Failure to Maintain Clean and Odor-Free Environment
Summary
The facility failed to treat two residents with respect and dignity by not maintaining a clean and odor-free environment. Resident #35's room had a strong odor of urine, and his floor mat and mattress were saturated with urine. The room's floor was sticky, and the laundry hamper was full of urine-soaked clothes. Despite multiple reports from staff about the foul odor, the issue persisted for at least two to three months. The facility's housekeeping and nursing staff were aware of the problem but failed to address it adequately, leading to a diminished quality of life for the residents involved. Resident #35, an elderly male with severe cognitive impairment and multiple health issues, including dementia and urinary incontinence, was found lying on a urine-soaked mattress. The resident's behavior of urinating in various places in the room, including the floor, trash can, and laundry hamper, was documented but not effectively managed. Staff interviews revealed that the resident's room had been deep cleaned multiple times, but the odor and unsanitary conditions persisted. The resident expressed feelings of discomfort and self-worth issues due to the smell and the lack of timely care from the staff. Resident #14, who shared the room with Resident #35, also suffered from the foul odor. Although non-verbal, Resident #14 indicated through gestures that the smell bothered him and that he wanted to move to another room. The facility's ambassador program, which was supposed to ensure the cleanliness and comfort of residents' rooms, failed to address the ongoing issue despite multiple reports during morning meetings. The facility's policies on promoting resident dignity and maintaining a clean environment were not followed, leading to the deficiency observed by the surveyors.
Penalty
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A severely cognitively impaired resident, fully dependent for ADLs and with multiple medical conditions, was observed seated alone in the dining room wearing only a hospital gown that left the back and legs exposed, with a full breakfast tray in front of him that he was not feeding himself. A CNA acknowledged bringing the resident to the dining room in the gown due to time and staffing constraints and recognized this was not appropriate but did not further cover the resident. An LPN stated it was acceptable for residents to be in the dining area in hospital gowns, despite the resident’s inability to choose his attire. This situation conflicted with the facility’s written policy requiring that residents be treated with dignity, respect, and privacy.
Staff unlocked and searched a resident's locked nightstand drawer without the resident present or obtaining consent, removing a vape pen from inside. The Maintenance Director provided the key and unlocked the drawer at the request of the UM, who then took the vape pen, while an OTA was also present. The OTA had previously reported the vape pen to therapy leadership and informed the UM but did not seek the resident's permission to search or retrieve items, and the resident did not request that staff retrieve anything. The DON later discovered the vape pen on their desk and had not discussed the search with the resident. The facility's smoking policy states that monitoring residents' rooms and belongings for smoking materials must be done in a way that does not violate resident privacy.
The facility failed to ensure a dignified dining experience for three cognitively impaired residents on puree diets who required staff assistance with eating. During a lunch meal, a CNA stood while feeding all three residents seated at the same table, rather than sitting at eye level as required by facility policy. The CNA acknowledged she should have been seated but stated she stood so she could reach all three residents, and the DON confirmed that standing over residents during feeding was a dignity concern and inconsistent with the facility’s feeding practices policy.
A resident with intact cognition and a history of mental health and medical conditions was served meals on disposable dishware and utensils without clear justification or reassessment, despite facility policy limiting such use to emergencies. Both the resident and staff were unaware of the reason for this intervention, and the Dietary Director confirmed that the practice had not been reviewed for continued appropriateness.
A resident with diabetes and cognitive communication deficit was observed eating lunch in his room while three full urinals hung on the footboard of his bed. The resident stated that staff would bring food and medications but did not empty the urinals, which he found undignified during meals. Staff notes indicated the resident had earlier requested privacy, but staff still entered for other tasks without addressing the urinals, resulting in a failure to provide a dignified dining experience.
Three residents with significant cognitive or physical impairments were not promptly assisted with eating during a meal service. One resident waited 45 minutes before being served and assisted, another waited to be fed, and a third was not seated properly and needed repeated cues to eat. Only one CNA was present to assist multiple residents, resulting in delays and a lack of dignified care, contrary to facility policy.
Resident Dignity Not Maintained When Brought to Dining Room in Exposing Hospital Gown
Penalty
Summary
Surveyors identified a failure to protect a resident’s dignity when a severely cognitively impaired memory care resident was observed seated alone in the dining room wearing only a hospital gown, with his back and legs exposed. The resident had multiple medical diagnoses including unspecified dementia, psychosis, delusional disorder, TIA, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. His most recent MDS showed a BIMS score of 0, highly impaired vision, unclear speech, and dependence on staff for all ADLs, including dressing, toileting, and eating. At the time of observation, he had a full breakfast tray in front of him but was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown and stated there was not enough time or staff to get him dressed before breakfast, acknowledging that this was not appropriate attire for the dining room but leaving him uncovered. An LPN reported she believed it was appropriate for residents, particularly skilled residents, to be in the dining area in hospital gowns, while also acknowledging that this resident could not choose how he was dressed due to his cognitive impairment. The resident’s spouse stated she believed staff did everything they could given staffing ratios and that responses could be delayed because staff were busy. The facility’s Dignity, Respect, and Privacy Policy stated that residents were to be treated with respect and cared for in a manner that protected their privacy, but this was not followed in this incident.
