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F0585
D

Failure to Honor Resident Grievance Regarding CNA Assignment

El Cajon, California Survey Completed on 12-11-2025

Penalty

Fine: $180,730
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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 honor a resident's grievance requesting not to be assigned to a specific CNA after the resident reported discomfort and inappropriate behavior by that CNA. The resident, who was cognitively intact and had the capacity to make decisions, filed a grievance stating that the CNA was too friendly and requested not to have the CNA provide care. Despite this, the CNA was assigned to the resident on at least one subsequent occasion, which was acknowledged by the Director of Nursing as an oversight. The facility's own policy required immediate action to resolve grievances and prevent further potential violations of resident rights during investigations, but this was not followed. The resident reported that the CNA had previously engaged in inappropriate touching during care, which made her feel uncomfortable and angry. She expressed concern for herself and other vulnerable residents who might not be able to voice similar grievances. Facility records confirmed that the CNA provided care to the resident after the grievance was filed, and interviews with facility leadership confirmed that this assignment should not have occurred according to the resident's request and facility policy.

An unhandled error has occurred. Reload 🗙