and appearance, especially if family visits. The facility's policy on dignity and quality of life, revised in 2022, states that each resident should be cared for in a manner that promotes their sense of well-being, self-worth, and self-esteem. The observed actions and inactions by staff, including not offering clothing choices and not maintaining personal cleanliness, were inconsistent with this policy and resulted in a failure to uphold the residents' dignity and respect.

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