F0550

E

Failure to Honor Resident Rights to Dignity, Communication, Call-Light Access, and Visitation

Napa, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to honor resident rights to dignity, self-determination, communication, and access to persons and services. A cognitively intact resident with chronic ulcer, cellulitis, dialysis, and diabetes reported that night nurses yelled profanities such as "F**k you" outside his room and that staff frequently spoke Spanish or another foreign language in front of him, which he felt was unprofessional and made him feel staff did not care. The same nurse was later observed multiple times exiting through the main lobby and exhaling vapor from a device immediately outside the main entrance where residents and families enter, and was described by the Administrator as having prior disciplinary action for being loud and lacking professionalism. The Activity Director stated staff were not supposed to be on the phone during patient care hours or speak a foreign language in front of residents or families, and Social Services stated she handled grievances but reported she had not heard of unprofessional staff behavior, despite a grievance log documenting 25 instances of unprofessional staff behavior, including 13 related to staff tone, HIPAA issues, inappropriate bedside manner, and lack of professionalism. The DON and Administrator both stated they were unaware of grievances about unprofessional behavior and did not review the grievance log for trends, even though the facility’s grievance policy required the Administrator to review findings with the grievance officer.

The deficiency also includes failures to ensure residents had access to call lights for assistance and emergencies. One resident stated staff moved his call light away, forcing him to yell for help, and his call light was not visible near his bed. Another resident’s call light was observed on the floor on the far side of his bedside table, out of his reach; he reported having a bowel movement and waiting two hours to be changed and said this happened frequently and made him feel staff did not want to help him. A third resident with left-sided weakness after a stroke had his call light pinned to the wall on his affected side, far out of reach, and he believed staff pinned it away on purpose so he could not call for help. A nurse confirmed that none of the residents in the room had access to their call lights and acknowledged this could lead to delays in care and be dangerous in an emergency. The DON stated call lights should always be within reach and that having them anchored out of reach or on the floor did not meet her expectations, and the facility’s call system policy required each resident to have a means to call staff directly from bed and that calls be answered immediately.

Another component of the deficiency concerns denial of access to visitors and communication practices that affected residents’ sense of dignity. A resident with osteoarthritis, heart disease, chronic pain, glaucoma, degenerative nerve syndrome, cognitive impairment, and substantial ADL assistance needs expressed a clear desire to see her daughter, stating her daughter helped her get out of bed, clean, and eat, and she cried and pleaded for her daughter to be brought back. Social Services and the Administrator stated they were following the guidance of the resident’s DPOA, who instructed the facility to prevent the daughter from visiting due to alleged interference with care and detriment to the resident’s well-being, and the facility was not allowing the daughter to visit. Additionally, four cognitively intact residents reported that staff frequently spoke foreign languages in hallways, in shared rooms, and during direct care, which made them uncomfortable and, in some cases, bothered them especially when it occurred during their own care because they did not know what staff were saying or whether they were being talked about. A nurse acknowledged staff occasionally spoke foreign languages and that there had been an in-service on the issue, and the DON stated staff were expected to speak the same language as the resident, especially around resident care areas. An in-service record documented that staff were expected to speak only in a language recognized and understood by residents after the training.