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F0557
D

Failure to Maintain Resident Dignity During Care Procedure

Montebello, California Survey Completed on 12-23-2025

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

Certified Nursing Assistants (CNAs) 2 and 3 failed to treat a resident with respect and dignity during a fecal disimpaction procedure. The resident, who was cognitively intact but fully dependent on staff due to quadriplegia and had a history of anxiety and depression, was present in the room when CNAs 2 and 3 engaged in a personal conversation that included derogatory and inappropriate comments. Specifically, while Registered Nurse (RN) 1 left the room to retrieve lubricant, CNA 2 made a comment, "What if you spit on it?" in response to CNA 3's remark, "You can either hit it or quit it," both of which were made in the presence of the resident. The resident reported feeling uncomfortable and upset by these comments and responded by yelling at the staff. Facility policy and procedures reviewed indicated that residents are to be treated with dignity and respect at all times, and demeaning practices are prohibited. The resident's care plan specifically noted the need for staff to maintain the resident's dignity and comfort during incontinence care. Interviews with the CNAs confirmed the inappropriate conversation took place in the resident's presence, and the Director of Nursing acknowledged that such comments could be perceived as hurtful and offensive, potentially resulting in psychosocial harm.

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