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F0557
D

Failure to Ensure Resident Dignity and Safe Handling During Personal Care

Torrance, California Survey Completed on 12-05-2025

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

A deficiency occurred when a certified nurse assistant (CNA) failed to treat a resident with dignity and respect during personal care, resulting in rough handling. The resident, who had a history of multiple rib fractures and a previous left arm injury from a car accident, required full assistance with toileting and personal hygiene. On the day of the incident, the CNA appeared rushed and in a bad mood, reportedly due to working a double shift. The resident expressed a preference for showering later in the day, but the CNA insisted on providing a morning shower and responded curtly when informed of the resident's preference. After the shower, the CNA left the resident in a wheelchair for about 30 minutes and did not return to clean the bedside area. Later that evening, while assisting the resident with putting on a gown, the CNA squeezed the resident's left hand very hard, despite being told to be careful due to the resident's prior injury. The resident reported feeling that the CNA was handling her too roughly and expressed concern during care, but the CNA did not respond and continued with the task. The following day, the resident noticed a purplish discoloration on her left thumb and reported it to a licensed vocational nurse (LVN), stating that the injury likely occurred when the CNA squeezed her hand. Interviews with staff and another resident corroborated the account of rough handling and emotional distress. The LVN and unit director of nursing (UDON) observed the discoloration and found the resident's report credible, noting that the injury was consistent with the described incident. Facility policy requires all residents to be treated with kindness, respect, and dignity, which was not upheld in this case.

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