Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for several residents during meal service and personal care. During a lunch meal service, two residents were left without meals while others at their table were served and finished eating. This delay in meal service was not in accordance with the posted mealtime schedule, and the staff failed to communicate effectively with the kitchen to address the issue. Resident #9, who is legally blind and has severely impaired cognition, and Resident #37, with moderate cognitive impairment, were among those affected by this oversight. In another incident, Resident #27 was exposed without clothing while lying in bed, as the privacy curtain was not closed during care. This resident, who has severe cognitive impairment and requires assistance with bed mobility and dressing, was left in a vulnerable position visible from the hallway. The staff's failure to maintain privacy during care compromised the resident's dignity. Additionally, a group of residents expressed concerns about the responsiveness of staff to call lights, reporting that their needs were often unmet, and call lights were turned off without follow-up. Resident #35's room was noted to have a strong urine odor despite cleaning efforts, indicating a persistent issue with maintaining a dignified living environment. Resident #24 was observed unable to reach their call light, which was on the floor, further highlighting the facility's failure to ensure residents' ability to communicate their needs effectively.