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C0990

Failure to Protect Resident from Verbal Abuse and Discrimination

Redding, California Survey Completed on 10-22-2025

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 protect the rights and dignity of a resident who identified as female and had a history of dysarthria following a stroke, transsexualism (transgender), and aphasia. The resident was her own responsible party and had a care plan indicating her female gender identity. Despite facility policies and training requiring staff to treat residents with respect and use their preferred gender identity and pronouns, a Certified Nurse Assistant (CNA) was witnessed verbally abusing the resident. Specifically, CNA B told the resident to "shut the [F word] up" and made derogatory remarks about the resident's gender identity, referencing her transition from male to female. This incident was reported by another CNA who intervened to stop the abuse. Observations and interviews with the resident revealed significant emotional distress following the incident. The resident, who had a low BIMS score indicating poor memory, became visibly upset, fearful, and unable to discuss the event in detail. She displayed signs of fear, such as trembling hands, watery eyes, and avoidance of eye contact, and confirmed through nonverbal cues and limited verbal responses that the incident had occurred and continued to affect her. Further interviews with CNA B showed a continued lack of respect for the resident's gender identity, as evidenced by the repeated use of incorrect pronouns and an aggressive tone during questioning. Facility policies explicitly prohibit discrimination against LGBT residents and require the use of preferred pronouns, but these were not followed in this case, resulting in a violation of the resident's rights and dignity.

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