Failure to Maintain Privacy for Residents with Urinary Catheters
Summary
The facility failed to maintain the dignity of residents with urinary catheters by not ensuring that urine collection bags were kept in privacy bags. This deficiency was observed in two residents. For Resident #419, multiple observations were made over several days where the foley bag was seen without a privacy cover, either on the floor or attached to the bed rail, visible from the hallway. Staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), acknowledged the absence of a privacy cover during these observations. Similarly, Resident #64's urine collection bag was observed without a privacy cover during an initial tour of the facility, visible from the hallway. The Registered Nurse (RN) assigned to the unit confirmed the observation and subsequently applied a privacy bag. A review of Resident #64's medical record indicated a care plan for catheter care, which included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. The Director of Nursing acknowledged the concern regarding the visibility of the urine collection bag from the hallway.
Penalty
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A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with CVA, schizophrenia, intellectual disability, and severe cognitive impairment, who required total assistance for hygiene and toileting and was incontinent of bowel and bladder, was found lying in bed on heavily urine-soaked linens, wearing only an incontinent brief, with multiple soiled linens, a soiled brief, feces, and dried food debris on the floor nearby. Despite this condition, a CNA delivered and left a lunch tray, which the resident fully consumed while still soiled. The care plan and Kardex lacked specific instructions for managing incontinence, staff acknowledged that incontinence care should occur every 2 hours and before meals, and leadership and a family member confirmed that the resident should not have been left in that undignified state, with the family member reporting ongoing issues of the resident being found soiled during visits.
A resident with multiple chronic conditions and moderate cognitive impairment experienced a dignity and respect violation when an LPN attempted to administer medication, then exited the room stating, “I don’t have to take this” with explicit language, which was captured on the resident’s electronic monitoring device. The resident, who reported depression and feeling that only a few nurses made her feel worthwhile, stated that some staff screamed at her, told her to “knock it off,” and were rude. The resident’s representative reported the video incident as mental abuse to facility staff and administration. In interviews, the LPN acknowledged making the explicit statement while leaving the room but claimed it was directed to a CNA and related to a prior conversation, while a CNA recalled the LPN’s difficulty giving medications and noted the LPN wore an earpiece and could have been on the phone. Staff interviews and facility policies confirmed that residents were to be free from verbal and mental abuse and to be treated with kindness, respect, and dignity.
A resident with severe cognitive impairment and dependence on staff for ADLs was left with an incomplete and uneven haircut after a beautician stopped the service when the resident moved too much and did not allow the haircut to continue. The beautician cut only one side of the resident’s hair, did not seek assistance from nursing staff, and left without notifying staff that the haircut was unfinished. Days later, a CNA noticed the resident’s hair was significantly shorter on one side and alerted nursing staff, and subsequent assessments by an RN and LVN confirmed the uneven appearance. The Social Services Director later learned from the beautician that the haircut had not been completed, and facility policy required that residents be treated with dignity and have their sense of well-being and self-esteem promoted.
A dependent, cognitively impaired resident with multiple psychiatric and physical diagnoses, including poor memory and total dependence for all ADLs, was found by a family member lying flat in bed completely undressed and uncovered. During the morning shift, a NA providing care left the room to obtain cream, closing the door and pulling the curtain but leaving the resident without any covering. The RN supervisor learned of the incident from the family member and was told by the NA that she had left to get cream but denied leaving the resident uncovered. The DON later confirmed that the incident was not reported to her at the time and that leaving the resident exposed violated the facility’s Resident Rights policy requiring treatment with dignity and respect.
