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F0550
D

Failure to Ensure Timely Response and Respectful Communication for Residents

Montebello, California Survey Completed on 11-13-2025

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 honor residents' rights to dignity and respect in two separate instances involving two residents. In the first case, a cognitively intact resident who was physically dependent on staff for all activities of daily living (ADLs) was observed waiting at least 19 minutes for assistance after activating the call light. During this period, staff were seen at the Nurses' Station while the call light remained illuminated and audible. The resident reported frequent delays in staff response, sometimes waiting up to an hour, and often had to rely on his roommate to seek help. Interviews with staff revealed confusion and lack of accountability regarding who was responsible for responding to the call light, with some staff assuming others would respond. The facility's policy required timely response to call lights, but this was not followed, resulting in unmet needs and compromised the resident's dignity and safety. In the second instance, another resident reported that a CNA used derogatory language, calling him a "stupid old man" after he requested hot water. The resident stated that when he confronted the CNA, the CNA responded, "I don't care." The resident felt disrespected and neglected, and subsequently noticed that the CNA no longer acknowledged or assisted him during assigned shifts. The incident was reported to a nurse, and the resident provided a description of the CNA involved. Documentation and interviews confirmed that the resident felt a change in the CNA's behavior towards him after the incident, leading to further feelings of neglect. Both cases were substantiated through interviews, observations, and record reviews. The facility's policies on answering call lights and treating residents with dignity and respect were not adhered to, resulting in residents experiencing delays in care and disrespectful communication. The deficiencies were directly observed and corroborated by resident statements, staff interviews, and review of facility records.

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