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F0550
E

Failure to Ensure Resident Dignity Due to Inappropriate Staff Comments

Chester, California Survey Completed on 09-05-2025

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 housekeeper (HSK A) made repeated inappropriate and provocative comments to a male resident, including remarks about his legs and face being 'sexy.' These comments were witnessed by a charge nurse (LN B) on multiple occasions since February, but were not reported to facility leadership at the time. The resident, who had a history of unsteady gait, confusion, mild cognitive impairment, and alcohol abuse, was assessed as cognitively intact. He reported feeling uncomfortable and unsafe around HSK A and tried to avoid her due to the frequency of these comments. The facility's policy requires staff to treat residents with dignity and respect at all times, and to address them with consideration and recognition of their individuality. Despite this, the inappropriate behavior continued for several months without intervention. The charge nurse admitted to not reporting the incidents earlier, believing the resident was not negatively affected because he appeared to be laughing and smiling during the interactions. The Director of Nursing (DON) confirmed that the resident was not treated with dignity and respect as required by facility policy.

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