F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of 2 sampled residents (Resident
2) was treated with dignity and respect during direct patient care when privacy was not provided, and
Resident 2 was rushed.
This failure resulted in Resident 2 feeling embarrassed, with increased anxiety, and difficulty sleeping.
Findings:
A review of the facility ' s policy revised 10/20/2017, titled, Resident Rights, indicated the purpose of this
policy is to assure protection of rights for residents in the facility. This facility ' s policy also indicted all
residents have the right to personal privacy. Staff will protect privacy by announcing themselves or knocking
on the door before entering room or privacy curtain and closing the door and pulling the privacy curtain
when providing or assisting with personal care.
A review of the facility ' s policy revised 9/15/2017, titled, Activities of Daily Living, indicated the purpose of
this policy is to preserve the resident ' s ability to carry out one ' s own basic activities of self-care as long
as possible and to receive assistance as needed to maintain one ' s dignity.
Resident 2 was admitted to the facility on [DATE] with diagnoses that included right femur and hip fracture,
right ulna (ulna, bone of the forearm) fracture, Chronic Obstructive Pulmonary Disease (COPD, a
progressive lung disease), difficulty walking, and heart disease.
A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 10/29/24,
indicated that Resident 2 was cognitively intact (able to think and reason) and made her own decisions, and
is her own responsible party (RP).
A review of a the most recent MDS dated [DATE], indicated Resident 2 is dependent on staff for activities
for daily living (ADLs-hygiene, toileting, grooming, dressing, and bathing) related to limited physical mobility
and a history of falls with injury. This MDS indicated Resident 2 needed substantial/maximal assistance for
toileting, showering, and dressing lower body.
During an interview on 11/6/24 at 12:10 pm, Resident 2 stated, The Certified Nursing Assistant (CNA) 2
and CNA 3 rushed me during my shower and did not provide privacy with a towel or the curtain when the
male CNA 5 popped in unexpectedly during my shower. I felt embarrassed, violated, and had
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555625
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
increased anxiety which made me lose sleep that night.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 11/6/24 at 1:09 pm, the Director of Staff Development (DSD) stated, I was told CNA
2 and CNA 3 needed more education, and I was updated [Resident 2] would not allow both CNAs back into
her room for any care. DSD confirmed rushing a resident and not providing privacy during a shower is a
violation of resident rights.
Residents Affected - Few
During an interview on 11/6/24 at 2:08 pm, Both the Director of Nursing (DON) and Assistant Director of
Nursing (ADON) confirmed rushing Resident 2 and not providing privacy during a shower is a loss of
dignity. ADON stated, I did not know the shower curtain was not closed for privacy.
During an interview on 11/6/24 at 2:15 pm, the Administrator (Admin) confirmed there was a violation of
rights related to privacy, and confirmed this would be considered a dignity issue. Admin stated, I know
[Resident 2] is alert and oriented, I agree her rights were violated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 2 of 2
