Facility Fails to Support Resident Dignity and Autonomy
Summary
The facility failed to provide an environment that supported and enhanced the dignity, self-worth, sense of satisfaction, and control over the lives of residents residing on the second and third floors. Observations and interviews with residents and staff revealed practices that disregarded residents' quality of life and were inconsistent with the facility's Resident Rights policy. Residents reported restrictions on their day-to-day lives, such as limitations on meeting without staff at Resident Council, accessing personal funds, moving freely within the facility, choosing dining options, having visitors, participating in social activities, and communicating privately by phone and mail. Observations confirmed these restrictions, showing that staff were not responsive to call lights, contributing to residents feeling neglected. Residents lacked access to information on outside assistance and survey results. Specific incidents included residents being limited to one soda per day, having to use plastic cutlery, and being restricted to certain floors. Residents expressed feelings of being jailed, trapped, and angry due to these limitations. Interviews with residents further highlighted their concerns, such as the inability to make private phone calls, restricted visitation hours, and limited access to personal funds. Some residents reported feeling trapped and unable to leave their floors without an escort. The facility's practices created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected.
Removal Plan
- Residents will be asked before each Resident Council whether they would like staff to attend the meeting or not. Residents are able to meet without staff present.
- A new Resident Council Form was implemented to include the question about staff attendance and the resident's response. The resident's response will be documented in the minutes of each Resident Council Meeting.
- Resident Council Meeting Minutes will be reviewed during QAPI to ensure compliance.
- Postings were updated with the correct contact information and are located in each neighborhood at wheelchair level.
- Postings will be monitored by the Leadership Team to ensure they are in place and at the proper level.
- Survey Results Binder is located in the Front Lobby on the first floor, containing surveys. Residents have access to the Survey Results independently.
- NHA or designee will update the binder with all annual and complaint surveys moving forward and ensure that the binder is in place.
- Resident #8's care plan was updated to include guardian input and court-ordered placement stipulations regarding movement throughout the community.
- A Resident Preferences Interview was conducted with Resident #8, and her care plan was updated to reflect her preferences.
- Resident #8's preferences will be updated as needed, and the community will maintain contact with resident's guardians for further care plan revisions and as needed.
- All residents are encouraged to eat in the dining areas. If a resident chooses to eat in their rooms, a room tray will be provided.
- The kitchen is open. If a resident misses a meal, they can request food or a tray during these times.
- Snacks are available in the neighborhoods.
- Dining Services will be reviewed with the Food Committee.
- Residents can purchase and/or request soda any time they wish. Residents on the second floor will have soda served to them in a disposable cup for safety.
- The use of disposable cups for soda will be discussed during the second floor Resident Council meetings.
- There is a cordless phone at the Nurses' Station in each neighborhood, available to all residents for private conversations.
- There are also stationary resident phones located throughout the community, and a private phone in the Town Hall Room on the first floor.
- The use of cordless phones will be discussed during the Resident Council Meetings for each neighborhood.
- Residents on the second floor will utilize plastic cutlery for safety. This information is located in the Resident Handbook for all admissions to the second floor.
- The use of plastic cutlery will be discussed during the Resident Council Meetings for the second floor.
- Visiting hours are twenty-four hours per day. Visitors may be asked to leave items in a locker if there are concerns about contraband.
- All responsible parties were notified of the visiting hours policy.
- Elevator operates and residents have access to it at all times.
- Elevator availability will be discussed during the Resident Council Meetings in each neighborhood.
- The facility will continue to follow the CDPHE directed plan regarding safe smoking.
- Resident smoking abilities are assessed, and care plans are updated accordingly.
- Mail is delivered if/when received from the USPS, and will be delivered by the Leader on Duty.
- The community follows regulations regarding resident's personal needs accounts, ensuring access to $100.00 ($50.00 for Medicaid residents) in cash within a reasonable period.
- Assessments and behavior care plans are developed and created on a resident-specific and individualized basis.
- A Resident Preferences Questionnaire has been completed, and residents have been interviewed regarding all of the above topics.
- All above items will be reviewed in QAPI and Safety Committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Delayed Provision of Bed Side Rails: A cognitively intact resident with Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain requested bed side rails to help with bed mobility and repositioning. Therapy documented that the resident would lay in bed if rails were available, but the request was not communicated or acted on promptly, and the bed did not have side rails when observed. Staff later stated side rails are usually installed the same day a request is made, and the DON acknowledged the delay should not have taken so long.
