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F0550
D

Resident Denied Dignified Toileting Assistance

San Dimas, California Survey Completed on 12-11-2025

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 licensed vocational nurse (LVN) instructed staff to place a resident on a bedpan instead of assisting the resident to the bathroom, despite the resident's ability to communicate needs and a care plan indicating that transfers could be safely performed with two staff members. The resident, who had diagnoses including abnormalities of gait, muscle wasting, and required assistance with personal care, expressed distress and did not want to use the bedpan. The resident's caregiver had specifically requested that the resident be assisted to the toilet, noting that the resident had previously been able to use the bathroom with assistance. The LVN cited low staffing as the reason for not assisting the resident to the toilet, although facility leadership later confirmed that staffing was adequate at the time. Review of the resident's care plan and Kardex confirmed that a two-person assist was required for transfers, and the Director of Staff Development stated that the resident should have been allowed to use the toilet, as this was their right and promoted dignity. Facility policy emphasized the importance of caring for residents in a manner that enhances well-being and prohibits practices that compromise dignity, including failing to promptly respond to toileting requests. The actions taken by the LVN and staff did not align with the resident's care plan or facility policy, resulting in the resident feeling disrespected and distressed.

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