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F0584
E

Failure to Provide Privacy and Safety in Shared Resident Bathroom

Concord, California Survey Completed on 09-07-2025

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 provide a safe, private, and homelike environment for two residents by assigning them to rooms that shared a single bathroom without a lock, resulting in both male and female residents having to share the same bathroom. During observation and interviews, a female resident expressed feeling unsafe due to sharing the bathroom with a male resident and noted the absence of a lock on the bathroom door. The male resident also reported discomfort with the arrangement and stated that there should be a lock for privacy. Both residents were cognitively able to express their needs and concerns, and their Minimum Data Set (MDS) assessments indicated they required only minimal assistance with toileting and ambulation. The shared bathroom was located between the two residents' rooms, and the lack of a lock required the male resident to signal when the bathroom was in use to avoid accidental entry. The Director of Nursing acknowledged that female and male residents should not be sharing bathrooms and recognized the lack of privacy as a risk, further stating that a bathroom lock was necessary to prevent abuse. The facility's policy emphasized providing person-centered care that respects residents' comfort, independence, and personal preferences, which was not upheld in this situation.

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