Failure to Obtain Resident Consent Before Searching Locked Personal Belongings
Penalty
Summary
A resident with COPD with acute exacerbation and tobacco use, admitted on 11/15/25, had a locked nightstand drawer containing a vape pen. On 03/02/26 at 11:27 A.M., the Maintenance Director entered the resident's room with the Unit Manager (UM) and an Occupational Therapy Assistant (OTA) present near the bedside stand. The Maintenance Director unlocked the resident's locked nightstand drawer and the UM removed the vape pen from inside. The resident was not in the room or nearby at the time. The UM confirmed removing the vape pen from the locked drawer and acknowledged that the resident was not present and that she did not obtain the resident's consent to search the property. The Maintenance Director confirmed providing the key, that the drawer was unlocked at the UM's request, and that no consent was obtained from the resident. The OTA reported notifying the Director of Therapy and verbally informing the UM that the resident had a vape pen, and confirmed the resident was not in the room when the vape pen was removed. The OTA further confirmed they were not asked by the resident to retrieve anything from the nightstand and did not ask the resident for consent to search the property. The DON stated they were unaware at the time that the resident's property had been searched and later found the vape pen on their desk with a note, and confirmed they had not spoken with the resident about the search. The resident reported that staff took the vape pen from the locked drawer while the resident was at therapy and confirmed that no one asked for consent to search the property or to retrieve anything from the room. Facility policy on resident smoking states that staff will monitor rooms and belongings of residents who smoke for smoking materials in a manner that does not violate the resident's right to privacy.
Failure to Provide Dignified Dining Assistance in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified dining experience for three residents on the memory care unit who required staff assistance with eating. All three residents had dementia, severely impaired cognition per their MDS assessments, and were on puree diets; two were documented as dependent on staff for eating, and one required staff assistance. During a lunch meal observation in the memory care dining room, the three residents were seated at the same table with their meal trays in front of them while a CNA provided eating assistance. Surveyors observed that the CNA stood while assisting all three residents with eating rather than sitting at eye level as required by the facility’s “Resident Dignity and Feeding Practices” policy. In interview, the CNA confirmed she was standing and acknowledged she should sit beside residents when assisting with eating, explaining she stood because she could not reach all three residents if seated. The DON also confirmed that the CNA should have been seated while providing eating assistance and stated that standing over residents during feeding was a resident dignity concern, consistent with the facility’s policy that staff should sit at eye level with residents during feeding.
Failure to Provide Appropriate Dishware and Silverware to Promote Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate dishware and silverware to promote dignity during meals. Record review showed that the resident, who had diagnoses including major depressive disorder, essential hypertension, and generalized anxiety disorder, was cognitively intact and had been receiving disposable dishware and utensils. The use of disposables was originally implemented due to the resident discarding smokeless tobacco into mugs and bowls, but there was no evidence of reassessment to determine if this intervention was still necessary. The resident's care plan indicated a risk for malnutrition, and the use of disposables was discontinued at a later date, but during the period reviewed, the resident continued to receive paper plates and plastic utensils without clear justification. Interviews with the resident and staff confirmed that the resident was unaware of the reason for receiving disposable dishware, and staff could not provide an explanation. The Dietary Director acknowledged that the intervention had been in place since the previous year and that no reassessment had occurred to determine if regular dishware and silverware should be reinstated. Facility policy stated that disposables should only be used in emergency situations, yet multiple residents, including the one reviewed, were receiving them outside of such circumstances.
Failure to Ensure Dignified Dining Experience Due to Unattended Full Urinals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including type II diabetes, muscle weakness, and cognitive communication deficit was observed eating lunch in his room while three full urinals were hanging by the handle on the footboard of his bed. The resident reported that staff would enter his room to deliver food, pick up trays, or administer medications, but did not address the full urinals. He expressed that he did not like having full urinals hanging on his bed during meals. The care plan did not note any behavioral concerns related to urinal use, and the resident's cognition was documented as intact, with some decline in care acceptance on certain days. Staff documentation indicated that the resident had requested staff to stay out of his room earlier in the day, which may have contributed to the urinals not being emptied prior to his meal. However, staff still entered the room for other reasons without addressing the urinals. Facility policy states that residents have the right to be treated with respect, kindness, and dignity. The presence of full urinals during mealtime was confirmed by both the resident and the facility administrator, indicating a failure to provide a dignified dining experience.
Failure to Ensure Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that residents who required assistance with eating were treated with dignity and respect. Three residents with significant cognitive and physical impairments were observed during a lunch period where their needs were not promptly or appropriately addressed. One resident, who was severely cognitively impaired and dependent for eating, was brought to the dining room but was not served lunch or assisted to eat until 45 minutes later. Another resident, who was cognitively intact but physically dependent for eating, was left waiting to be fed after being brought to the dining room. A third resident, with moderate cognitive impairment and requiring setup and cues for meals, was not seated close enough to the table and had to be prompted and physically moved to access her meal. A CNA confirmed she was the only aide present in the dining area and had to assist multiple residents with eating, resulting in delays and a lack of dignified care. The facility's policy required all employees to treat residents with kindness, respect, and dignity, but these standards were not met during the observed meal service. The findings were based on direct observation, staff interview, and policy review.
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