Based on observation, interview, and record review, the facility failed to ensure care was provided to three out of ten sampled residents (Resident 1, 2 and 3) in a timely manner that enhanced their individual and dignity to prevent accidents. 1) Resident 1 who sustained a fracture to the distal left femoral (is the larger and stronger of the two bones in the leg below the knee) about knee stated, Nurses take a long time to respond to the call light. 2) Resident 2 stated who prefer to remain anonymous, Nurses take 40 minutes to answer call light and sometimes I just have to pee on my bed. 3) Resident 3 stated who prefer to remain anonymous, The 3-11 night shift takes up to 40 minutes to answer the call light and sometimes I need to request pain medication, but have to wait. …
F241
Resident Rights Deficiencies
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F241 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D787.5% | E112.5% | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F241 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interviews and record reviews, the facility failed to treat one (Resident 1) of 50 resident with dignity and respect, when Unlicensed Staff A refused to change Resident 1's wet brief (adult undergarment) and argued with Resident 1 about whether it needed to be changed or not. This failure by staff to assist Resident 1 when Resident 1 asked for assistance, left Resident 1 feeling disrespected and, shaky about how she was treated. Findings: During an interview on 10/18/17 at 2:22 p.m., Complainant X stated Resident 1 reported Unlicensed Staff A refused to change her wet brief, despite Resident 1 asking for it to be changed. Unlicensed Staff A had argued with Resident 1 about it not needing to be changed. …
Smith Ranch Skilled Nursing & Rehabilitation Cente · California
Based on interview and record review, the facility failed to promote resident dignity by not answering call lights timely and not providing peri-care (to clean the body area for urination and excretion) for one of two sampled residents (Resident 1). This deficient practice caused the resident to fell anxious and had the potential to not meet the resident's care needs and to not enhance the resident's dignity and respect of their individuality. Findings: During an interview on 8/15/17 at 3:35 p.m., Resident 1 stated when he used the call light it would take up to 30 minutes for the staff to answer the call light. Resident 1 stated when he was soiled from urine or stool, he would use the call light to request for staff to clean him up. …
Based on observation, interview and record review, the facility failed to ensure a dignified dining experience by making sure the original items were not served in the original packaging for 19 out of 94 residents who eat orally. There were 119 residents in the facility at the time of the survey. Findings include: Record review of the Quality of Life-Dignity Policy and Procedure (written 2001; revised January 2017) revealed: Policy Statement-Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.; Policy Interpretation and Implementation-1) Residents shall be treated with dignity and respect at all times; 2) Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and… …
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