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F0550
D

Failure to Treat Resident with Dignity and Respect

Petaluma, California Survey Completed on 06-16-2025

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

A deficiency occurred when a licensed nurse made a humiliating comment to a resident in a public area of the facility, stating, "I am not going to give you your medication until you take a shower!" This statement was made in the presence of other residents and staff, resulting in the resident feeling embarrassed and humiliated. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, osteoarthritis, hoarding disorder, and major depressive disorder, reported feeling disrespected and stated that the incident was deeply embarrassing. Multiple staff interviews confirmed that the nurse's actions were inappropriate and did not align with the facility's expectations for maintaining resident dignity and privacy. The Assistant Activities Director reported that the nurse had also expressed to her that the resident should not participate in activities until she showered, and confirmed hearing the nurse make the comment out loud in a public area. The Director of Nursing and the Administrator both stated that such matters should be addressed privately and that denying participation in activities or medication based on hygiene in a public setting is not acceptable. A review of the facility's policies and procedures on Resident Rights and Dignity indicated that all residents are to be treated with kindness, respect, and dignity, and that staff are expected to promote, maintain, and protect resident privacy. The policies specifically prohibit demeaning practices and require that residents be encouraged to attend activities of their choice. The nurse's public comment and actions were in direct violation of these established policies, resulting in a failure to honor the resident's right to dignity and respect.

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