Multiple residents with conditions such as Parkinson’s disease, stroke, diabetes, kidney disease, and mobility impairments reported that a CNA repeatedly failed to provide dignified and respectful care. The CNA allegedly refused or delayed toileting and incontinence care, told a resident to have a BM in a brief instead of using the toilet, used profane and degrading language about residents’ incontinence and weight, changed a colostomy bag in a public area, and left a resident partially naked and improperly positioned in bed. Residents also reported that the CNA ignored or dismissed call lights, refused or inadequately assisted with showers and hygiene, placed meal trays out of reach, disregarded food preferences, roughly handled belongings, and verbally stated that tasks were not his/her job or that residents expected too much. Facility leadership reported that several residents described similar concerns about the CNA’s uncaring and rude behavior.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Provide Dignified Incontinence Care and Clean Environment During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity, including maintaining cleanliness and appropriate incontinence care. The resident had diagnoses of CVA, schizophrenia, and intellectual disability, was severely cognitively impaired, and required total assistance for personal hygiene and toileting, with documented bowel and bladder incontinence. The resident’s care plan and Kardex specified total assistance for hygiene and toileting but did not include specific interventions or instructions for managing bowel and bladder incontinence. On the survey date, the resident was observed in bed wearing only an incontinent brief, a small blanket, and a flat sheet that was visibly soaked and soiled with urine from shoulders to the foot of the bed. Between the bed and the wall, there were multiple soiled flat sheets, a soiled brief, a large amount of feces, and dried food debris on the floor. Later the same day, the resident remained in bed on the heavily soiled sheet while their lunch tray, which had been fully consumed, sat on the overbed table, and the soiled linens, brief, feces, and food debris remained on the floor. CNA staff reported that the resident had been washed and provided incontinence care earlier in the morning and acknowledged that incontinence care should be provided every two hours, that they had not returned to the room since the morning, and that the resident should have been cleaned before receiving lunch. Video surveillance showed that the same CNA delivered the lunch tray shortly before the resident was observed eating while still soiled. Although the bed linens were later changed, the dried food debris and large amount of feces remained on the floor behind the bed. The unit manager, corporate DON, and a family member all stated that the resident should have been provided care and that the situation was undignified, with the family member reporting that the resident was always soiled with urine and feces during visits and that prior complaints to staff had not resulted in changes.
Failure to Treat Resident With Dignity and Respect During Medication Encounter
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect when a nurse used explicit language while exiting the resident’s room. The resident was an older female with diagnoses including UTI, Parkinsonism, polyneuropathy, muscle wasting and atrophy, and type II diabetes. Her quarterly MDS showed she was usually able to make herself understood and understand others, with a BIMS score of 10 indicating moderate cognitive impairment. She required moderate assistance with toileting, lower body dressing, and bathing, and her care plan identified potential for pain related to polyneuropathy with multiple monitoring and reporting interventions. Evidence from an undated electronic monitoring video, reviewed on 3/23/2026, showed an LPN walking to the resident’s bedside with a small cup in her hand, attempting to hand the resident a medication cup, then turning away and exiting the room. As the nurse exited, she stated, “I don’t have to take this (explicit language),” after which the resident placed her hands on top of her head. In an interview, the resident reported that some staff treated her with dignity and respect, but that staff also screamed at her, told her to “knock it off,” and were rude to her. She stated she had depression, took medication for it, and had reported a staff member who treated her poorly, though she could not identify the nurse other than that she worked on a different hall. The resident said there were only a few nurses who made her feel that she was worth something. The resident’s representative reported having a video from the resident’s electronic monitoring device from 12/12/2025 at 10:00 p.m. and stated she had reported the incident to a nurse and the previous administrator, describing the incident as abuse “in a sense” and more mental abuse because the resident needed care. In a telephone interview, the LPN involved stated that on 12/12/2025 the resident was complaining of nausea and felt she was going to get sick, and that while walking out of the room she said, “I am sick of this (explicit language).” The LPN claimed the statement was directed to a CNA and related to a previous conversation, declined to discuss the lead-up to the statement, and could not recall if she administered the resident’s medication. A CNA interviewed later said she had not heard anyone talking rudely to residents, recalled the LPN attempting to give the resident medications and then stating she did not know what was wrong because the resident would not take them, and noted there was no conversation outside the door before or after the LPN entered the room. The CNA mentioned the LPN wore an earpiece and could have been on the phone, and acknowledged that if a resident overheard something, they could think staff were talking to them. Other staff interviews confirmed expectations that residents be treated with dignity and respect and that disrespectful interactions could negatively affect residents emotionally. An LPN stated she had been in-serviced on abuse, neglect, exploitation, dignity, and respect, and recognized that overheard statements could make a resident feel disliked and depressed. The ADON, who was not employed at the time of the incident, reported hearing about the video and that the facility had to report it, and stated that everyone was responsible for ensuring residents felt safe and were treated with dignity and respect. The administrator stated the LPN’s statement could be taken wrong and could be abuse, and that she expected staff to talk to residents in a manner that showed dignity and respect and to report any disrespect immediately. Review of the LPN’s personnel file showed she was hired on 8/14/2025 and terminated on 12/17/2025 for “Resident Interaction.” Review of grievance/complaint logs for December 2025 did not show a grievance related to this incident or other concerns about the LPN, and the facility’s policies on abuse prevention and resident rights required that residents be free from verbal and mental abuse and that employees treat all residents with kindness, respect, and dignity.