A resident who was cognitively intact activated a call light during breakfast to request assistance with toileting and reported waiting approximately 1.5 to 2 hours before staff responded. Facility call light records confirmed the call was activated and not answered for over two hours. Staff interviews indicated that management had communicated expectations that call lights be answered within about 15–20 minutes, but this expectation was not met in this instance, resulting in a prolonged delay in meeting the resident’s expressed need for assistance.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident admitted with a right hip fracture and cognitively intact status had physician transfer orders for an orthopedic follow‑up visit and staple removal within two weeks, but staff did not schedule or complete this follow‑up as ordered. The resident reported not seeing the orthopedic surgeon after admission and stated that the staples remained in for a long time before being removed, which was painful. Record review showed the staples were removed more than seven weeks after admission, and the DON acknowledged the transfer orders were not carried out due to an oversight, despite the administrator’s expectation that admission/transfer orders be completed as instructed.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident with multiple medical conditions, including a femur fracture, gout, COPD, and HTN, activated the call light for incontinence care but remained in a soiled brief for over 40 minutes while lunch was served. A CNA entered the room without knocking, turned off the call light, initially ignored the resident, and stated she could not provide peri-care because the roommate was eating. The CNA later claimed she had been told not to provide such care when someone in the room was eating, while the CN and DSD denied giving such instructions and referenced expectations for immediate response and use of privacy curtains. Review of the facility’s dignity policy and the DON’s statements confirmed that required practices for prompt toileting assistance, respect, and privacy were not followed.
Delayed Provision of Bed Side Rails
Penalty
Summary
The facility did not ensure that R25 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing when requested side rails for bed mobility were not provided in a timely manner. R25 was admitted with diagnoses including Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain, and his BIMS score of 15 indicated he was cognitively intact. During interview, R25 stated he had asked for side rails to help him get into bed, reposition himself, and move around in bed, and he reported he could not get into bed without them. Survey observation confirmed that his bed did not have side rails at that time. Record review showed the PT discharge summary documented that R25 reported he would lay in bed if he had bed rails to assist him with rolling and scooting. Therapy staff stated they had requested side rails from maintenance on 4/27/26 so R25 could have increased independence with bed mobility and had also discussed the need with nursing. However, maintenance staff reported they were unaware of the request, and environmental services stated she was only notified on 5/6/26 and then transferred a bed with side rails into R25's room. Nursing leadership acknowledged that once a request is made, side rails are usually installed the same day and stated R25's side rails should have been addressed sooner.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
Facility staff failed to respond to a cognitively intact resident’s call light within a reasonable time, resulting in a documented delay of over two hours. The resident, who had been admitted earlier in the month, reported that during breakfast he activated his call light to request assistance with toileting and waited approximately 1.5 to 2 hours before staff responded. Facility records from the call light system on the same date showed the call light was activated at 6:22 AM and not answered until 2 hours and 23 minutes later. During interviews, a CNA stated that management had communicated an expectation that call lights be answered in about 15 minutes, and the Administrator stated that staff had been told they should ideally answer call lights within 20 minutes of activation. The facility’s failure to respond to the resident’s call light in a timely manner was cited under WAC 388-97-1060(1) for not honoring resident preferences, choices, values, and beliefs, and placed residents at risk of unmet care needs and diminished quality of life.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Failure to Follow Physician Orders for Timely Post-Operative Staple Removal
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not carrying out a physician’s transfer order for a cognitively intact resident admitted with multiple diagnoses including a right hip fracture. The 5‑day MDS dated 02/20/2026 showed the resident was cognitively intact, and transfer orders dated 02/13/2026 directed staff to schedule a follow‑up appointment with the orthopedic provider for staple removal in two weeks. Interview and record review revealed that the resident reported not having been seen by the orthopedic surgeon since admission and stated that the staples had remained in for a long time before being removed, which was painful. The electronic health record showed the staples were not removed until 04/08/2026, 51 days after admission, and the DON/RN acknowledged that the transfer orders were not carried out due to an oversight, despite the expectation that admission/transfer orders be completed as instructed. This failure was cited under WAC 388-97-1060 (1)-(3) for not honoring each resident’s preferences, choices, values, and beliefs and for not providing care in accordance with professional standards of practice for one of three sampled residents reviewed for quality of life.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to honor a resident’s dignity and comfort. Resident 1, who had diagnoses including a left femur fracture, gout, COPD, hypertension, and a history of falling, reported that she activated her call light at 11:00 AM because she needed a diaper change. She stated that a CNA brought her lunch at 11:30 AM but refused to assist with the diaper change. At 11:41 AM, the resident was observed in bed stating she had been waiting since 11:00 AM for incontinence care. At 11:43 AM, while the surveyor was present, the resident again activated her call light. CNA 1 entered the room in less than a minute without knocking or announcing her presence, turned off the call light, ignored the resident, checked only on the roommate, and was about to leave the room until the visibly distressed resident requested assistance, stating she would not eat while soiled. CNA 1 told the resident she could not change the diaper because the roommate was eating. In a subsequent interview, CNA 1 stated she had been on lunch break from 10:40 AM to 11:20 AM, believed another staff member had answered the earlier call light, and claimed she had been instructed by the DSD not to provide peri-care if someone in the room was eating, and that the charge nurse had told her she could not do it. The charge nurse denied instructing CNA 1 not to change the resident and stated she had told CNA 1 to pull the privacy curtain and assist with the diaper change. The DSD denied ever instructing staff to delay care due to a roommate eating and stated staff were expected to attend to residents’ needs immediately and use privacy curtains during personal care. Review of the facility’s “Dignity” policy showed requirements that residents be treated with dignity and respect, that staff knock and request permission before entering rooms, promote and protect privacy, and promptly respond to toileting requests. The DON acknowledged that the policy was not followed when staff did not provide necessary personal care and left the resident in a soiled diaper for more than 40 minutes, in violation of facility standards and CMS regulations.
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