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F0550
D

Failure to Treat Resident with Dignity and Respect During Staff Interaction

Fowler, California Survey Completed on 12-10-2025

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

Two Certified Nurse Assistants (CNAs) spoke loudly and disrespectfully to a resident, accusing her of taking her roommate's remote control and adjusting the television to face herself. The CNAs called the resident a liar and engaged in an argument with her, raising their voices in a manner that was described as unprofessional and hurtful by the resident. This interaction was witnessed by a Licensed Vocational Nurse (LVN), who confirmed that the CNAs were yelling at the resident and making inappropriate statements, including calling the resident a liar and referencing the possibility of losing their jobs. The resident involved had no cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, and had a medical history including type 2 diabetes mellitus, protein-calorie malnutrition, stimulant abuse, bipolar disorder, major depressive disorder, post-traumatic stress disorder, and chronic pain syndrome. The incident was corroborated by interviews with staff, including another CNA, the LVN, the Registered Nurse (RN), the Director of Nursing (DON), and the Infection Preventionist (IP), all of whom stated that staff should not yell at residents and must treat them with dignity and respect. The facility's policies on promoting and maintaining resident dignity and resident rights were reviewed and indicated that all staff must speak respectfully to residents and avoid yelling or scolding. The deficiency was identified through interviews and record reviews, which established that the CNAs' actions failed to honor the resident's right to a dignified existence, self-determination, and respectful communication. The staff's behavior was found to be inconsistent with facility policy and placed the resident at potential risk for emotional distress, as directly stated in the report.

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