Incomplete Haircut Left Resident With Uneven Appearance
Penalty
Summary
The facility failed to ensure a resident’s right to dignity and proper grooming when the contracted beautician did not complete a haircut and left the resident with uneven hair. The resident, who had diagnoses including unspecified hypotension, anemia, and schizoaffective disorder, had severely impaired cognition per an MDS dated 3/7/2026 and was dependent on staff for ADLs. On 2/16/2026, the beautician attempted to cut the resident’s hair but, according to her written statement and later interview, stopped after cutting only one side because the resident was moving too much and did not allow her to continue. She did not request assistance from nursing staff, did not notify staff that the haircut was incomplete, and left the facility without completing the service, resulting in the resident having short hair on the right side and significantly longer hair on the left side. On 3/6/2026, a CNA noticed the resident’s hair was short and uneven and notified nursing staff. An SBAR and change of condition documentation were completed, noting the discovery of the short, uneven hair on the right side of the resident’s head and the resident’s inability to clearly report when the haircut occurred. RN and LVN staff who assessed the resident confirmed the hair was uneven, with the right side much shorter than the left, and stated that it is important for residents to look their best as a matter of dignity. The Social Services Director reported that the beautician acknowledged she had been unable to complete the haircut on 2/16/2026 and had not charged for the service because it was not completed. The facility’s dignity policy stated that each resident shall be cared for in a manner that promotes well-being, self-worth, and self-esteem, and that residents are to be treated with dignity at all times.
Resident Left Uncovered and Exposed During Personal Care
Penalty
Summary
A resident with schizophrenia, depression, anxiety, adult failure to thrive, muscle weakness, poor memory recall, and total dependence on staff for all ADLs, including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting, was found undressed and fully exposed in bed. The resident’s care plan directed staff to allow extra time to complete tasks, encourage the resident to make choices as able, praise efforts, and report changes in functional ability to the physician. A family member reported entering the resident’s room and finding the resident completely undressed, lying flat in bed with nothing covering the body. The 7AM–3PM nurse aide assigned to the resident stated that while providing care she left the room to obtain cream, pulling the curtain and closing the door but leaving the resident on the bed without any covering. The 7AM–3PM RN supervisor reported that the family member informed her that the resident had been found exposed, and that the nurse aide told her she had left the room to get cream but denied leaving the resident uncovered. The DON stated it had not been reported to her that the resident was found exposed, and confirmed that facility policy requires all residents to be treated with dignity and respect. The DON acknowledged that the resident was not treated with dignity when left in bed without being covered and that the nurse aide made an error in judgment. The facility’s Resident Rights policy states that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Provide Dignified, Respectful Care by CNA
Penalty
Summary
The deficiency involves multiple instances in which a certified nurse aide (CNA A) failed to treat residents with dignity and respect and did not provide care in a manner that maintained or enhanced their quality of life. One resident with Parkinson’s disease, osteoarthritis, diabetes, impaired balance, and frequent incontinence reported that after asking to use the bathroom in the evening, CNA A refused to assist with toileting, stated that his/her back hurt, and told the resident to have a bowel movement in his/her brief instead of using the toilet. The resident stated that CNA A knew a bowel movement occurred in the brief and that the brief was not changed until the next morning. The same resident reported that on another occasion, while the resident was still having a bowel movement, CNA A commented, “You are still shitting on