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F0550
D

Resident Awakened at Night for Non-Urgent Room Change Decision

Rancho Mirage, California Survey Completed on 08-11-2025

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

Staff failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) awakened her late at night to ask about a potential room change. The resident, who had osteoarthritis and was recovering from joint replacement surgery, had previously requested a room move but declined an offer earlier in the day, stating she would move in the morning. Despite this, the CNA, following instructions from the outgoing Registered Nurse (RN), approached the resident between 11:00 p.m. and 11:15 p.m. to ask if she wanted to move that night or the following day, thereby disturbing her sleep. Facility policy and the resident's rights documents both indicate that residents should be treated with consideration and respect, and that room changes should be discussed when residents are awake unless medically necessary or for safety reasons. The Director of Nursing (DON) confirmed that the facility's practice is not to disturb residents during sleep for such discussions. This incident demonstrated a failure to honor the resident's right to a dignified existence and self-determination by unnecessarily disrupting her rest.

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