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F0658
D

Failure to Maintain Professional Communication Standards with Resident

Lynwood, California Survey Completed on 12-12-2025

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 follow professional standards of care by not ensuring staff communicated appropriately with a resident who had a history of verbal aggression and legal blindness. The resident, who was able to understand and make decisions, required supervision and setup assistance for some activities of daily living but was otherwise independent in mobility. The care plan documented multiple prior episodes of verbal aggression and outlined interventions such as assessing the resident's understanding, allowing time for expression, encouraging communication, and respecting privacy. Despite these interventions, an incident occurred in which the resident and a Certified Nurse Assistant (CNA) engaged in a verbal altercation at the nurse's station. Progress notes indicated both parties used inappropriate language, and interviews revealed conflicting accounts regarding whether the CNA yelled at the resident or made inappropriate remarks. The incident was further complicated by the resident's request to switch CNAs based on personal preference, which escalated into an argument involving both the CNA and a Registered Nurse (RN). The RN acknowledged that yelling at residents could be considered a form of abuse, and both the resident and CNA reported feeling disrespected during the exchange. The facility's failure to ensure staff maintained professional communication standards contributed to a situation where verbal aggression occurred, contrary to the resident's care plan and professional standards of quality.

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