yourself,” and frequently used terms such as “shit” and “piss” when referring to the resident’s and roommate’s incontinence, which made the resident feel worse about his/her loss of independence. Another resident, who was cognitively intact, wheelchair-bound, and dependent on staff for most cares including colostomy and catheter management, reported that CNA A was abrasive, uncooperative, and argumentative, often saying he/she did not feel like performing requested tasks such as taking the resident to the bathroom. This resident stated that CNA A once changed his/her colostomy bag in front of others at the nurses’ station, which the resident found humiliating, and that on another occasion CNA A failed to take the resident to the bathroom and later falsely claimed to other staff that the task had been completed. A resident with expressive/receptive aphasia, severe cognitive impairment, and a history of stroke, who was normally continent but temporarily on strict bedrest due to severe leg swelling, reported that CNA A repeatedly responded to call lights without providing needed incontinence care, resulting in the resident being found wet through his/her brief, clothing, bedding, and with urine on the floor. When directed by a nurse to provide care, CNA A reportedly raised the bed, threw the resident’s blankets on the floor, left the resident naked and half hanging off the high bed with an unsecured brief and no sheets, refused to lower the bed, and stated, “You’re too fat and I ain’t gonna do you no more,” and “You’re too heavy,” before leaving. The resident also reported that CNA A routinely ignored preferences for meals, brought unwanted food, became angry when it was not eaten, turned off call lights without returning, and became upset when the resident took time to express him/herself. Additional residents described similar patterns of disrespectful and unhelpful behavior by CNA A. One resident who used an electric wheelchair, had diabetes, Parkinson’s disease, chronic kidney disease, and required extensive assistance for transfers and toileting reported that CNA A initially placed a meal tray on a table out of reach, refused to give his/her name to avoid being reported, frequently complained of being tired, told the resident, “You expect too much,” left the resident on the toilet without returning, and later ordered the resident to “turn the damn light off” when the call light was used to request help. Another resident, cognitively intact and dependent on staff for transfers, toileting hygiene, and shower assistance, stated that CNA A refused or inadequately washed his/her legs, back, and feet during showers, did not make the bed properly or use fitted sheets, failed to respond to call lights, and repeatedly claimed to be too busy or too tired to provide care. A further cognitively intact resident who was mostly independent but occasionally incontinent reported that CNA A was “horrible and very mouthy,” was observed answering the call light phone at the nurses’ station and hanging up while saying, “That’s not my job,” refused to change sheets on shower days, threw meal plates down in front of residents, and was neither patient nor kind. During the facility’s investigation, the Administrator and DON stated that multiple residents reported similar concerns about CNA A being uncaring and unhelpful, and that CNA A had prior write-ups for rude demeanor, while CNA A denied all allegations. These combined accounts show that CNA A’s actions and inactions included refusing or delaying toileting and incontinence care, using degrading and profane language about residents’ bodily functions and weight, exposing a resident’s colostomy care in a public area, leaving a resident partially naked and improperly positioned in bed, ignoring or dismissing call lights, failing to assist with hygiene tasks the residents could not perform, disregarding residents’ meal preferences, and handling residents’ belongings roughly. These behaviors directly conflicted with the facility’s abuse and neglect policy requiring staff to prevent verbal or nonverbal conduct that could cause humiliation, intimidation, fear, shame, agitation, or degradation, and resulted in multiple residents reporting that they felt humiliated, disrespected, and that CNA A did not want to care for them.
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