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F0550
E

Failure to Ensure Respectful and Dignified Treatment of Residents

Houston, Texas Survey Completed on 10-31-2025

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 ensure that multiple residents were treated with respect and dignity, resulting in a deficient practice that affected at least four residents. Certified Nursing Assistant (CNA) G was identified as the staff member whose interactions with residents led to feelings of being threatened, treated like a child, having their feelings hurt, and not being treated as a human. Specific incidents included CNA G making a comment to a resident about taking him outside and 'whooping his butt' when he refused to get out of bed, which the resident reported made him feel uncomfortable and as though he was being threatened, even if not physically. Other residents described CNA G as abrupt, rude, and rough in her approach, with one resident stating that CNA G treated her like a child and another stating that CNA G's tone was boisterous and explosive, making her feel bad. The residents involved had various medical and psychological conditions, including hemiplegia, diabetes, chronic kidney disease, Parkinson's disease, bipolar disorder, dementia, chronic obstructive pulmonary disease, morbid obesity, and epilepsy. Several residents had documented histories of depression and moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. These conditions made them particularly vulnerable to the negative effects of disrespectful or undignified treatment. Residents reported that CNA G's manner of communication and approach to care did not honor their preferences or emotional well-being, with some residents stating they did not feel safe or respected and that their feelings were hurt by her actions. Interviews with other staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that residents have the right to be treated with dignity, to refuse care, to ask questions, and to be treated as adults. Staff were trained in resident rights and recognized that failing to respect these rights could negatively affect residents emotionally. The facility's own policy required employees to treat all residents with kindness, respect, and dignity, and to honor their rights to a dignified existence. Despite this, the actions and approach of CNA G, as reported by multiple residents and corroborated by life satisfaction rounds, did not meet these standards, resulting in a deficiency related to resident rights and dignity.

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